UWORLD pearls Flashcards
Who gets an abdominal ultrasound for screening for AAA?
Men 65-75 w/ h/o smoking
Intermittent claudication next step?
ABI
</= 0.90 is diagnostic of occlusive PAD in symptomatic patients
Trauma guy who has an elevated pulmonary capillary wedge pressure after fluids (14–22!)?
Myocardial contusion
Knee total replacement then has infection 6 months later
Staph epidermidis
If it were more acute, more likely staph aureus
First diagnostic test for upper vs. lower GI bleed?
Fluids…and
NG suction gives bilious fluid, but NO BLOOD= lower GI
Then you do colonscopy to look for source.
If that’s negative, labeled erythrocyte scintiscan
Patient with an acute spinal cord injury needs what after ABCs and spine immobilization?
Bladder cath!
“Pt has abdominal pain”
Crohn’s patient gets a kidney stone…why?
Increased absorption of oxalate.
Terminal ileum not absorbing fatty acids like they normally do. So unabsorbed fatty acids reach colon, combine with calcium, then free oxalate is absorbed.
Too much oxalate in body, so kidney tries to pee it out and when it gets there it binds up Ca–> calcium oxalate stones
Acalculous cholecystitis?
Severely ill ICU patients with severe trauma, burns sepsis, or prolonged TPN
Dx: Gallbladder wall thickening and distention in the presence of pericholecystic fluid
Rx: Abx + percutaneous cholecystostomy…then cholecystectomy when condition stabilizes
Diverticulosis vs. diverticulitis sx?
Osis has PAINLESS (usually) bleeding
-itis has abdominal pain, fever but usually no bleeding
Classic presentation for acute epidural hematoma?
UNCONSCIOUSNESS–>lucid interval–>n/v/ha/seizure/deterioration of consciousness
Contained aortic rupture
Widened mediastinum + L-sided hemothorax
Colonic ischemia facts?
- After AAA repair, iliac repair
- CT scan- thickening of bowel wall
- Colonoscopy- cyanotic mucosa with hemorrhagic ulcerations
Distal L colon MC affected
IMA is usually ligated during the AAA repair. If bowel ischemia is discovered DURING the procedure, the IMA should be reimplanted into the graft to restore flow.
(This ischemia often from poor collateral flow)
Breast lesion causing intermittent bloody unilateral nipple discharge?
Intraductal papilloma
1cm
Trauma patient with hypotension/tachycardia but normal hemoglobin?
HGB READING DOES NOT HELP YOU… it doesn’t exclude internal hemorrhage
For appendiceal abcess what do you do?
If they’re CLINICALLY STABLE
- IV ABX
- Bowel rest
- Maybe percutaneous drainage
- Appendectomy 6-8wks LATER to let inflammation calm down
Posterior shoulder dislocation how they hold arm? Rx?
Adducted and internally rotated. Won’t move outwards.
-Closed reduction (in OR or ED)
WHAT ACTUALLY HAPPENS WITH ATELECTASIS?
The V/Q mismatch leads to hypoxemia.
WOB increased so patient hyperventilates
pH higher (7.5), PO2 too low, pCO2 low (breathing it off)
HAPPENS FROM THE 2ND-5TH DAYS POST-OP…not that mnemonic
Especially common after ABDOMINAL surgeries
Guy being treated for furuncles with a psoas sign?
Psoas abcess from hematogenous spread or contiguous spread of bacteria.
GET CT SCAN TO CONFIRM
Lumbar burst fracture with neuro deficits. Best way to diagnose extent of damage?
MRI
WHAT ACTUALLY HAPPENS WITH ATELECTASIS?
The V/Q mismatch leads to hypoxemia.
WOB increased so patient hyperventilates
pH higher (7.5), PO2 too low, pCO2 low (breathing it off)
HAPPENS FROM THE 2ND-5TH DAYS POST-OP…not that mnemonic
Especially common after ABDOMINAL surgeries
What is the FIRST indicator of hypovolemia?
Tachycardida! Pulse rate increases.
Don’t be fooled by the patient with distended neck veins and refractory hypotension but a NORMAL cardiac silhouette and small pleural effusion
IT’S PERICARDIAL TAMPONADE
Only 100-200mL needed to cause sx, bc it’s acute (no time for remodeling) and a small bag
Which patients DO have an enlarged cardiac silhouette?
Patients with CHRONIC processes (eg. cancer or renal failure)… pericardial fluid slowly accumulates and gradually increases intrapericardial pressure so LIKE 1-2 L OF FLUID CAN ACCUMULATE…THAT’S HUGE
Intrinsic renal disease test/finding?
FeNa > 1
Mech of lowering ICP by hyperventilation?
It induces vasoconstriction
Nerve that does knee extension and hip flexion
Femoral.
It does the anterior compartment of the thigh.
Nerve that does the medial compartment of thigh?
Obturator nerve
Which side is diaphragmatic rupture more common and why? What should you look for?
Left side because the R is protected by the liver
Look for the NG tube twisted coming up into the R lung space
You placed a central venous catheter. Next step?
CHEST X-RAY to verify placement.
Complications include arterial puncture, mycardial perforation, pneumothorax/hemothorax
Normal WBC count in patient who obviously has appendicits?
It can be normal. Next step is laparoscopic appendectomy.
Supracondylar fracture of humerus from FOOSH MC complication?
