TRUELEARN Flashcards
Causes of paralytic ileus (4)
opiates, antihistamines, alpha-adrenergic agonists, and anticholinergics.
Trauma patient bleeding out from liver laceration, improved with pringle maneuver. NSM? Assoc complications?
Ligate the hepatic artery
Increased risk for hepatic abscess/biloma
Two types of pleural effusions and causes of each?
Exudative- increased cap permeability. Large prots escape. (neoplasm)
Transudative- poor balance of osmotic/hydrostatic pressure across pleural memebrane (CHF)
Flail segment 24 hours develops increasing tachy,tachypnea, and increasing O2 requirements?
Pulmonary contusions. Supportive care consider intubation
Peripheral axon regeneration growth per day?
1 – 2 mm / day (or about 1 inch per month).
how do you diagnose compartment synd
clinically with classic sxs
MOST EFFECTIVE Tx for CO posioning
Inital tx 100% on NRB mask
BEST tx 100% O2 hyperbaric oxygen chamber
Distal pancreatic body transection. Grade injury? Tx?
grade III pancreatic injury, and is best treated by distal pancreatectomy with or without splenectomy.
Indications for CVL? (5)
administration of total parenteral nutrition solution, chemotherapeutic agents, hypertonic saline (3% saline) and vasopressor medications. Central venous catheters are also indicated when an appropriate peripheral venous catheter could not be placed (dumb ass med residents)
ABSOLUTE Indication for IVC filter placement (3)
- contraindication to anticoagulation,
- recurrent thromboembolic disease despite adequate anticoagulation therapy,
- significant bleeding complications of anticoagulation therapy
Type neck reveals a fracture through the base of the dens, with posterior displacement.
Type II dens
requires fusion vs halo. Others (I, III) nonop
check for airway swelling!!
What happens to HR, BP during preggos
HR increases 10-15 beats
dec SVR -> dec BP 1st and 2nd trimesters
MCC of pevlic fractures
MVC or MCC (50%). MVC vs ped 2nd
HIV + with AIDS MCC of lower GIB
CMV
What incisions are required to repair subclavian artery injury R vs L?
Left:
- Proximal control ant thoracotomy 3ICS
- Distal control subclavicular incis
- Repair artery via supra clavicular incision
Right:
-median sternotomy
How to rapidly reverse coumadin in bleeding patient requiring emergent surgery
PCC plus vitamin K to avoid rebound anticoagulation
%EWL (Excessive Weight Loss) Formula
%EWL = weight loss (kg)/excess weight (kg), with excess weight being the difference between actual weight and ideal weight.
Best conduit for lower extremity vascular injuries needing repair?
Contralateral reverse GSV
Tx traumatic pancreatic duct transection at body/tail
Distal pancreatectomy
TNF a secreted from?
Macrophages (principle mediator of inflammation against gram (-) bac
Part of Gram (-) cell wall initates bacterial response?
Lipid A (endotoxin). A component of the LPS
what type of collagen is found in a scar?
Type I
What do leukotrienes stim macrophages to release?
PAF (platlet aggregating factor)
Trauma patient with arm lac. Hypotensive GCS 7 NSM?
Intubate (ABC)….then tourniquet
Tx for greater than 50% injury to the intestinal wall circumference?
primary resection and anastamosis
Nonop mgmt of spleen in child what constitues failure.
1) Unstable
2) OR Tranfusion requirement equal to half blood volume (40ml/kg)
What element forms free radical ?
IRON Fe++ in ferrous state
what factors (2) are involved in chemotaxsis and cell prolif during inflammatory response?
PDGF and TGF-B from platlets
IAH vs Compartment synd difference?
IAH Pressure >=12
Comp syn >20 & end organ dysfucntion
Sentinel Bleeding s/p trach. First step mgmt?
Flexible bronchoscopy
Platelet count threshold transfuse to limit spon bleeding?
