Week 5 - General, Trauma, Neurosurgery, & Vascular Flashcards
List 5 disease(s) a surgeon may be at risk from while performing surgery?
Infectious agents for which donated blood is screened in the United States
1. Babesia microti (babesiosis)
2. Cytomegalovirus
3. Hepatitis B
4. Hepatitis C
5. HIV
6. Treponema pallidum (syphilis)
7. Trypanosoma cruzi (Chagas disease)
8. West Nile Virus
9. Zika Virus
What are 3 indications for tetanus booster?
Discuss the treatment of Tetanus-Prone Wounds? (4)
After splenectomy, what are 4 methods taken to prevent infective complications in the longer term?
What are 3 agents commonly used for hand preparation during a surgical scrub?
List 5 hazards of radiological investigation?
List 5 Hazards/Complications associated with Surgical pneumoperitoneum?
Surgical pneumoperitoneum refers to the intentional introduction of carbon dioxide (CO2) gas into the peritoneal cavity during laparoscopic or minimally invasive abdominal surgeries.
You are asked by your consultant to inform a patient that they have an inoperable cancer of the pancreas and there is no surgical treatment possible. What are the principles of breaking bad news? Describe how you would approach this task. (10)
SPIKES
What 5 causes of hypertension are amenable to surgical treatment?
List & Explain 7 complications of renal transplantation and immunosuppression?
An 18 year pedestrian is hit by a car travelling at high speed and is brought into the emergency hospital 15 minutes after the accident. The patient is unconscious and bleeding from the left ear with a blood pressure of 80/50 and a pulse rate of 140. Discuss your management of this patient.
- 7 Steps?
Describe the Stepwise management of elevated ICP in patients with severe TBI (Glasgow Coma Scale <9):
- Tier Zero?
- Tier One?
- Tier Two?
- Tier Three?
Discuss 6 ways in which the gross anatomy of the brain is affected by trauma.
What is the tentorial notch? What is its clinical significance?
The tentorial notch refers to the anterior opening between the free edge of the cerebellar tentorium and the clivus for the passage of the brainstem. The midbrain continues with the thalamus of the diencephalon through the tentorial notch.
Midbrain passes through the tentorial notch and this notch provides the only communication between the supratentorial and infratentorial compartments. The area between the brainstem and free tentorial edge is divided into the anterior, middle, and posterior incisural spaces.
What is the significance of the ‘tentorial notch’ in the development of neurological symptoms following head trauma?
Overall, the tentorial notch is a critical anatomical landmark in the development of neurological symptoms following head trauma. Damage to structures passing through this space can result in significant neurological deficits and can be an important consideration in the assessment and management of patients with traumatic brain injury.
9 Steps in the Management of a patient with a head injury?
What is the Monroe-Kelly doctrine?
Overall, the Monroe-Kelly doctrine provides a conceptual framework for understanding the delicate balance of intracranial contents and the dynamic relationship between intracranial volume, pressure, and cerebral blood flow. It serves as a guiding principle in the assessment, treatment, and monitoring of patients with various intracranial pathologies.
Describe the pathophysiology of secondary brain injury?
8 Strategies to minimize secondary brain injury?
In a patient with intermittent claudication of the leg, what techniques are available to improve their symptoms?
- Lifestyle modifications? (3)
- Medications? (3)
- Interventional Procedures? (2)
- 3 Others?
Intermittent claudication is a symptom of peripheral arterial disease (PAD) characterized by pain or cramping in the leg muscles during physical activity. The pain is typically relieved with rest. The primary goal of treatment for intermittent claudication is to improve symptoms and increase functional capacity.
Definition of Varicose Veins?
What are 7 signs and symptoms of varicose veins?
Varicose veins: a type of CVD characterized by cylindrical dilation (diameter > 3 mm) and tortuosity of superficial veins.
Varicose veins are enlarged, twisted veins that usually appear in the legs and feet. They occur when the valves within the veins become weak or damaged, leading to blood pooling and increased pressure in the veins.
5 Treatment options for Varicose Veins?
- 2 Medications?
- 3 Minimally Invasive Procedures?
- 2 Surgical Interventions?
What is meant by the term “critical ischaemia” How would you manage a patient presenting with this condition?
- 3 Medical Management strategies?
- 2 Revascularization Procedures?
- 2 Limb Salvage Techniques?
- 2 Wound Healing Support?
