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MRCS part B > Surgical and critical care deck > Flashcards

Surgical and critical care deck Flashcards

1
Q

What is the Glasgow scale of pancreatitis

A

PANCREAS
PaO2 <7.9
Age >55
Neutrophils (really WCC) >15
Calcium <2.0
Renal function: urea >16mmol/L
Enzymes: LDH >600 IU/L
Albumin <32 g/L
Sugar >10mmol

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2
Q

What are the causes of pancreatitis

A

I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps/malignancy
Autoimmune disease
Scorpion sting
Hypertriglyceridemia/Hypercalcaemia
ERCP (endoscopic retrograde cholangiopancreatography)
Drugs: commonly azathioprine, thiazides, septrin, tetracyclines

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3
Q

What is the reason for hypocalcaemia in patients with pancreatitis

A

Saponification of fat from the enzymes released. Free fatty acids that are released chelate calcium.

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4
Q

What is the reason for hyperglycemia in patients with pancreatitis?

A

Destruction by enzymes of insulin-producing islet cells

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5
Q

What are the complications of pancreatitis

A

Early: DIC, ARDS and pleural effusions, metabolic, paralytic ileus, renal failure, portal vein thrombus, death

Late: Diabetes and malnutrition

Local: Haemorrhage, pseudocysts, necrosis, ascites

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6
Q

What equation controls acid base balance

A

Henderson hasselbach equation. Largely, carbonic anhydrase acts as a buffer

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7
Q

How is aCO2 carried in the body

A

Dissolved, buffered in water as carbonic anhydrase and attached to proteins (eg haemoglobin)

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8
Q

What is the chloride shift

A

In peripheral tissues, the CO2 enters RBCs and is converted to HCO3 via carbonic anhydrase and then leaves the RBC
In the lungs, the reverse occurs, and HCO3 enters RBC and CL leaves allowing HCO3 to be converted to CO2 and expelled. The ‘chloride shift’ allows for this to happen

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9
Q

What are the causes of respiratory alkalosis

A

Anxiety
Pain
High altitude
Asthma
Salicylate poisoning

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10
Q

What are the causes of respiratory acidosis

A

Flail chest
lung contusion
Pneumonia
ARDS

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11
Q

Metabolic alkalosis

A

Vomiting
Renal loss of H+
Diuretics

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12
Q

Definition of an aneurysm

A

Local dilatation of blood vessels to more than 1.5 times its size

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13
Q

How are aneurysms classified

A

Aetiology: Inflammatory, infective, congenital, tru or false
Site: Thoracic, abdominal, intracranial
Size: giant vs berry
shape: Fusiform, saccular

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14
Q

When would you consider an infrarenal aorta aneurysmal

A

normal diameter is 2cm so anything above 3

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15
Q

When would you consider repair of AAA

A

Above 5.5 or above 4 and has increase in size by >1cm over the past year

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16
Q

Monitoring for AAA

A

Below 3 cm patient can be discharged

3 - 4.4: Monitor annually
4.5 - 5.4: Monitor 3 monthly
>5.5cm should be referred to vascular for repair

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17
Q

What is the mortality with AAA

A

Elective 3-5%
Emergency: 50% mortality rate
50% of ruptured AAA don’t arrive the hospital

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18
Q

What specific complications of EVAR

A

Intraoperatively, there can be a rupture as well as an endoleak
Post op: Infection, MI, renal failure, mesenteric ischemia,

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19
Q

Aortic dissection classification

A

Stanford A for ascending and B for descending
A often requires surgery whereas B can be managed with medical therapy to prevent extension of aneurysm

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20
Q

What are the complications of open AAA repair

A

Immediate: Haemorrhage, distal limb thrombosis and embolisation
Early: Spinal cord ischaemia, acute mesenteric and renal ischemia, MI, CVA
Late: False aneurysm, graft infection, mycotic aneurysms and aorto-duodenal fistulas

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21
Q

FACT

A

In BC, the aerobic bottle goes first and then the anaerobic

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22
Q

6 hours of a painful and cool leg, what are the possible differentials

A

ALI, CLI, arterial dissection, traumatic disruption of blood flow, neurological compromise