Entrapment of the brachial artery or median nerve.
Small amount of cloudy fluid present in the wound drain. EKG shows afib with RVR and widening of the mediastinum.
Acute mediastinits
Rx: Drain it, surgical debridement and abx
Doppler u/s confirms first time DVT. What next?
Start heparin, bridge to warfarin rx for at least 3 months (INR goal 2-3)
Meniscal tears signs?
A POPPING SENSATION. Swelling is GRADUAL.
Ligament injuries have RAPID SWELLING from hemarthrosis.
What is torsus palatinus?
Benign bony growth (exostosis) located on the midline suture of the hard palate. CONGENITAL.
Why are burn patients at high risk for respiratory compromise?
Their supraglottic airway exchanges heat really well so it’s susceptible to thermal injury and acute obstruction from edema that follows.
Guy with diverticulitis comes in, gets abx, comes back bc of persistent abdominal pain. CT shows 5cm perisigmoid fluid collection…
It’s an abscess
3cm needs CT-GUIDED PERCUTANEOUS DRAINAGE
Guy has complicated GERD. Biopsies show irregular ulceration of squamocolumnar junction. 4 hours later gets tachycardic/tachypneic and CXR shows small L pleural effusion that wasn’t on CXR from 2 wks ago
Iatrogenic esophageal rupture
Order a water-soluble contrast esophagram (preferred over barium bc it causes less pleural irritation)
Next: need to repair the esophagus (primary closure) and DRAIN the mediastinum WITHIN 6 HOURS to prevent mediastinitis
Lady rescued from burning building has seizure en route to hospital, normal breath sounds, pulse ox 96%, scattered end-expiratory wheezes and slight confusion. Best initial rx?
OXYGEN…
Pulse ox can be NORMAL with CO poisoning bc it can’t differentiate from carboxyhemoglobin and Hgb
Cholecystitis in the hospital. Stable. Next step?
Cholecystectomy within 72 hrs
Major trauma. Abdominal CT reveals no abnormalities. Patient sent home then returns a week later with fever/chills, poor appetite, deep abdominal pain
Pancreatic laceration
Not necessarily detected on early CT scan.
SHOULD DO SERIAL CT SCANS to detect evolution.
CT: Gland enlargement, parenchymal destruction, peripancreatic fluid collections, areas of dec contrast uptake ie. dec perfusion
Newborn with hydrocele?
Reassurance observation. Most resolve spontaneously by 1 year old.
Warfarin made INR too high. Rx?
FFP
VITAMIN K IS TOO SLOW FOR EMERGENCIES. Liver needs to synthesize NEW clotting factors with it!
Causes of arterial occlusion in the lower extremity?
Embolus/thrombus/trauma
Afib–>embolus–> SUDDEN onset of the P’s
The rule about CT scans?
ONLY IN STABLE PATIENT.
If AAA ruptured and patient is bleeding out SKIP IT and do bedside u/s.
Old man got a hip fracture. What next?
Needs definitive surgical correction but needs surgical clearance first…and also needs to find out WHY it happened (palpitations, dyspnea may be afib or PNA)
Scaphoid fracture that shows “radiolucent line across the waist of the scaphoid bone”
This is a NONDISPLACED scaphoid fracture.
Displacement has a gap between broken bone
Paralytic ileus happens after abdominal surgery obvi. What else?
Vertebral fracture from trauma–> retroperitoneal hemorrhage
Rx: Bowel rest, supportive care, treat cause
Who gets duodenal hematomas?
Usually kids. Direct BAT.
Blood collects in submucosal/mucosal layers of the duodenum causing obstruction.
EPIGASTRIC PAIN/VOMITING.
MOST RESOLVE SPON IN 1-2 WKS SO RX: NG SUCTION, PARENTERAL NUTRITION
Pulsatile mass in R groin causing anterior thigh pain?
Femoral artery aneurysm
Popliteal #1 and femoral artery #2 aneurysms MC peripheral artery aneurysms
OFTEN A/W AAA
Femur fracture that makes you think fat embolism. Signs?
Respiratory distress, mental status changes, petechiae
AFTER LATENT PERIOD 12-72 HOURS
Hint that it’s pulmonary contusion?
Unrestrained driver, bilateral chest pain, pO2 gets LOWER WITH FLUID ADMIN
Nml pulmonary capillary wedge pressure?
2-15
Hints that it’s medial meniscus injury?
Popping sound at time of injury
McMurray’s sign- palpable or audible snap while slowly extending leg at knee while applying tibial torsion
Trauma patient is semi-ok. BP 70/30 pulse 100. Bruises over anterior chest/upper abdomen. Pulmonary capillary wedge pressure is 14 then goes up to 22 with rapid infusion of 1L NS, but BP is 75/30 still.
Myocardial contusion. L ventricle not pumping well so hypotension and elevated intracardiac filling pressures.
Urgent Echo.
Prosthetic joint infection >3 months out? What do you do?
Coagulase negative Staph (epidermidis), propionibacterium, enterococci
Implant removal/exchange :(
Prosthetic join infection
Staph aureus, GNRs (E. coli), anaerobes
For this you COULD maybe leave it in if you debride it well.
Parotid neoplasm most likely to cause…
Facial droop.
Facial nerve courses directly through the parotid gland.
Bilateral lower extremity edema and stasis dermatitis caused by
Venous hypertension.