Critical ischemia, also known as critical limb ischemia (CLI), refers to a severe form of peripheral arterial disease (PAD) where there is a significant decrease in blood flow to the extremities, typically the legs or feet. It is characterized by chronic pain, non-healing wounds or ulcers, and the threat of limb loss. Critical ischemia is considered a medical emergency requiring immediate intervention to prevent tissue death (gangrene) and limb amputation.
What is the anatomy of the venous system of the lower limbs in regards to varicose veins?
What is the pathophysiology of varicose veins?
Varicose veins (VV) are dilated, tortuous subcutaneous veins that permit reverse flow. They are most commonly found in the lower limb and may be primary, or secondary to deep venous pathology. The GSV system is most frequently affected with the SSV being involved in about 20% of cases. The aetiology of VV at a microscopic level is still disputed but the essential defect macroscopically is generally agreed to be the failure of venous valve closure resulting in the superficial veins becoming dilated, elongated and tortuous. The main factor contributing to the development and progression of varicose veins is sustained venous hypertension that increases the diameter of the superficial veins resulting in further valve incompetence.
A 65-year-old man is found to have a 6cm abdominal aortic aneurysm. He asks you what this means and what needs to be done. Describe the management approach.
If a large (> 5.5 cm) aneurysm is seen on ultrasound in a patient presenting with abdominal pain, refer the patient for treatment immediately.
A 65-year-old man is found to have a 6cm abdominal aortic aneurysm. He asks you what this means and what needs to be done. Describe what you would tell him.
What is meant by the term ‘diabetic foot’ and what is the management of this condition? (7)
- MADADORE?
A diabetic foot disease is any condition that results directly from peripheral artery disease or sensory neuropathy affecting the feet of people living with diabetes. Diabetic foot conditions can be acute or chronic complications of diabetes.
The term “diabetic foot” refers to a range of foot complications that can arise in individuals with diabetes. Diabetes can cause damage to the nerves (diabetic neuropathy) and impair blood flow to the feet (peripheral arterial disease), leading to various foot problems. These problems can include ulcers, infections, deformities, and difficulties in wound healing. If left untreated or poorly managed, diabetic foot complications can progress and potentially lead to severe consequences, including amputation.
What are the effects of atherosclerosis of the carotid vessels? (5)
To evaluate the extent of carotid artery disease and its effects, imaging tests such as carotid ultrasound, CT angiography, or magnetic resonance angiography (MRA) may be performed. Depending on the severity of the disease and the individual’s overall health, treatment options can include lifestyle modifications, medications to control risk factors (such as high blood pressure and cholesterol), antiplatelet therapy, and, in some cases, surgical interventions like carotid endarterectomy or carotid artery stenting.
What are 4 complications of under hydration?
What are 3 complications of over hydration?
Underhydration
1. Decreased tissue perfusion
2. Anastomotic Leak
3. Renal Failure
4. MODS
Over hydration
1. Acidosis
2. Coagulopathy
3. Oedema
What are the 5 Renal Rules of Fluid Replacement?
- The kidneys cannot function without adequate perfusion
- Renal perfusion depends on an adequate blood pressure
- A surgical patient with a poor urine output usually requires more fluid
- Absolute anuria is usually due to urinary tract obstruction.
- Poor urine output in a surgical case is NOT due to frusemide deficiency.
What are 6 questions to ask yourself when thinking anout fluid balance?
- What are normal losses?
- What are normal intakes?
- What is the metabolic response to injury?
- What are the abnormal losses?
- Which fluid to use?
- How to monitor fluid therapy?
What are your Intracellular vs. Extracellular electrolytes?
INTRA = potassium
EXTRA = Na/Cl/Ca
in mL
8 causes of Abnormal fluid losses?
Amounts?
Abnormal Losses
1. NasogastricTube
2. Increased insensible losses (200mls per degree)
3. Diarrhoea
4. Vomiting
5. Stoma
6. Fistula
7. Intra-operative Bleeding
8. Third Spacing
What is Third Spacing? 5 Examples of conditions that cause this?
ECF that is not intravascular or interstitial (extravascular)
Fluid accumulates in the lumen of the paralysed bowel (ileus)
How do you assess a patients fluid level?
What to look for on examination? (11)
2 investigations?
ASK - History taking
Examination
1. PULSE
2. SKIN PERFUSION
3. CARDIO- RESPIRATORY
4. BP
5. TEMPERATURE
6. MUCOUS MEMBRANES
7. SKIN TURGOR
8. WEIGHT
9. URINE OUTPUT
10. OEDEMA
11. JVP
What are the 3 aims of fluid prescription depending on the patients fluid status?