1.0*10^10
tx for postop delirium in elderly
haloperidol low dose
MIVF for pediatric pt
D5 NS w 20 k
Correction rate of hypernatremia kid Na 160
0.5meq/hr 10 mEq
sxs of hypoNa
HA, seizure, AMS
Non gap Metabolic acidosis in surgery pt
High ileostomy output
When to start EPO in CKD
Hbg <10
NOTE: Check Fe stores first!
Mechanism of renal failures in HRS (hepatorenal syndrome)
1) Activation of RAS due to systemic hypotension
2) Activation of Symp nervous system 2/2 systemic hypo an increased intrahepatic sinusoidal pressure
3) Decreased vasopression due to systemic hypotension
4. Reduced heaptic clearance of vascular dilators PGE, endothelian etc
Role of Ferritin
1) Bind and stores Fe (prevents free radicals)
2) Acute phase reactant (ACD)
CI to liver trn? (3)
extraheaptic malig
recent ICH
unfit for operation
MOA of Imuran (azathioprine) and CellCept (mycophenolate)?
Inhibit purine synthesis -> growth of T cell
Painful, swollen, fluctuant FINGERPAD!
Vs Nailbed. Dx?
- Felon finger- I&D
- Nail bed is acute paronychia
Why dont we use IFN type I’s anymore for Hep C etc?
Wide range of immunomodulation. Can induce or uncover autoimmune disorders. Dirty drug
1 yr % survival living donor kidney trn? 5yrs?
97 and 85%
Fight bite pain passive ROM NSM?
Surgical drainage for septic arthritis
1st step in pancreatic exposure?
open the lesser sac (by incising the gastrocolic ligament)
Suspect what organ injury in child hit handles bars or steering wheel to epigastrium?
pancreatic injury
(2) Principles of mgmt of pancreatic injuries
- Identify site of injury relative to neck of pancreas
2. status of pancreatic duct
Incision for distal mediastinal tracheal injury?
Right thoracotomy
Traumatic diapharm injury. Incision and method of repair
1) Midline laparotomy,
2) two alices to central tendon of diaphragm
3) primarily close with non-asorbable suture
Method of repair two small 2mm close tears of aorta
1) Connect tears
2) Primarily repair transervely with polypropalene sutures
Pediatric pt mild hypotension and bradycardia. Fluid choice following initial bolus??
Blood 10 ml/kg
(brady sign of imepending cardiovascular collpase
MCC following pancreatic injury?
Fistula, manage with drains high and low output (<200ml/day)
Treatment for Zone I RP trauma of ANY kind?
Surgical exploration 100% of the time!!
What determines mild TBI?
Base on GCS NOT CT findings
- Mild -> GCS 13-15
- Moderate -> 9-12
- Severe-> 8 or less
stacked rings with linear furrows of esophagus on EGD?
Eosinophillic esophagitis
Sxs: Dysphagia for solids, hx of asthma
Duration of antibioitcs following surgical source control ie diverticulitis?
4-7 days
What does adding epi to local do? (2)
vasoconstriction-> dec vasc absorption -> inc # of molecules to diffuse to nerve memb.
Results in:
1) increased duration
2) inc density of blockade
Best method to confirm ET tube in trachea not esophagus?
ET CO2 Monitor.
Risk of preop hypothermia
Increase risk of infections
Need documented temp >36*C preop
What trn drug causes chorea, confusion
Prograf (tacrolimus)
STSG what is sequence of incorporating?
1)Imbebition
2) Inosculation (growing together Tree branches)
3) Revascularization
Process takes about 7 days
MC pathogen DM foot infection?
Virulence factor?
Staph areus
Collagenase
Indication for OR based on tube thoracostomy output?
1500ml initially or >200ml/hr for four hours
Time to wait after PCI before operating:
1) Angioplasty alone
2) BMS
3) DES
1) 2wks
2) 1 month
3) 6 months
SCIP periop glucose recommendations
NCE SUGAR trial strict control = bad
Keep glucose below 180
32 yo F 24 wks with fever, emesis, acute abdominal pain WBC 15k NSM?