Venous blood pools, postcapillary venule pressures are high
WATCH OUT FOR MEDIASTINAL DEVIATION
You confuse this with tracheal deviation.
Mediastinal deviation is aortic injury
Thing you see with 7% of surgical repairs of AAA?
Ischemic colitis
CT scan shows thickening of the bowel wall
Can you palpate an intraductal papilloma?
No! It’s up to 2mm! Tiny!
Just see unilateral bloody nipple discharge
When do you suspect blunt aortic injury?
MVAs and falls from >10 ft
Who gets dumping syndrome? Rx?
Partial gastrectomy patients
Rapid emptying of hypertonic gastric content into duodenum (not chewed on by stomach very well)–>fluid shifts into the SI
Initial rx: DIETARY MOD
Later rx: Octreotide
Intractable: Reconstructive surgery
Free intraperitoneal fluid in the context of BAT, anemia, and low BP
Splenic laceration
Succussion splash
Sloshing sound that represents gas and fluid in an obstructed organ
GASTRIC OUTLET OBSTRUCTION
Dude who swallowed acid 3 months ago for suicide attempt
Bringing arms down in adduction. Arm drops rapidly at midpoint of descent
Rotator cuff tear
Popeye sign/weakness with supination
Rupture of tendon of long head of biceps
Popeye is when biceps muscle belly becomes more prominent in the mid upper arm
Suspected psoas abscess next step
CT scan
It happens from osteomyelitis or another abscess –> hematogenous spread
Burst fracture
Anterior cord syndrome
Proprioception normal
Guy comes in with totally a kidney stone…
Do an abdominal u/s when the suspicion is very high and in pregnant patients
Ugh. NOT CT of abdomen/pelvis.
Atelectasis and acute pulmonary embolism can have VERY SIMILAR ABGs
High pH, Low Po2, Low PCO2
Pulm embolism also has DECREASED PULM VASCULAR MARKINGS ON CXR
Easy way to inc FRC in post-op patient?
Elevate HOB. Lets diaphragm hang down by gravity and lung expands better.
Weird thing that can happen with AAA rupture?
Aorto-caval fistula (rare)
Aneurysm erodes into IVC, causes high output cardiac failure, renal insufficiency…
Gross hematuria from venous conjestion in retroperitoneal structures
Damage to what in direct blow of abdomen/PELVIS causes Kehr sign?
Bladder dome b/c it’s the only region covered by peritoneum and therefore is the only injury that would permit leakage of urine into peritoneum
Guy reaching really high to catch a basketball causes
Axillary nerve damage
Can cause paralysis of deltoid and teres minor muscles, and loss of sensation in lateral upper arm
Intraperitoneal free fluid detection
That’s the FAST exam duh
Problem with PEEPing a trauma patient?
Need to make sure they’re volume rescuscitated!! PEEP will decrease venous return to the heart and CAUSE CIRCULATORY COLLAPSE if the volume isn’t replaced first!
What is etomidate? Who shouldn’t get it?
Short acting anesthetic for induction/sedation
Bad for ppl with HPA suppression from exogenous cortisol bc it can cause acute adrenal crisis
How long do you have to take steroids to have HPA suppression?
> 3 weeks of 20mg
How long do you have to take steroids to have HPA suppression?
> 3 weeks of 20mg
What is Ludwig angina? How do you get it?
Rapidly progressive bilateral cellulitis of the submandibular/sublingual spaces
Infected 2nd or 3rd mandibular molar (Strep and anaerobes)
MC complication of supracondylar fractures of the femur?
Entrapment of brachial artery or median nerve
Guy go got CABG develops worsening retrosternal pain on POD3 despite continuous analgesia; small amt of pericardial fluid and widening of the mediastinum, elevated WBC count
Acute mediastinitis from the median sternotomy
Pts present w/in 14 post-op days w/ chest pain, leukocytosis, and purulent discharge
Surgical debridement w/ immediate closure, prolonged abx
Shallow inhalations, dec breath sounds at lung bases, RR 22, low pO2 and pCO2, temp 98
Atelectasis- surgery pain causing shallow breathing/impaired cough…mucus plugging in small airways.
Hypoxia stims RR–> low CO2
LOOK AT THE TEMPERATURE, THIS IS NOT PNA. NO RHONCI OR CRACKLES IN THIS PT EITHER, JUST DEC BREATH SOUNDS
First DVT
Heparin then transition to warfarin for at least 3 months
When is it safe for a patient to start anticoagulation after surgery ?
48-72 hours (ie. someone who has had a DVT or other clot; have to be hemodynamically stable)
What factors contribute to post-op ileus?
Increased sympathetic tone of the splanchnics after violating the peritoneum
Local release of inflammatory mediators
OPIATE ANALGESICS
Guy with BAT and blunt chest wall trauma who has fracture of 8th rib, vesicular breath sounds, but BP only semi-responds to fluids. What are you worried about? How do you diagnose?
Intra-abdominal injury…SPLEEN, which appears hours later
GET AN ABDOMINAL CT WITH CONTRAST
Vesicular breath sounds are NORMAL (there’s bronchial and vesicular)
Person on mechanical ventilation for a few days.
“Ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. Why?”
This is the RESPIRATORY QUOTIENT and it’s >0.8 when the person is having too much dietary carbohydrate; inc their fats
*This is especially important in patients with preexisting lung disease
Guy gets a CABG. 5 hours after the procedure his BP drops, no CP, no n/v/abdominal pain. Flat neck veins. Fluids barely help. What’s going on?
