High Yield Surgery Shelf Exam Review Complete

High Yield Surgery Shelf Review PRE-OP EVALUATION Contraindications to surgery – Absolute? Diabetic Coma, DKA – Poor nutrition? albumin 150 or encephalopathy – Smoker? stop smoking 8wks prior to surgery If a CO2 retainer, go easy on the O2 in the post-op period. Can suppress respiratory drive. Goldman Index: Who is at greatest risk for surgery #1 = CHF • Check? EF. If 70) #5 = Surgery is emergent #6 = Aortic stenosis, poor medical condition, surg in chest/abd • Murmur of AS: Late systolic, crescendo-decrescendo murmur that radiates to carotids. ↑ with squatting, ↓ with decr preload Meds to stop 2 wks: Aspirin, NSAIDs, vit E 5 days: Warfarin – drop INR to 100: Uremic platelet dysfunction. – Coag panel: Normal platelets but prolonged bleeding time

VENT SETTINGS • 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: pressure given at the end of cycle to keep alveoli open (5-20). *Used in ARDS or CHF* • Best test to evaluate vent management? ABG • LowPaO2? increase FiO2 • High PaO2? decrease FiO2 • Low PaCO2 (pH is high)? Decr RR or TV • High PaCO2 (pH is low)? Incr rate or TV TV is more efficient to change.

*Remember minute ventilation equation & dead space*

ACID-BASE DISORDERS Respiratory: pH and PCO2 move in opposite directions Metabolic: pH and PCO2 move in same direction pH < 7.4 = acidotic. High pCO2: Acute Respiratory Acidosis  High pCO2 and HCO3? Chronic Low HCO3: Acute Metabolic Acidosis  Low HCO3 and pCO2? Chronic • Anion gap: (Na – [Cl + HCO3]) Normal: 8-12 • Anion-gap acidosis = MUDPILES (Methanol, Uremia, Diabetic ketoacidosis, Propylene glycol, Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates) • Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV) pH > 7.4 = alkalotic. High HCO3: Acute Metabolic Alkalosis  High HCO3 and pCO2? Chronic Low pCO2: Acute Respiratory Alkalosis  Low HCO3 and pCO2? Chronic  Decrease in serum K and ionized Ca o Paresthesias, carpopedal spasm, and tetany.  Urine [Cl] o [Cl] < 20: Vomiting/NG, antactids, diuretics  [Cl] > 20: Conn’s, Bartter’s, Gittleman’s

TRAUMA ABCDE: Airway, Breathing, Circulation, Dysfunction (neurological), Exposure (examine whole body) AB: Airway, Breathing  Patient comes in unconscious or GCS 90% Traumatic Aortic Injury

Hemothorax

Burns American Burn Association Criteria for Referral to a Burn Center       

Partial- or full-thickness burns of > 10% BSA in pts < 10 or > 50 y/o Partial- or full-thickness burns of > 20% BSA in pts of other ages Partial- or full-thickness burns involving face, hands, feet, genitalia, perineum, or skin over major joints Full-thickness burns of > 5% BSA at any age Significant electrical (incl. lightning) & chemical burns Lesser burn injury in conjunction with inhalational injury, trauma, or preexisting medical cond’ns Patients requiring special social, emotional, or rehabilitation assistance (i.e., child or elder abuse)

Rule of 9s

Start resuscitation with 1L LR bolus adults, 20 mL/kg for children  Parkland formula: 2-4mL/kg/%BSA burn (adults)  children, 3-4mL/kg/%BSA  Give ½ over 1st 8h, rest over next 16h NO PO or IV abx; use topical tx  Painless, but doesn’t penetrate eschar, var. gram-neg cov’g, can cause leukopenia: Silver sulfdiazine  Penetrates eschar, but hurts like hell, can cause acidosis via c. anhydrase inhib, poor Candida cov’g: Mafenide acetate  Painless, but doesn’t penetrate eschar, stains black, causes hypoK and hypoNa: Silver nitrate Circumferential burns: Consider escharotomy (bedside, no anesthesia needed) Inhalational burn: Singed nose hairs, wheezing, soot in mouth/nose  Low threshold for intubation  Pt w/confusion, HA, cherry-red skin: Check/monitor carboxyHb (pulse ox = worthless) o Treatment: 100% O2 (hyperbaric if CO-Hb is ↑↑↑) Chemical burn: Irrigate > 30min prior to ER Electrical burn: EKG first!  If LOC or abnormal EKG: 48 hours of telemetry  If urine dipstick + for blood but microscopic exam negative for RBCs: Myoglobinuria  ATN  Check for hyperkalemia due to RBC lysis!