3 types of fluid you can give?
Is the patient?
Euvolaemic
Hypovolaemic
Hypervolaemic
Aims of Fluid Prescription
1. Maintenance
2. Replacement
3. Resuscitation
What is the definition of Oliguria?
Approach?
Oliguria
- “Passage of less than 400mls in a day”
- <0.5ml/kg/hr
- Oliguria is common after surgery.
- Prerenal causes predominate for postoperative oliguria.
- Intravenous fluid challenges treat most oliguria after surgery.
- Do not overlook retention, urinary catheter obstruction, SIADH, and abdominal compartment syndrome in the postoperative patient.
Describe a 7 step approach to managing a post-operative patient with oliguria?
5. Investigate the possible causes:
- Obtain laboratory tests, including serum electrolytes, renal function (creatinine, blood urea nitrogen), urine analysis, and urine output measurements.
- Consider imaging studies, such as renal ultrasound or Doppler studies, to evaluate for obstructive uropathy or renal blood flow abnormalities.
6. Consider reversible causes and interventions:
- Ensure adequate intravascular volume by administering intravenous fluids cautiously.
- Address any identified electrolyte imbalances or acid-base disturbances.
- Identify and treat any potential urinary obstruction, such as bladder distention or urinary retention.
- Evaluate and manage medications that may contribute to renal dysfunction or oliguria.
7. Involve a nephrologist or critical care specialist:
- If the patient remains oliguric despite appropriate interventions or if there are concerns for severe AKI or renal failure, consult a specialist for further evaluation and management.
Describe normal body compartment composition.
What is normal Circulating Blood Volume?
Composition of body fluid compartments
Adult body weight 60% water
- 75% as neonate
- 50% at 80 yrs
Of this 60%
- 40% intracellular fluid
- 20% extracellular fluid
- 15% interstitial fluid
- 5% plasma
Circulating Blood Volume (plasma +cells) = 7mls/kg=5000mls
Describe the pathophysiology of Hyperchloraemic Metabolic Acidosis from Normal Saline administration?
Hyperchloraemic Metabolic Acidosis
- Normal saline has high Chloride but is
Missing K, Ca, Glucose, Mg, Bicarbonate.
- Recommendations: Hartmann’s or Ringer’s less risk of hyperchloraemic acidosis.
(Unless hypochloraemic)
What is 5% Dextrose and where does it go?
What is Hypertonic Saline?
5% Dextrose
- Goes intravascular
- Glucose removed
- Water then redistributes
- Not nutritive 170Kcal/l
Hypertonic Saline
- Volume expander
- 1ml HTS 7mls water drawn into EC space
- Lasts 15 minutes due to equilibrium between IV and EV space
- May decrease ICP and ICH
Example Four
A 36 year old woman 2 days following a laparotomy and small bowel resection for SBO. She has had poor urine output for 2 hours. She is thirsty. On examination she has dry mucous membranes. She has a temperature of 38, pulse of 86, BP 110/70, SaO2 95.The catheter has small amounts of concentrated urine.
What will you do?
Example Five - 2 causes of the following urine output post-operatively?
- Blocked catheter
- Retention
Example Six - A 54 year old man, 5 days after Whipple’s. He is NBM. Clinically dry. P 100 BP 130/80 Temp 38.5 NG Chart review NG loss 900 Urine 1500 Left drain 600, right drain 200 Transfusion 2 units IV 2l Drugs 200 Negative 1L from yesterday.
Calculate his fluid losses?
Discuss the principles of fluid and electrolyte, and acid-base physiology.
- 6 points?
- Buffering equation?
Describe the electrolyte and fluid losses that may occur in illness and post-operative recovery.
5 Metabolic responses to injury?
The metabolic response to injury, also known as the systemic inflammatory response, can have significant effects on fluid balance in the body.
List 7 differential diagnoses and describe the treatments for metabolic acidosis.
- Metabolic acidosis is a condition characterized by a decrease in blood pH and bicarbonate (HCO3-) levels, resulting in an excess of acid in the body.
- In some cases, correction of the underlying condition may be sufficient to restore acid-base balance. In more severe cases, additional interventions such as IV bicarbonate or renal replacement therapy (e.g., hemodialysis) may be required to correct the acidosis.
List 7 differential diagnoses and describe the treatments for metabolic alkalosis.
- Metabolic alkalosis is a condition characterized by an elevation in blood pH and bicarbonate (HCO3-) levels, resulting in an excess of base in the body.