Retroperitoneal hematoma from bleeding from the ARTERIAL access site (eg. femoral)
Dx: NON-CONTRAST CT OF ABDOMEN/PELVIS,
or abdominal u/s
Is low mag or low calcium the cause of tetany in this patient?
Low mag causes tetany but on the heart it has effects of HIGH calcium.
So you can look at EKG:
Hypocalcemia has prolonged QT, T wave inversion, heart blocks)
Hypermagnesima has prolonged QT, PR intervals; ST depression, torsades)
Correct the calcium:
Corrected calcium = Ca + 0.8 (4.0 - serum albumin), where 4.0 represents the average albumin level in g/dL.
MAG DEFICIENCY COMMON IN PATIENTS WITH LARGE GI LOSSES
Small bowel operation preop abx?
Single parenteral dose of antibiotic against aerobes/anaerobes
Guy with PVD, DM, htn needs hernia surgery. What needs to happen first?
PHARMACOLOGIC cardiac stress test and Echo
…exercise stress test not good bc he has symptomatic PVD
They ask you to analyze a guy’s acid base abnormality. He has an NG tube…
Metabolic alkalosis… it’s sucking the acid out of the stomach
HIT rx?
Stop heparin, start direct thrombin inhibitor (lepirudin or argatroban)…then convert to oral warfarin when appropriate
Guy with MI gets abdominal pain and generalized abd tenderness. Next step
Angiography. He probably has mesenteric ischemia. Skip the CT or whatever to ID the bleeder.
Then laparotomy
Sepsis
SIRS+source
Septic shock
SIRS + source + organ dysfunction + HYPOTENSION
Severe sepsis
SIRS + source + organ dysfunction or hypoperfusion
If someone needs a massive transfusion, what else happens that you need to address?
Dilutional thrombocytopenia and deficiencies in factors V and VII.
GIVE FFP AND PLATELETS EARLY TO DEC MORTALITY!
FFP contains the labile as well as stable components of the coagulation, fibrinolytic and complement systems; the proteins that maintain oncotic pressure and modulate immunity; and other proteins that have diverse activities.
Jejunostomy when to start feeds?
Can start 24 hours later.
For colostomy it usually takes 3-4 days for colon to get working.
Starting TPN in a severely malnourished patient?
Slowly! Refeeding syndrome risk so replete magnesium, potassium, phosphate levels
Hemophilia A mild vs. severe treatment?
DDAVP
Add aminocaproic acid in severe (this is an inhibitor of fibrinolysis)
Cryprecipitate also works
Cryoprecipitate is a source of fibrinogen. Fibrinogen is vital to blood clotting. It is usually used in the treatment of patients with reduced levels of, or poorly functioning, fibrinogen with clinical bleeding, an invasive procedure or trauma.
Stop NSAIDs
3-4 days before surgery for platelets to come back
Jehovah’s witness is bleeding out…
Give NS or lactated ringers in a ratio of 3:1 (of blood lost)
LR is better bc NS has a lot of chloride and can cause a non-anion gap metabolic acidosis
SODIUM BICARB EXCHANGER (BICARB EXCRETED)
Fluids for 60 kg guy who has an NG tube and just had surgery?
D5 1/2 NS at a rate of
4x10=40
2x10=20
1x40=40
100mL/hr
High output ileostomy electrolyte depletions?
Loss of bicarb, Na, K.
Non-anion gap metabolic acidosis
GIVING NORMAL SALINE AND KCL WILL EXACERBATE THE ACIDOSIS
REPLACE FLUIDS AND GIVE STOOL BULKING AGENT
Stress factor (what you multiply daily calories by) in different conditions
Starvation- 50% body 2x
Person with tracheostomy tube develops lots of bleeding at site. Next step:
Tracheo-inominate artery fistula!
Bleeding stopped: fiberoptic bronchoscopy
Still bleeding: inflate baloon cuff on trach to compress the artery
When is it ok to attempt extubation?
Rapid shallow breathing index (RR:TV) between 60-105
Make sure PEEP is less than 5cmH2o
Minute ventilation (TV x RR)
Rx during hemolytic transfusion rxn?
STOP IT IMMEDIATELY
Give mannitol (diuresis keeps the Hgb from precipitating in the renal tubules)
Sodium bicarb- alkalinze the urine bc the Hgb precipitation is INHIBITED IN AN ALKALINE ENVIRONMENT (ACID PROMOTES)
FLUIDS (unless there’s severe oliguria…then it’s too late, AKI happened and now you need to fluid restrict)
ARDS diagnosing with clinical values?
Bilateral pulm infiltrates on CXR (duh)
PaO2/FiO2
Low pO2, high PCO2 in an agitated patient w/ hematemesis. How to treat?
Intubate them.
They’re retaining too much CO2 and not oxygenating well. Intubation corrects both.
Rx for TRALI?
It’s NOT from volume overload so DON’T DIURESE them!
Stop the transfusion, give supportive respiratory care like mechanical ventilation if needed
Indicators of heart not pumping well? Rx?
Low cardiac output (normal is ~5)
High PCWP
DOBUTAMINE IS INOTROPIC AGENT OF CHOICE IN CARDIOGENIC SHOCK!
Cardiac index?