Chest Trauma  Inward mvmt of ribcage on inspiration: Flail chest > 3 consec. rib fx o Tx: O2 and pain control  Acute SOB, confusion, petechial rash on chest/axilla/neck after long bone fx (esp. femur): Fat embolism  Patient dies suddenly after removal of central line: Air embolism o Suspect during: Lung trauma, vent use, major vascular surgery Hypotensive/tachycardic/cool skin: Shock  Hypovolemic, cardiac tamponade, tension pneumo  Flat neck veins and normal CVP: Hypovolemic o Next step: 2 large-bore (14-16 gauge) periph. IV- 2L LR over 20min o Follow with blood transfix o Do not exceed CVP of 15mmHg  Muffled heart sounds, JVD, pulsus paradoxus: Pericardial tamponade o Confirmation: FAST scan o Treatment: Needle decompression, pericardial window or median sternotomy  Decr. unilateral BS w/ tracheal deviation AWAY: Tension pneumo o Next step: Needle decompression, followed by 26-French chest tube—NOT CXR! Types of Shock Hypovolemic Loss of circ. blood vol. (hemorrhage, interstit. d/t bowel obstr., excessive vom./diarrhea, polyuria, burn)

Vasogenic Decreased periph. vasc. resistance sepsis (LPS) and anaphylaxis (histamine)

Neurogenic Vasogenic d/t spinal cord injury/anesthesia, adrenal insuff. (susp. in pts on steroids w/acute stressors) acute loss of sympathetic vascular tone

Cardio-compressive Cardiac tamponade (pressure preventing it fulfilling role as pump)

Cardiogenic Failure of heart as pump, as in arrhythmia or acute MI

Physical Exam

Swann-Ganz Catheter

Treatment

Hypotensive, tachycardic, diaphoretic, cool, clammy extremities

RAP/ Pulm. capill.WP↓ Systemic vasc. resist.↑ Cardiac output↓

Crystalloid resuscitation

Early: AMS, hypotn, warm/dry extrem. Late: Resembles hypovolemic

RAP/Pulm. capill.WP ↓ Systemic vasc. resist.↓ Cardiac output↑ (EF↓)

Hypotensive, bradycardic, warm, dry extremities, absent reflexes and flaccid tone. Adrenal insuff.: hypoNa, hyperK

RAP/Pulm. capill.WP ↓ Systemic vasc. resist.↓ Cardiac output↑

Fluid resuscitation (may cause edema), tx offending organism, epinephrine/antihist. Tx adrenal insuff w/ dexamethasone; taper over several wks.

Hypotensive, tachycardic, JVD, decreased HS, norm. BS, pulsus paradoxus (10-pt PP drop w/inspir.) SOB, clammy extrem., bilat. rales/decr. BS, S3, pleural effusion, ascites, periph. edema

FAST scan shows fluid in pericardial space

Head Trauma GLASGOW COMA SCALE (GCS): Classification of head injury  Severe: 8 or less  Moderate: 9–13  Mild: 14 or 15.ir

RAP/ Pulm. capill.WP↑ Systemic vasc. resist.↑ Cardiac output↓

Needle pericardiocentesis, pericardial window, sternotomy Diuretics, raise HR to 60100, rhythm control; vasopressors if necess.

Eyes 4, verbal 5, motor 6 Eye Verbal Motor

1 Does not open eyes No sounds No movements

GLASGOW COMA SCALE 2 3 Opens eyes to pain Opens eyes to voice Incomprehensible sounds Inappropriate words Decerebrate posturing Decorticate posturing

4 Opens eyes spontaneously Confused, disoriented Withdraws from pain

5

6

Converses normally Localizes pain

Obeys commands

Increased ICP: Hematoma, edema, tumor  Symptoms: Headache, vomiting, altered mental status  Treatment: Elev. head, hyperventil. to pCO2 28-32, diuresis (furosemide, mannitolwatch renal fxn)  Surgical: Burr hole, ventriculostomy Neck Trauma Penetrating trauma vs. GSW

Zone 3 = ↑ angle of mandible  Aortography and triple endoscopy Zone 2 = Angle of mandiblecricoid  2D doppler +/- exploratory surgery Zone 1 = ↓ cricoid  Aorto/angiography Abdominal Trauma Penetrating Abdominal Trauma: Do not pass go! Go directly to exploratory laparotomy.  GSW to abdomen: Ex-lap. (plus tetanus prophylaxis)  Stab wound w/unstable ptrebound tenderness & rigidity OR evisceration: Ex-lap. (plus tetanus prophylaxis) o Stab wound w/stable pt: FAST exam; diag. peritoneal lavage (DPL) if FAST is equivocal  Ex-lap if either are positive. Blunt Abdominal Trauma: w/hypotn/tachycardia, Ex-lap. If stable OR stable w/epigastric pain: Abdominal CT  Lower rib fx + abd. bleed: Spleen or liver lac.  Lower rib fx + hematuria: Kidney lac.