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23
Q

What are the classifications of ALI

A

Bascially the muscles should be the last to go and if muscle weakness or paralysis then the limb might need to be amputated

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24
Q

What is reperfusion injury

A

Reperfusion with blood distal to the site of obstruction. It is complex but involves inflammation and the generation of oxygen free radicals

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25
Q

What layers do you go through to make a trachy

A

Skin, sub-cut fat, platysma, investing fascia, strap, pre tracheal fascia, thyroid isthmus, trachea

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26
Q

Define pain

A

It is an unpleasant sensory stimulus to actual or potential tissue damage. A pain receptor is called a nociceptor

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27
Q

What is allodynia

A

Sensation of pain from a normally non painful stimuli

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28
Q

What is neuropathic pain

A

Pain caused by damage to the pain-signalling pathway
It can occur in the form of stinging or burning in diabetes or nerve damage or impingement like in sciatica for example

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28
Q

FACT

A

Patients with a CHADVASC2 score of more than 2 should be offered anticoagulation. Orbit score assess the risk of bleeding whereas CHADVASC2 score assess the risk of stroke

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29
Q

What is the shelf life of packed RBC

A

35 days if stored in a freezer appropriately

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30
Q

Define a massive transfusion

A

Blood volume grater than the patients circulating volume given within 24 hours or >50% of circulating blood volume given in a 4 hour period

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31
Q

What are the possible options for transfusion for jehovas witness

A

Medically correct low iron or folate and or B12, EPO, TXA
IV fluids to increase circulatory volume and maintain CO
Haemostasis and cell salvage in theatre

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32
Q

Explain the medical management of IBD

A

Steroids: USe sparingly
Aminosalicylates: Mainly used in order to maintain remission
Thiopurines: Aza and typically useful for remission as well as maintenance
Methotrexate
Biologic: Infliximab and TNF alpha inhibitors

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33
Q

What is the Charcot triad

A

Jaundice
RUQ pain
Pyrexia

add low BP and tachycardia to this and we have the raynaulds pentad

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34
Q

Explain LFTs

A

ALT and AST are produced by the liver but ALT is more sensitive as AST can be produced in many other places
ALP is produced outside the liver in the bile duct and hence ALP > ALT/AST can indicate a cholestatic picture

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35
Q

Where else is ALP found

A

Pagets disease and pregnancy

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36
Q

Where is GGT located

A

In hepatocytes

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37
Q

How is bilirubin formed

A

RBCs are broked down at the end of their life and haem is converted to bilirubin and bilivirdin.
Bilirubin then conjugates in the liver and is mixed into bile

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38
Q

What is the fate of conjugated bilirubin

A

Is digested by bacteria in the gut to form stercobilinogen which is further oxidised to stercobilin and this gives the faeces their brown colour
Small amount of stercobilinogen is excreted in the urine as urobilinogen which undergoes further oxidization to form urobilin and this gives urine its yellow colour

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39
Q

What are some of the resons for ET tube insertion

A

Burn/inhalation injury
Trauma to the neck
MAX FAX trauma
<GCS
Airway obstruction/ oedema
ITU for ventilation

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40
Q

What are the criteria for non operative management of extradural haematoma

A

<30 cm size
<15mm thick
<5mm midline shift
GCS >8 and without focal neurology

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41
Q

Define the Monroe kelly doctrine

A

the contents of the cranium – which are the brain parenchyma, blood, and cerebrospinal fluid (CSF) – are constant/fixed
An increase in one must mean a reduction in one of the others and vice versa

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42
Q

What is the cushings reflex

A

HTN, Brady and chaine stokes breathing as response to raised ICP due to mixed symp and parasymp responses

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43
Q

What can distort pulse oximeter readings

A

Fake nails
CO poisoning can overestimate it
Poor perfusion
Jaundice will underestimate the true reading

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44
Q

What are the risks of using colloids

A

Anaphylaxis
Reduced platelet agg and dysfunction

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45
Q

At what point do you assess for brainstem arreflexia

A

evidence of irreversible brain injury on scan and clinical presentation
It should only be done when reversible causes of coma and/or apnoea are excluded