- Treatment may involve discontinuing or adjusting medications, correcting fluid and electrolyte imbalances, and providing supportive care. In some cases, administration of IV fluids with chloride or acetazolamide (a carbonic anhydrase inhibitor) may be used to promote renal excretion of bicarbonate and restore acid-base balance.
List 6 differential diagnoses and describe the treatments for respiratory acidosis.
Respiratory acidosis is a condition characterized by an increase in carbon dioxide (CO2) levels and a decrease in blood pH due to impaired ventilation.
List 7 types of blood and blood components available in the elective and emergency surgical situations.
Describe 7 hazards of blood transfusion.
What is Degenerative disk disease? What are the 2 ways it can present?
Define:
- Disk protrusion?
- Disk herniation?
- Disk sequestration?
- Spondylosis?
Disk protrusion: protrusion of the vertebral disk nucleus pulposus through the annulus fibrosus
Disk herniation (disk extrusion or disk prolapse): complete extrusion of the nucleus pulposus through a tear in the annulus fibrosus
Disk sequestration: extrusion of the nucleus pulposus and separation of a fragment of the disk
Spondylosis: a broad term used to describe degenerative changes of the spine that may result in irritation and/or damage of the adjacent nerve roots or spinal cord
Describe the pathophysiology of degnerative disk disease?
Where do Intervertebral disks usually protrude/herniate?
What are the clinical features of degenerative disk disease in general?
- As dermatomal territories often overlap (except in autonomous sensory zones) and muscles are often supplied by several myotomes, sensory and motor deficits may be absent or minimal if a single spinal root is compressed.
Which nerve root is compressed in disk herniation in the cervical region?
Which nerve root is compressed in disk herniation in the lumbar region?
- Cervical nerve roots C1-C7 run superior to the named vertebrae - eg. If disk C4-5 is herniated then the C4 nerve root gets compressed.
- Lumbar nerve roots run inferior to the named vertebrae so an L4-5 disc herniation would cause L5 nerve compression.
- Herniated lumbosacral disks commonly cause radiculopathy below the level of the herniated disk (e.g., L4–L5 disk herniation results in L5 radiculopathy). However, a far lateral disk herniation can cause radiculopathy above the level of the disk (e.g., L4–L5 far lateral disk herniation resulting in L4 radiculopathy).
Cervical radiculopathy
- 3 Symptoms?
- Exam findings?
Symptoms of Cervical radiculopathy
1. Neck pain commonly associated with radiculopathy
2. Can manifest with difficulty with fine motor skills
3. Can be accompanied by headache and/or shoulder pain
Lumbosacral radiculopathy
- 3 Symptoms?
- Exam findings?
Lumbosacral radiculopathy - Symptoms
1. Low back pain (lumbago) commonly associated with radiculopathy
2. Pain characteristically worsens with lumbar flexion (e.g., on sitting).
3. Worsening of low back pain with lumbar flexion (e.g., on sitting) is suggestive of lumbar disk herniation, while improvement of pain with lumbar flexion is suggestive of lumbar spinal stenosis.
What are 4 Provocative maneuvers to screen for lumbosacral radiculopathy?
Australian Triage System - Category 1 (Red)
- Response time?
- Description of Category?
- Clinical Descriptors?
Australian Triage System - Category 2 (Orange)
- Response time?
- Description of Category?
- Clinical Descriptors?
Australian Triage System - Category 3 (Green)
- Response time?
- Description of Category?
- Clinical Descriptors?
Child at risk of abuse/suspected non-accidental
injury
Behavioural/Psychiatric:
- very distressed, risk of self-harm
- acutely psychotic or thought disordered
- situational crisis, deliberate self-harm
- agitated / withdrawn
- potentially aggressive
Australian Triage System - Category 4 (Blue)
- Response time?
- Description of Category?
- Clinical Descriptors?
Australian Triage System - Category 5 (White)
- Response time?
- Description of Category?
- Clinical Descriptors?
Summary of ophthalmic emergency predictors (OEP) for the ATS?
What are 9 signs of an acute embolism of the lower limb which lodges in the distal superficial femoral artery?
Arterial Ulcer of Lower Limb
- Description?
- Risk Factors?
- Clinical Features?
- Investigations?
- Management?
Venous Ulcer of Lower Limb
- Description?
- Risk Factors?
- Clinical Features?
- Investigations?
- Management?
Neuropathic Ulcer of Lower Limb
- Description?
- Risk Factors?
- Clinical Features?
- Investigations?
- Management?
What condition may Neuropathic ulcers be seen alongside?