=CO/BSA
So CI= (SV x HR)/ BSA
Physiologic parameters of septic shock
Increased CO, decrease in PVR, relatively normal central pressures
“Fam hx of prolonged paralysis during general anesthesia”
Should NOT get succinylcholine or mivacurium bc they probably have a pseudocholinesterase defiency
(Malignant hyperthermia is DIFFERENT it’s a mutn in the ryanodine receptor for calcium)
Lab values with alveolar hypoventilation?
pH too low bc of pCO2 increase (poor gas exchange)
pO2 also low
Weird thing associated with cholesterol atheroembolization? (ie. guy just had angiography study)
Eosinophilia
Elevated ESR, microscopic hematuria, proteinuria
Vasopressor for septic shock?
Norepinephrine or dopamine
Person getting an anesthetic develops dilated loops of bowel on xray. What was it?
Nitrous oxide.
Air trapping of it.
Hypotensive shortly after induction. What was drug?
Morphine
Bleeding time?
Assesses platelets + formation of platelet plug
Thrombin time?
Fibrinogen qualitative abnormalities and inhibitors of fibrin polymerization
Margins for
1cm
Rx for pyoderma granulosum of Crohn’s?
SYSTEMIC steroids + immunosuppressants (eg. cyclosporine)
Rx of frostbite?
Immersion in water up to 111 degrees. Elevate to minimize edema, abx and tetanus shot, debride necrotic skin
Silver nitrate for burns. Side effects?
Silver sulfadiazine side effect?
Mafenide acetate side effect?
Hyponatremia, hypokalemia, hypocalcemia, hypochloremia, methemoglobinemia
Neutropenia
Metabolic acidosis 2/2 inhibition of carbonic anhydrase
Secondary intention
Leave wound open and it reapproximates on its own
Margins for 1-4mm melanoma?
2cm, AND SENTINEL LYMPH NODE BIOPSY
If it’s positive THEN you do lymph node dissection
Burn that didn’t require skin grafting when AA lady was a kid. There was a growth there subsequently and it was removed. Then it grew back- shaded purple with smooth top. What is it?
KELOID
Dirty wound presents after 6 hours. Rx?
Local wound care but leave it OPEN. NO prophylactic abx, weirdly.
50% BSA burn in an 80kg man. At what rate should LR be given in first 8 hours?
4 x 80 x 50%= 16000
16000/2= 8000
8000/8hrs= 1000mL/hr
How long do you have to save limb function in severe ischemia
6-8 hours
Exploratory laparoscopy AKA diagnostic laparoscopy
Hemodynamically stable blunt/penetrating injuries with suspected intra-abdominal injuries
The main advantage of diagnostic laparoscopy over traditional open laparotomy is reduced morbidity, decreased postoperative pain, and a shortened length of hospital stay
Acute injury/trauma. What happens to metabolism?
Immediate relase of catecholamines causes transient drop in insulin but then INSULIN INC SIGNIFICANTLY. Overall result is also hyperglycemia (there’s peripheral insulin resistance too)
Thyroid hormones REMAIN CONSTANT though.
Trauma patient with a duodenal obstruction with no other injuries. “Coiled spring appearance of the 2nd and 3rd parts of the duodenum” Rx?
Duodenal hematoma
NG tube and observe.
She’s not getting a laparotomy bc we already ruled out any other injuries.
If she HAD other injuries and was getting an exlap, evacuate the hematoma to r/o perforation or injury to the head of the pancreas
Tachycardic patient with increasing ICP. Best next step…
Hyperventilation NOT HOB elevation! Why? Because they haven’t been volume resuscitated yet and this can worsen their cerebral hypotension
Knee dislocation but palpable pedal pulses in motorcycle accident next step?
Measure ABI…
IF
Kid gets kicked in the kidney. Peri-renal hematoma. Next step?
Strict bed rest for 1-3 days with serial hemoglobins
He’s stable so he may not need surgery
Enterocutaneous fistula
Happens from trauma and surgical repair. Womp.
Proximal small bowel fistulas are usually HIGHER OUTPUT than more distal ones in the ileum or colon.
GIVE TPN and hope for SPONTANEOUS closure of the fistula
If that fails you need surgery
In what case would you actually surgically repair an EXTRAperitoneal bladder leak?
If you’re doing internal fixation of the pelvis, bc you don’t want it to infect the hardware
How do you use u/s and DPL results
To decide about ex-laparotomy in an unstable patient.
RBC >100,000/ul
WBC > 500/ul
Elevated amylase, bilirubin, or alk-phos
Neurogenic shock pt vs. hypovolemic shock pt?
Neurogenic and anaphylactic warm/pink
Hypovolemic cold and clammy
Initial reuscitation actual calculation
20mL/kg body weight
What finding in the pelvis mandates an ex lap?
Free fluid in the pelvis
This could be a small bowel or mesenteric injury
Person has pericardial tamponade. What steps?
Needle decompression aka pericardial in ER (ideally in OR)
EMERGENT PERICARDIOCENTESIS or subxiphoid pericardial drainage in OR
Tumor lysis syndrome done by which cell
CD8 T cells
Positive cross match is…
BAD THAT’S WHEN YOU DON’T TRANSPLANT
What does cyclosporine inhibit
IL-2 mostly
What is grading and which cancers are guided by grade for prognosis?
Degree of anaplasia of the cells.
Soft tissue sarcoma, bladder cancer, astrocytoma, chondrosarcoma
GI stromal tumor rx?