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46
Q

What are the criteria for brainstem death

A

Fixed pupils
No corneal, oculovestibular reflexes
No bronchial stimulation cough reflex with suction catheter
No response to supraorbital pressure

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47
Q

How do you perform the apnoea test

A

Adequately pre-oxygenate the patient
Hypoventilates until PCO2 >6 and PaO2 <7.4 on ABG
Disconnect from the ventilator and maintain oxygenation via C circuit of endotracheal tube for 5 mins. Then repeat ABG. If 0.5 kPa more pCO2 then apnoea confirmed

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48
Q

What is the absolute contraindication to organ donation

A

HIV or CJD illness

Organs may not be donated in sepsis, malignancy, dysfunction, extended periods of hypoxia

49
Q

What are some of the causes of pseudohyponatraemia

A

taking blood from the drip am
multiple myeloma

50
Q

What are the signs and symptoms of hyponatraemia

A

Confusion, seizures, headache, reduced GCS

51
Q

What are the stages of hypotension

A
52
Q

What are partial thickness burns

A

Burns that have epidermis and dermal involvement
Superficial dermal when the upper layer of dermis are involved and deep dermal when all of dermis is involved

53
Q

What should you check for in a CXR post CV insertions

A

Pneumothorax
Position of the radio-opaque catheter TIP in the SVC just superior to its insertion into the right atrium

54
Q

What are the layers that you go through to insert a subclavian vein catheter

A

Skin
Subcutaneous fat and fascia
Pec major
subclavius muscle
Subclavian vein

55
Q

What are the guidlines of drainage of a diverticular abscess

A

More than 3 cm requires drainage
It can be perc, lap or open depending on the location and severity of the abscess

56
Q

What is the hinchey classification of diverticular abscess

A

0 - mild with no abscess
1 - Pericolic inflammation or abscess formation
2 - pelvic, distal intra abdo or retroperitoneal
3 - purulent peritonitis
4 - faecal peritonitis

1 and 2 can be managed conservatively or drained perc
3 and 4 need emergency surgery

57
Q

What are the key characteristics of ARDS

A

Bilateral pulmonary infiltrates on chest radiograph

58
Q

What is the prognosis of ARDS

A

normally 30-60% and with sepsis it can be as high as 90%

59
Q

How would you deal with a blocked CVP line

A

Assess the patient and line and check for any bends or kinks
Re-check the procedural note as well as the XR
Ask the patient to cough as this changes IT pressure
urokinase?

60
Q

What is DIC

A

It is a form of pathological consumptive coagulopathy. Prolonged PT and APTT with thrombocytopenia, low fibrinogen and anaemia. Causes the clotting cascade to aggressively activate and can then lead to blood loss

61
Q

What is the most common cervical vertebrae to be injured

A

C5

62
Q

What is the difference between a spinal shock and a neurogenic shock

A

Neurogenic shock is a disruption of sympathetic outflow that causes hypotension and bradycardia

Spinal shock is causes flaccid paralysis, areflexia and parasthesia associated with spinal cord injury

63
Q

What is a hangman fracture

A

Fracture of both pedicle of cervical vertebrae. CT angio should be done as well in this case to check for vertebral artery injury

64
Q

Bulbocavernous reflex

A

Feeling internal and external anal sphincter function by tugging on a foley catheter as well as pressing on the glans of the penis in a male or the clitoris in a female

65
Q

What is autonomic dysreflexia

A

Injury at the level of T6
Below it there is sympathetic stimulation that leads to vasoconstriction and hypertension
Above is parasympathetic that leads to vasodilation and hypotension
This can cause CVA, arrhythmia, cardiac arrest and respiratory arrest

66
Q

What is myoglobin

A

It is the oxygen-binding protein that is found in muscles. It is released during rhabdomyolysis

A higher proportion of myoglobin means that muscles can continue to function without O2 for longer. This becomes especially important in deep sea diving creatures that have to operate at low PaO2 atm

67
Q

How would you identify a hypovolaemic patient

A

Pale, clammy, cool peripheries, Sinus tachycardia and tachypnoea
Dry mucous membranes
<2s cap refill time

68
Q

Spinal vs epidural

A

Epidural is only for certain segments eg: inserted at t3 would have an effect on T4 and T5 nerve roots
Spinal will block everything below the level it has inserted