CT abd/ pelvis
3-4 rads
MCC of omental torsion and presentation
Patients appear to have perforation, RLQ pain from tumor, hernia, adhesion or inflammation.
Thx is resection of twisted omentum diagnosed intraop most times
How is omentum hemostatic
Inc amts of TF -> act extrinsic path -> fibrin plug-> adheres omentum in place
Peritoneal catheter infection MC bug?
Staph epi
Coagulate -negative staphylococci
When to start cirrhotic on abx for Primary (spontaneous) bacterial peritonitis? What MC bug?
Aerobic enteric flora (ecology, klebsiella)
Start if high risk (bleeding varies or ascitic proteins fluid low <1g, or T bill greater 2.5
Diag old lady on BT no trauma acute abdominal pain with palpable abdominal mass unchanged with contraction of rectus muscle. Tx?
Rectus sheath hematoma from inferior epigastric artery
Next step CT scan
Manage nonop with serial hbg
Caution!! If below accurate line no aponeurotic post covering to rectus so it can cross midline and cause bilateral lower quad abd pain
Treatment for GIST? Most common location
Stomach> small bowel/rectum
Imatinib versus resection
Determine recurrence/Tx based on size and mitotic index
Normally don’t biopsy
Apthlous ulcers Transmural inflammation including submucosa Longitudinal ulceration Cobblestoning appearance Diag?
Crohns
Why renal pt at increased risk of DVT
CRD increased factor VII and vWF
Nephrotic syndrome dec antithrombin
Operating for SMA ischemia best maneuver to isolate SMA?
Lift omentum and trans colon cephalad
Retract small bowel to right
Divide ligament of trietz and mobilize duodenum right
Shake hands with root of transverse colon mesenteary to find SMA
Common femoral occlusion what artery provides collateral. Flow to leg?
Deep circumflex artery (DCA)
DCA and inf epigastric are two branches off Ext illac artery
DCA runs behind inguinal ligament and anastamoses with lateral femoral circumflex to provide flow to leg
Intermittent abd pain, jaundice and upper GI bleed? Tx?
Hemo bilia Angio
Tx for fibromuscular dysplasia HTN 200s?
Percutaneous tranluminal angioplasty curative
Supparitive thrombophlebitis of PIV site MC. Bug?
Staph aureus remove catheter
Treatment of anal melanoma
WLE equal to APR
MEN2A
AD RET proto oncogene
MTC, Pheo, Hyperparathyroidism
Ppx Thyroidectomy by age 5
Mucinous neoplasm of appendix vs mucinous adenoca?
Nonruptured mucinous neoplasm no further workup or screening. DONE
Right hemi for adenoca
Heparin bolus, maintenance rate goal PTT for ALI
80 units per kg
18””
60-90 sec
Anal cancer tx
Chemo radiation with nitro protocol
5FU, mitomyocin C and radiation (all stages!)
Incidental or six mesenteric cyst tx?
Same enucleation, remove risk of local external compression
What is location of inslinomas
Evenly distributed throughout pancreas
Patchy segments of ulceration, erythema and edema throughout colon? Causes?
Ischemic colitis= affects arterioles of colon
Consider hypercoag. Infectious, embolic, vasculitis drugs is cocaine
Amphotericin B side effects and electrolyte abnormalities
Hypo K, Mg. Liver failure
Linezolid Side effects?
MOA inhibitor do not give with other serotnergic drugs
MOA- DNA synthesis inhibitor
Anti-angiogenic factor induced by hypoxia
Interferons
% Infection risk for contaminated cases?
10-17% ie fecal spillage during colectomy
what is cushings dz? 1st line tx? 2nd?
inc ACTH secreting pituitary adenoma.