Imatinib bc it expresses c-kit
This is either for neoadjuvant or palliative chemo
Lady w/ BRCA1 mutation doesn’t want prophylactic bilateral mastectomy. What do you do?
Clinical exams q 6 months starting at age 25
You did a LEFT HEMICOLECTOMY for adenocarcinoma in the proximal sigmoid. It’s T3N1. What do you do next?
5-FU + leucovorin bc there’s a positive node
Azathioprine side effect?
Bone marrow toxicity- monitor WBC and platelet counts immediately after transplant
What does “multifocal disease” mean wrt breast cancer?
It’s multiple tumors WITHIN one quadrant so they can STILL do a partial mastectomy
“Diffuse microcalcifications” is MORE THAN 1 QUADRANT
DCIS vs. LCIS?
DCIS needs total simple mastectomy (which LEAVES AXILLARY NODES IN). Bc high rate of recurrence if just local excision is done.
LCIS just needs frequent self exams and yearly mammograms
You have someone severely symptomatic with hypercalcemia. What do you do?
IV fluids to prevent renal calculi
Diuresis should be done with furosemide NOT THIAZIDES bc thiazides cause hypercalcemia
Hemodialysis should be considered, in addition to the above treatments, in patients who have serum calcium concentrations in the range of 18 to 20 mg/dL (4.5 to 5 mmol/L) and neurologic symptoms but a stable circulation, or in those with severe hypercalcemia complicated by renal failure.
Cushing disease?
Pituitary tumor and subsequent bilateral adrenal hyperplasia
Adrenocortical carcinoma?
More likely when mass is BIG. En bloc resection of tumor and involved adjacent structures.
When to start alpha blockade before pheo removal?
1-3 weeks before. They’ll also need volume expander.
Nipple itching and ulceration? Next step? Rx?
Paget dz of breast.
50% have an associated breast mass (usually infiltrating ductal carcinoma)
Do mammogram and biopsy.
Then modified radical mastectomy
How to decrease risk of thyroid storm post-op?
Rx of thyroid storm after it happens?
Lugol iodine solution 10 days before surgery
Fluids, beta blockers, PTU/methimazole, iodine solution, steroids
Lady has a 3cm ductal carcinoma and palpable axillary LNs but WANTS BREAST CONSERVING RX
Do wide local excision w/ axillary LN dissection
ITP rx upon diagnosis?
Steroids + IVIG
Bleeding esophageal varices medical rx?
Octreotide dec splanchnic blood flow- used for ppl who are hemodynamically unstable
Beta blockers prevent RECURRENT bleeding
Gallstone ileus rx?
Ileotomy for removal of the stone + cholecystectomy
Surgical indications for diverticulitis?
Recurrent episodes
Intractable to medical rx
COMPLICATED DIVERTICULITIS EG. PERFORATION (HARTMAN PROCEDURE), ABSCESS (resection w/ primary anastomosis)!!
Acute mesenteric ischemia vs. Ischemic colitis
Acute mesenteric ischemia is SMALL BOWEL and requires EMERGENT INTERVENTION
Ischemic colitis is colon and RARELY REQUIRES SURGERY- only if there’s full thickness necrosis, perforation, or refractory bleeding.
Manage expectantly with IVF, bowel rest, and supportive care
Do you resect a hepatic adenoma?
Actually YES. Small but real risk of turning into hepatocellular carcinoma! The other liver tumors don’t
Acute hemorrhage of gastric varicies that caused splenic vein thrombosis (seen with pancreatitis). Rx?
Splenectomy. They’re hemorrhaging.
Splenic vein thrombosis LEADS to gastric varicies
How do you determine the T stage of esophageal carcinoma?
Endoscopic ultrasound. Also lets you biopsy.
CT and MRI less accurate
You did a LEFT HEMICOLECTOMY for adenocarcinoma in the proximal sigmoid. It’s T3N1. What do you do next?
5-FU + leucovorin bc there’s a positive node
Nigro protocol for SCC of ANUS is 5-FU and mitomycin
How do you determine the T stage of esophageal carcinoma?
Endoscopic ultrasound. Also lets you biopsy.
CT and MRI less accurate
Apple core lesion on transanal contrast study?
Large bowel obstruction
Needs surgical resection and prox colostomy
Super distended loops of bowel in old man with excruciating abdominal pain
Most likely cecal or sigmoid volvulus.
Need to rule out sigmoid volvulus with a proctosigmoidiscope WHICH WILL ALSO ALLOW RECTAL TUBE DECOMPRESSION
What is neostigmine
Adrenergic antagonist to get bowels moving
NOT for ppl with bradycardia, bronchospasm, free perf
Old lady has AAA repair then develops acute abdominal pain and distention. Kidney bean shaped structure in LUQ. Rx?
This is a cecal volvulus and she needs a R HEMICOLECTOMY.
Colonoscopy for decompression has a HIGH RISK OF RECURRENCE
Echinococcal cysts in liver?
Could give mebendazole to shrink them but they NEED TOTAL PERICYSTECTOMY or they’ll recur
Does paraesophageal hernia or sliding hiatal hernia need surgery?
Only paraesophageal bc there’s a high risk of strangulation and obstruction
(Thats the one where there’s a little bulge stuck up top above diaphragm)
SLIDING HIATAL MORE COMMON though
Rx for MAJOR hemobilia from a liver procedure?