69
Q

What are the risks of a high thoracic block

A

Blocks sympathetic stimulus to the heart
Dermatomes and myotomes of that region affected
Affects intercostal muscles and hence can affect respiration

70
Q

What are some of the signs of local anaesthetic toxicity

A

Hypertension and tachy early and then hypotension, arrhythmia and arrest

Seizures
Peri-oral numbness or tingling
Fasciculations and tremors

71
Q

What is capacitance

A

It is the ability to hold charge

72
Q

What are the different fistula types based on output

A

Low <200mls per day
Medium 200-500mls per day
High <500mls per day

73
Q

How much should a normal adult urinate per day

A

0.5mls/kg/hr

74
Q

IV fluids as maintenance

A

25–30 ml/kg/day + any losses from stoma or fistula

75
Q

When would you consider renal replacement therapy

A

Anuria/ oliguria
Hyperkalaemia
Severe acidosis
Fluid overload
Uremic complications
Drug overdose
Temperature control

76
Q

What type of immunosuppressant drugs are there

A

Glucocorticosteroids
Alkylating agents like cyclophosphamide
Methotrexate, aza and tacro ciclo are all antimetabolites

Biologics

77
Q

What is bloods tested for normally before a transfusion

A

Hep B and C
HIV
Syphilis
Human T lymphotropic virus (first time donors only)

78
Q

How long can you store blood products and at what temperatures

A

RBC/ 35 days/ 2-6C
Plt/ 5 days/ 20-24C
FFP and cryo/ 1 year/ -30c

79
Q

What are the contents of FFP

A

Albumin, all clotting factors, complement, vWF and fibrinogen

80
Q

What are the contents of cryoprecipitate

A

Factor 8, 13, fibrinogen and vWF

81
Q

What is the definition of hypothermia

A

Core body temp less than 36 degrees

82
Q

What is a J wave and when does it happen

A

It happens in hypothermia and is also known as the Osbourne wave. It is a pathological upward deflection between the QRS complex and T wave

83
Q

What are the complications of hypothermia

A

Reduction in CO and increase in Hb affinity to O2 leading to decreased tissue perfusion
Decreased drug metabolism
Reduced clotting function and hence increase bleeding

84
Q

What are the NICE guidelines for perioperative hypothermia

A

Bear hugger and warm IVI and irrigation
Patient should not leave recovery unless temp is above 36C

85
Q

What is normal body water distribution

A

1/3rd is extracellular and 2/3rd is intracellular
Out of the 1/3rd extracellular, 25% is intravascular and 75% is interstitial

This is hence 5% of the total body water that is intravascular or 250mls

86
Q

How will 1L of crystalloid be distributed in the body

A

25% intravascular and 75% interstitial
This is contrary to blood, that remains intravascular

87
Q

Why is 5% dextrose not used for resus

A

Rapidly lost from the extravascular compartment as glucose is taken up by the cells
2/3rd goes into the intracellular space and 1/3rd goes into the extracellular space.
Of the extracellular, only 25% stays intravascular

88
Q

How does a septic shock differ from a hypovolaemic shock

A

Septic shock has warm peripheries and it is in the presence of an infection, potentially +vs BC with a raised lactate and WBC CRP.

89
Q

How do aspirin and clopidogrel work

A

Both are anti-platelet agents and prevent platelet aggregation
Both roughly last 8 days as this is the lifespan of a platelet
Aspirin - irreversible COX 1 and 2 inhibition
Clopi: Reduces platelet aggregation through irreversible inhibition of receptor for ADP on cell membranes

90
Q

What is respiratory failure

A

The inability of the body to maintain adequate arterial oxygenation. Typically PaO2 less than 8

91
Q

What is the formula for ventilation

A

Tidal volume x resp rate

92
Q

What is the minute ventilation for a 70kg man

A

Normal tidal volume is 7ml per kg
Hence
Ventilation = TV x RR = 500ml x 12 = 6L/min

93
Q

When should patients be weaned off a ventilator

A

When the initial injury has subsided
Adequate gas exchange
Adequate respiratory drive and power