Tx:
1 Transphenoidal resection of pituitary 75% success rat. 2. radation
3. bilateral adrenalectomy
Nodular submucosal lymphoid hyperplasia on scope. NSM?
Assoc with Immunsupression check for HIV test
Swimmer with Venous thoracic outlet syndrome. Best initial tx?
IV heparin AND thrombolysis
45 yo F presents to PCP with HTN, HA, diaphoresis palpitations. Urine metanephrines elevated 24 hours. Diagnosis
Danny davito- Pheo
10% extrea adrenal, malignant, bilateral, familial
MCC young female renal HTN. Pathological findings?
FMD- multifocal fibrodysplasia
Thickening of media and collagen formation
Contraindication to clostazol
CHF
Best test to diagnose cushing syndrome
24 hours urine free cortisol
Ways to inc length for total proctocolectomy with ileal anal J pouch if pouch under tension? (3)
1) Mobilize mesentery to D3, pancreas
2) Divide ileum flush with cecum
3) Steplappder relaxing incisions over the front and back of mesenteric vessels along tension lines (ie SMA)
Pt with elevated urine cortisol and elevated ACTH. Next best test to establish diagnosis?
Cushing dz.
High dose dexamethasone suppression test.
If suppressed -> Pituitary adenoma
If NOT suppressed -> Ectopic tumor
Two things to evaluate prior to reversing ostomy?
1) evaluate intraop for other colonic patholgy or malignancy
2) Evaluate intact anal sphincter mechanism contience via
Where should IVC filter be placed?
Inferior vena cava below renal veins
MC gene defect in colorectal cancer
APC (gene involved in FAP)
MC complication after Whipple? Tx?
Delayed gastric emptying
Tx supportive surgery last resort
Definition of oncologic resection of colorectal cancer? (Margins, nodes)
2-5 cm margin
12 nodes negative
Location of gastrinomas vs insulinomas
Gastrinomas- passaros triangle mostly duodenum
Insulinomas- evenly distributed throughout the pancreas
Criteria for metabolic syndrome
Fat + risk factors for stroke, CAD, DM (lower threshold)
Fat-
Males- waist >40
Female >35cm
Risk factors
Glucose >100 fasting or DM
TG>150
HDL <50
Systolic BP >130
Where are gastrin secreting cells primarily located
Antrum- activate parietal cells to secrete H+
D cells- somatostatin also here
Why Pts with ulcer dz get antrectomy
MEN 2A
MTC, pheo, 4 gland parathyroid hyperplasia
How to differentiate btw parathyroid adenoma and carincoma lab values?
Both present with palpable neck mass with sxs of 1* hyperparathroid
Adenoma:
PTH <100 (normal 50)
ca++ 1 meq above normal
Carcinoma
PTH 500s
Ca++ 3-4 above normal (>=13)
Why is previous DVT risk factor for venous insufficiency ?
Secondary valvular incompetence -> venous reflux on US
Parietal vs Visceral periotneum
Different blood supplies
Parietal few nerves pain generalized, covers intraabdominal organs
Visceral covers body wall, lots of pain fibers localized
Name RP structures
SAD PUCKERS
Supradrenal glands
Aorta/IVc
Duodenum (2,3)
Pancreas Ureters Colon (ascending and descending) Kidneys Esophagus Rectum
Cause of direct vs indirect inguinal hernia
Indirect- patent process vaginalis
Direct- weakness in conjoined tendon
Pancoast tumor present with horners. Type of cancer and treatment.
NSLC
Tx:
Chemo followed by surgery
Chemo radiation if unresectable
Absolute c/I to surgery:
1) N2 mediastinal or N3 contralateral supraclavicular node
2) distant Mets
3) invasion to trachea, esophagus.
4) >50% vertebral body involvement
5) Brachial plexus involvement above T1
Hemoptysis recurrent pneumonia and pink/purple friable mass covered by epithelium
Carcinoid- type of neuroendocrine tumor