Transarterial embolization
Minor bleeding can be treated more conservatively with correction of the coagulopathy and biliary drainage if needed
Stress ulceration = acute gastric or duodenal erosive lesions following shock, sepsis, major surgery, trauma, burns. What do they look like?
Multiple shallow lesions w/ discrete areas of erythema along with focal hemorrhage. Body or fundus and spare antrum.
Chronic benign ulcers are found along lesser curvature or in antrum
End stage cancer patient needs cholecystectomy. Best option?
Tube cholecystostomy. They shouldn’t be operated on.
Incidental hemangioima in liver on CT scan. What do you do?
Observe. The risk of rupture and hemorrhage is extremely low.
Toxic megacolon seen in UC or Crohn’s?
Subtotal colectomy w/ end ileostomy
Aortic stenosis in healthy vs. not patients?
Healthy- aortic valve replacement
Not healthy- percutaneous aortic balloon valvuloplasty
You perf’d the esophagus of a lady with distal esophageal cancer. What do you do?
Thoracotomy and esophagectomy…
She has CANCER.
Pay attention to the underlying disorder. You fix the perf AND THAT when you open.
You perf’d the esophagus of someone who was going routine screening for Barrett’s. What do you do?
Repair the perforation and drain the mediastinum
Initial rx of lung abscess
Systemic abx against causative agent
If it fails to resolve with this, THEN you surgically or percutaneously drain it
Initial treatment of a descending aortic dissection?
Beta blockers to reduce shear on aortic wall
You knicked the thoracic duct and it’s started draining chyle into the mediastinum. Rx?
Tube thoracostomy and low fat diet
If it keeps draining for like 2 weeks, THEN you need to go in and ligate the duct
Bronchial carcinoid that is in lower lobe and ipsilateral mediastinal LNs rx?
Lobectomy and mediastinal LN dissection
CHEMO HAS NO ROLE
Reiter syndrome cardiac abnormality?
Aortic regurg
Septic shock vasopressors?
Norepinephrine and dopamine
Neurogenic shock vasopressor?
Phenylephrine
Can also be used for refractory hypotension in the setting of tachycardia
When is epi used?
Short-term IV boluses during cardiac arrests and in patients with cardiac dysfunction refractory to dobutamine
When is nitroglycerin used?
For acute myocardial ischemia
When is nitroprusside used?
Arterial AND venous vasodilator; need to monitor serum cyanate levels bc it could cause cyanide toxicity (see ACIDOSIS)
Severe cardiogenic shock to reduce afterload OR to treat severe hypotension
Dopamine at different doses?
Low- dopamine receptor binding for renal vasodilation so inc urine output
Medium- Beta1 receptors in heart to inc myocardial contractility
High- alpha receptors to vasoconstrict which inc bp
Who gets carotid endarterectomy
70-80% stenosis asx
Which popliteal aneurysms get repaired
Symptomatic and >2cm
Ligate the aneurysm and leave it in situ
Claudication in lower extremity. Where is the obstruction?
COMMON OR SUPERFICIAL FEMORAL (1 level above where sx!)
Sliding hiatal hernias are MORE COMMON reasons to have GERD sx and nausea and vomiting and strictures…
…so don’t pick paraesophageal hiatal hernia if it asks most common
Chronic occlusion of L iliac and femoral veins and they’re going to surgery. Anticoagulation?
LOW DOSE PROPHYLACTIC heparin
12h after undergoing drainage of pancreatic abscess, 52 yoM with alcholism becomes bradycardic and hypoxic and requires intubation and mechanical ventilation. Weighs 70kg. Ventilator is set at an FiO2 of 100%, tidal volume of 1000 mL, and positive end-expiratory pressure of 2.5cm H2O. Arterial blood gas analysis shows:
pH 7.36
PCO2 40 mmHg
PO2 48 mmHg
Which is most appropriate next step?
a) begin IV acetazolamide therapy, b) begin IV furosemide therapy, c) begin IV heparin therapy, d) begin IV sodium bicarb, e) begin IC urokinase, f) Decrease FiO2, g) decrease tidal volume, h) increase PEEP, i) increase tidal volume
ABG shows patient is hypoxemic. 2 ways to increase PO2 are increasing FiO2 (already at 100%) and increasing PEEP. Peep of 2.5 is pretty low, so you’ve got some room to maneuver. As an aside, tidal volume of 1000 for 70kg man is way high, especially for likely ARDS (which you usually treat with low tidal volume/increased PEEP ventilation). But monkeying with tidal volume will not correct the patient’s hypoxemia.
Nuclear inclusion bodies in colon biopsy from HIV lady with bloody diarrhea and perforated cecum
CMV colitis
Opening snap, mid-diastolic rumble?
Mitral stenosis
Valve replacement vs. balloon valvuloplasty vs. open commisurotomy
Loud holosystolic, high pitched, radiating to axilla
Mitral regurg.
Loud crescendo-decresendo systolic ejection murmur, radiates to carotids. Louder with squatting, softer with valsalva. Pulsus parvus et tardus.
Aortic stenosis
Holosystolic murmurs
Tricuspid regurg, mitral regurg, VSD
Eaton lambert a/w…
Small cell lung ca (but an equal % who have it don’t have cancer at all)
What is a “dissection”
Tear in the INTIMA
Major complication of thoracic aortic aneurysm repair
Paraplegia. Avoid perioperative hypotension
How angiography works
Depending on the type of angiogram, access to the blood vessels is gained most commonly through the femoral artery, to look at the left side of the heart and at the arterial system; or the jugular or femoral vein, to look at the right side of the heart and at the venous system
How do you diagnose acute arterial insufficiency and what next?
