Surgery Rotation 9 Flashcards
Management for fx of metatarsal
Middle metatarsals (2, 3, 4) - can usually heal with rest and analgesics
5th metatarsal has increased risk for nonunion - managed with casting or internal fixation
Causes of post-op fever
Malignant hyperthermia (immediate) Bacteremia Atelectasis Pneumonia UTI (3 days later) DVT (5 days later) Wound infection
Remember: 4 Ws for timing Wind - atelectasis Water - UTI Walking - DVT Wound - infection Wonder where - abscess
Contents of the spermatic cord
Ductus deferens Testicular artery Pampiniform plexus Genital branch of genitofemoral nerve Cremasteric muscle
What is the referred subscapular pain from gallstones called?
Boas sign
What is Charcot’s triad
For cholangitis
Jaundice, fever, RUQ pain
What is the pentad of sx associated with cholangitis
Reynold’s pentad
jaundice, fever, RUQ pain, hypotension, AMS
Boundaries of femoral canal
- Cooper’s ligament posteriorly
- Inguinal ligament anteriorly
- Femoral vein laterally
- Lacunar ligament medially
Most important factors for predicting mortality for surgery
- CHF - check EF
- MI within 6 months - check EKG
- Arrhythmias
- Old age
- Emergent surgery
- Aortic stenosis - listen for murmur (late systolic, crescendo-decrescendo)
Meds to stop before surgery
Aspirin, NSAIDs, Warfarin, metformin (lactic acidosis)
Formula for anion gap + normal value
Na - (Cl + HCO3)
Normal = 8-12
What is the concern when correcting hypernatremia
Cerebral edema
Treatment for hyperkalemia
Calcium gluconate (to stabilize cardiac membranes), insulin and glucose, albuterol (also shifts K+ into cells), last resort = dialysis
Formula for fluid resuscitation in adult burn victim
(Kg) x (% burn surface area) x (3-4)
Formula for fluid resuscitation in child burn victim
(Kg) x (% burn surface area) x (2-4)
What do you see on X-ray of paralytic ileus
Dilated gas-filled loops of bowel with no transition point
What will you see on CT in colonic ischemia
Edema and air (pneumatosis) in the bowel wall
What will you see on colonoscopy of colonic ischemia?
Segments of cyanotic mucosa and hemorrhagic ulceration with sharp transition from affected to unaffected mucosa
Management of colonic ischemia
- IV fluids and bowel rest
- Antibiotics with enteric coverage
- Colonic resection only if necrosis develops
Management of penile fracture
Urological emergency = urgent operative care
If there is evidence of urethral injury (blood at meatus, hematuria, dysuria, urinary retention) - indication for retrograde urethrogram
Management of blunt abd trauma in hemodynamically unstable patients
FAST (US) exam
- If positive (intraperitoneal fluid) = urgent laparotomy
- If negative = stabilize if signs of extra-abd hemorrhage, or stabilize then CT if no signs of extra-abd hemorrhage
Management of blunt abd trauma in hemodynamically stable patients
Positive FAST exam = CT abd
Management of hemodynamically stable patient with penetrating abd trauma and signs of peritonitis (rebound/guarding)
Urgent exploratory laparotomy
Causes of hypervolemic hyponatremia
CHF, nephrotic syndrome, cirrhosis
Causes of hypovolemic hyponatremia
vomiting, diuretics
Causes of euvolemic hyponatremia
SAIDH, Addisons, hypothyroidism
Cause of post op pt with thromocytopenia and increased clots
HIT - Heparin-induced thrombocytopenia
Cause of bleeding with normal platelets but increased bleeding time and PTT
vWD
vWF needed to activate platelets = increased BT
vWF stabilizes factor VIII = increased PTT
Damage and presentation of humeral mid-shaft fracture
Damage to radial nerve - sensation to posterior arm, forearm, and dorsolateral hand; extensor muscles
Presentation of uncal herniation
Ipsilateral hemiparesis and CN III (oculomotor) palsy
Presentation of pulmonary contusion
Presents <24 hours after blunt thoracic trauma
Tachypnea, tachycardia, hypoxia
CT scan or CXR with patchy, alveolar infilatrate
Management of abd fistula
- fluid replacement
- electrolyte replacement
- elemental nutrient replacement (something that won’t stir up enzymes)
- protection of abd wall from bowel contents (suction device)
Things that prevent a fistula from healing
FETID
- Foreign body
- Epithelialization (epithelium from skin and from bowel can grow towards each other to line the lumen)
- Tumor
- Infection, irradiated tissue, IBD
- Distal obstruction
Management of flail chest
Pain control, supplemental O2
Positive pressure ventilation (+/-) chest tube if respiratory failure
Will you have increased or decreased bowel sounds in small bowel obstruction and in ileus
SBO = increased bowel sounds Ileus = decreased/absent bowel sounds
Muscles of rotator cuff
SItS:
- Supraspinatus (initial abduction of arm, before deltoid)
- Infraspinatus (lateral rotation)
- Teres minor (lateral rotation and adduction)
- Subscapularis (medial rotation and adduction)
What structures are at risk for damage in a supracondylar fracture of the humerus (right above the elbow)
Entrapment of brachial artery (which branches into radial and ulnar artery) or median nerve
Components of Whipple procedure
- Cholecystectomy
- Truncal vagotomy
- Antrectomy
- Pancreaticoduodenectomy—removal of head of pancreas and duodenum
- Choledochojejunostomy—anastomosis of common bile duct to jejunum
- Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum
- Gastrojejunostomy—anastomosis of stomach to jejunum
Fluid given for hypovolemic hypernatrermia (both symptomatic and asymptomatic)•
Non-symptomatic
o 5% dextrose
Symptomatic
o 0.9% saline (isotonic solution) until Euvolemic, then 5% dextrose (hypotonic solution)
What causes metabolic alkalosis
♣ Causes: • Losing H+ excessive vomiting, diuretics, hyperaldosteronism ♣ Differential of metabolic alkalofis (pH > 7.45; HCO3- > 24) • Low urine chloride ♣ Will respond to saline o Vomiting/nasogastric aspiration o Prior diuretic use • High urine chloride o Hypovolemia/euvolemia ♣ Current diuretic use • Will responds to saline ♣ Bartter & Gitelman syndrome • Saline unresponsive o Hypervolemia ♣ Excessive mineralocorticoid activity o Saline unresponsive • Primary hyperaldosteronism • Cushing disease • Ectopic ACTH production
What causes metabolic acidosis
• Anion gap Adding acid to the blood o MUDPILES: ♣ M – Methanol ♣ U – Uremia (renal failure) ♣ D – Diabetic ketoacidosis ♣ P – Propylene glycol/Paraldehyde ♣ I – Isoniazid/Iron ♣ L – Lactic acidosis ♣ E – Ethylene glycol (antifreeze) ♣ S – Salicylates (aspirin) • Non-anion gap Losing excessive HCO3- o Diarrhea, Renal tubular acidosis, Spironolactone, Acetazolamide
IV fluids given to treat DKA
♣ 0.9% normal saline initially
♣ Add dextrose 5% when serum glucose <200 mg/dL