94
Q

What is the classification used for pelvic fractures

A

Young and burgess
1) Anterior - posterior compression
2) Lateral compression
3) Vertical sheer - associated with falling from a height

95
Q

At what level should a pelvic binder be applied

A

At the level of the greater trochanters

96
Q

What are the options for pelvic haemorrhage

A

Activate MHP
Pelvic binding
IR and embo
Peritoneal packing

Urgent vascular opinion if very large vessel

97
Q

What is the lethal triad in trauma

A

Hypothermia, acidosis and coagulopathy

98
Q

What are the features of TURP syndromes

A

Confusion, hypotension, restlessness, blurred vision
The use of glycerine rich hypotonic solution causes it. This can cause severe dilutional hyponatraemia

99
Q

How does hyponatraemia cause confusion

A

By causing cerebral oedema

100
Q

How would you manage TURP syndrome

A

Keep operating time low of less than 1 hour
Change irrigation fluid to NACL
Management of hypotension
Ask anaesthetics to consider intubation
ICU or HDU

101
Q

What is the metabolic response to injury

A

Ebb phase where there is reduced CO and metabolic rate with hypothermia

Flow phase which is made up of catabolic and anabolic phases

102
Q

What is the resp quotient

A

It is the ratio of CO2 excretion to O2 consumption.
RQ of carbs is 1
Protein is 0.9 and Fat is 0.7

103
Q

What is the difference between NJ and NG tubes

A

NJ are longer and narrower and are more prone to kinking
NJ bypasses the stomach and hence there is a reduced risk of aspiration
NJ is placed under endoscopic/fluoroscopic guidance leading to a delay in feeding

104
Q

Why is NJ preferred in pancreatitis

A

As it bypasses the duodeno-jejunal flexure. Food passing through this region can cause a release of cholecystokinin which exacerbates the inflammatory process

105
Q

How is tolerance to feeding monitored

A

Absorption and SE such as NVD and aspiration of feed
Blood test can also be helpful

106
Q

How would you improve poor tolerance to feeding

A

NJ, check position, dietitian input, monitor bloods

107
Q

What are some of the complication of burns

A

Fluid shift and hypothermia
Inhalation injury
Renal failure
ARDS
DIC

108
Q

What is the definition of ARDS

A

Diffuse form of lung injury associated with reduced lung compliance, marked pulmonary infiltration and hypoxaemia

109
Q

What is the difference between spinal shock and neurogenic shock

A

In spinal shock, there is total and complete loss of power, sensation and reflexes below the level of the injury

Neurogenic shock is a sudden loss in the sympathetic nervous system response

110
Q

What are the contraindications for a urinary foley catheter placement

A

Pelvic fracture
Urethral and penile trauma

111
Q

Primary vs secondary brain injury

A

Primary is at the time of injury and secondary is after such as hypoxia, hypotension, raised ISCP

112
Q

What are the vitals for children

A

Systolic BP = 90 + (age x 2)
Diastolic BP 2/3 systolic BP
Lowest systolic BP = 70 + (agex2)

113
Q

WHat is the initial resuscitation formula for children

A

20ml/kg of initial crystalloid

114
Q

What diuretic to use in TURP syndrome

A

Mannitol

115
Q

Cause of death in liver cirrhosis

A

Varicies

116
Q

Why is vascular surgery more pro-coagulant

A

Because there is more endothelial injury and all fibrinolysis is temporarily shut down

117
Q

What is the definition of massive blood loss

A

Entire blood volume in about 24 hours
>50% blood volume loss in 3 hours
>150ml/min

118
Q

Why does warfarin need to be bridged

A

In the acute period, it can cause a more coagulable state by inactivation of protein C.

119
Q

What is the difference between UFH and LMWH

A

LMWH is sorter chain and only works on Factor 10 and is more predictable
UFH is a longer chain and works on factor 2 and 10 and hence is more unpredictable
UFH requires aptt monitoring and LMWH requires no monitoring

120
Q

What are the types of surgical haemorrhage

A

Primary: Bleeding occurs in the surgery
Refractionary: 24 hours bleeding due to slipping of staple for eg
Secondary: In 2 weeks time due to sloughing of vessel for example

121
Q
A

MRCS part B (10 decks)

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