If diagnosis is certain, STRAIGHT TO OR.
Cold, newly pulseless, painful extremity
Muscles soft–>doughy–>hard
When is ABI normal in someone who totally has claudication sx?
Diabetics bc ABI is falsely elevated (ie. closer to normal) bc their vessels are less compressible from the disease
Explain subclavian steal?
Subclavian occlusion makes blood flow RETROGRADE through the vertebral arteries so there’s dec flow to the PCAs
BKA contraindicated when
Gangrene is more proximal than the ankle (like in our guy who got the AKA)
When is ABI normal in someone who totally has claudication sx?
Diabetics bc ABI is falsely elevated (ie. closer to normal) bc their vessels are less compressible from the disease (calcification
What do you often find with popliteal artery aneurysm?
AAA
Which vessel is never involved if the cause is atherosclerosis?
External iliac
Carotid injury with hematoma. Which CN affected?
IX-XII
Cyclosporine MOA
Calcineurin inhibitor. Prevents transcription of genes needed for T cell activation (IL-2 inhib)
What should you never use in liver transplant for immunosuppression?
Azathioprine
What should you never use in liver transplant for immunosuppression?
Azathioprine
Hyperacute rejection done by
Antibodies
Complement mediated lysis. Procoagulant effect–> thrombosis of graft
Happens from presensitization to donor antigen…from pregnancy, transfusion, or prior transplant
Kidney transplant pt seen in ED with abdominal pain, fever, and creatinine bump…
Likely acute rejection.
Confirm with u/s guided BIOPSY.
Pulse steroid rx.
Graft thrombosis rx?
Immediate reoperation to salvage
What should you never use in liver transplant for immunosuppression?
Azathioprine
Tacrolimus is used
Cremasteric reflex spinal cord levels?
L1-2 or injury of the ilioinguinal nerve during hernia repair
Can also see loss in testicular torsion
Assist-control
set TV and rate but if pt takes a breath, vent gives the volume
Pressure support
pt rules rate but a boost of pressure is given (8-20)
IMPORTANT FOR WEANING
CPAP
pt must breathe on own but + pressure given all the time
PEEP
USED IN ARDS OR CHF
pressure given at the end of cycle to keep alveoli open (5-20)
Low PaO2
Increase the FiO2
High PaCO2
Increase RR or tidal volume! (Tidal volume more efficient to change)
AT III deficiency key concept?
Heparin WON’T WORK
Normal platelets, inc BT and PTT
vWD
INTUBATE ANYONE WITH A GCS
Intubated. Next step?
Check bilateral breath sounds
If decreased on L..you intubated the R main stem bronchus.
Pull back your tube. Check pulse ox and keep it >90
Neurogenic shock
A form of vasogenic shock where spinal cord injury, spinal anesthesia, or adrenal insufficiency (suspect in pts on steroids encountering a stressor) causes an acute loss of sympathetic vascular tone
Necrotizing fasciitis
IV PCN, Go to OR and debride skin until it bleeds
Gaspy or Clostridium perfringens
Dantrolene blocks ryanodine receptor and DEC INTRACELLULAR CA.
Pressure ulcers
Stage 1-2 get special mattress, barrier protection
• Stage 3-4
get flap reconstruction surgery
– Before surgery, albumen must be >3.5 and bacterial load must be
Lung abscess
Tx initially w/ abx- IV PCN or clinda
– Indications for surgery = abx fail,
abscess >6cm, or if empyema is present.
–Pt
CXR or CT scans q2mo to look for growth
Characteristics of malignant lung nodules?
(smoker, old), If >3cm, eccentric
calcification
Dysphagia worse with hot and cold liquids, chest pain that feels like MI, NO REGURG
DES
Rx: CCBs or nitrates (can also give these for achalasia)
Gastric cancer
Blummers shelf, virchow’s node
Lymphoma- HIV
MALT lymphoma- H pylori
Bilious vomiting, post-prandial pain, and recently lost 200lbs?
SMA syndrome.
Can do roux-en-y
Choledochal cyst
Roux-en-Y anastomosis to the biliary duct.
15 year old boy with a small pleural effusion
Small spontaneous pneumothoraces typically resolve without treatment and require only monitoring.
Diagnostic/confirmatory test for carpal tunnel?
Nerve conduction studies
NOT EMG THAT’S OLD SCHOOL
Sedation/induction
Thiopental
Etomidate
Midazolam
Ketamine
Paralyze patient
Succinylcholine, vecuronium
Chalazion vs. hordeolum
Chalazia and hordeola (styes) are sudden-onset localized swellings of the eyelid. A chalazion is caused by noninfectious meibomian gland occlusion, whereas a hordeolum usually is caused by infection. Both conditions initially cause eyelid hyperemia and edema, swelling, and pain. With time, a chalazion becomes a small nontender nodule in the eyelid center, whereas a hordeolum remains painful and localizes to an eyelid margin. Diagnosis is clinical. Treatment is with hot compresses. Both conditions improve spontaneously, but incision or, for chalazia, intralesional corticosteroids may be used to hasten resolution.