  

Kehr sign (mult. air/fluid levels) + viscera in thorax on CXR: Diaphragmatic rupt. Handlebar sign: Pancreatic rupt. Fluid found in retroperitoneum: Consider duodenal rupt.

Pelvic Trauma If hypotensive, tachycardic: FAST and/or DPL to r/o bleeding in abd. cavity Can exsanguinate into abdomen, pelvis, & thigh: Stop bleeding by fixing fxinternal fix’n if stable, external if not  Blood at urethral meatus and/or high-riding prostate: Consider urethral/bladder injury o Test: Retrograde urethrogram (NOT FOLEY!)  If normal: Retrograde cystogram to evaluate bladder o Check for extravasation of dye; 2 views (full/empty) to ID trigone injury  Extraperitoneal extravasation: Ex-lap and surgical repair  Intraperitoneal extravasation: Bed rest + foley Orthopedics XRs at 90° angles, including joints above and below Fractures that go to the OR:  Depressed skull fx  Severely displaced or angulated fx  Open fx (w/in 6h)  Femoral neck or intertrochanteric fx (risk of necrosis) Common fractures:  Shoulder pain s/p seizure/electrical shock: Post. shoulder dislocation  Arm ext. rotated/numbness over deltoid: Ant. shoulder dislocation  Old lady fell on outstretched hand (FOOSH) distal radius displaced: Colle’s fracture  Young person FOOSH, anatomic snuff box tenderness: Scaphoid (carpal navicular) fracture o Initial XRs NEGATIVE unless displaced (surgery indic.); will show on XR 2-3wks. PI  “I swear I just punched a wall…”: Metacarpal neck fracture (‘Boxer’s fracture’) o May need K wire  Clavicle: Most commonly broken between middle and distal 1/3s o Need figure-of-8 device Extremity extremely tender, numb, white, cold (pulse may or may not be attenuated): Compartment syndrome  Compartment pressure >30mmHg  Treatment: May require fasciotomy (through all fascial compartments)

Scaphoid fx

Depressed skull fx

Femoral neck fx Intertrochanteric fx Bone malig. in adults = mets from lung, prostate, breast Colle’s fx

   

4-5 y/o w/ a painless limp: Avascular necrosis o Adultssteroid use, s/p femoral head/neck fx 12-13 y/o w/knee or hip pain: SCFE Most common primary bone malig. (us. peds): Osteosarcoma o Distal femur, proximal tibia @ metaphysis, around the knee o Codman’s triangle (raised periosteum), sunburst appearance Night pain, fever, elevated ESR: Ewing sarcoma o Diaphysis of long bones o Lytic bone lesions, “onion skinning” o Neuroendocrine (small blue) tumor

HERNIAS     

Umbilical: Peds close spontaneously by age 2 o In adults: 2/2 obesity, ascites or pregnancy Indirect inguinal: MCthrough inguinal ring (lateral to epigastric vessels) in spermatocord o R > L, more often congenital (patent proc. vaginalis) Direct inguinal: through Hasselbeck’s triangle (medial to epigastrics), more often acq. weakness Femoral: More common in women Treatment: Emergent surgical repair if incarcerated (to avoid strangulation) o Elective if reducible

CARDIAC MURMURS         

Systolic ejection murmur (SEM) cresc/decresc, louder w/squatting, softer w/valsalva + parvus et tardus: Aortic stenosis SEM louder w/valsalva, softer w/squatting or handgrip: Hypertrophic cardiomyopathy Late systolic murmur w/click; louder w/valsalva and handgrip, softer w/squatting: Mitral prolapse Holosystolic murmur radiates to axilla: Mitral regurgitation Holosystolic murmur w/late diastolic rumblepeds: VSD Continuous machine-like murmur: PDA Wide, fixed splitting in S2: ASD Rumbling diastolic murmur w/opening snap, LAE and A-fib: Mitral stenosis Blowing diastolic murmur w/widened pulse pressure: Aortic regurgitation

INFLAMMATORY BOWEL DISEASE          

Involves terminal ileum: Crohn’s o Mimics appendicitis, Fe deficiency Continuous involving rectum: UC o Rarely, ileal backwash, but never higher Incr. risk for Primary Sclerosing Cholangitis: UC o PSC leads to higher risk of cholangioCA Highest risk of colon cancer: UC (another reason for colectomy) Fistulae likely: Crohn’s (give metronidazole) o For Crohn’s, give metranidazole for ANY ulcer or abscess Granulomas on biopsy: Crohn’s Transmural inflammation: UC Smokers have lower risk: UC o Smokers have higher risk for Crohn’s Associated w/ p-ANCA: UC Treatment = ASA, sulfasalzine to maintain remission o Corticosteroids to induce remission o Azathioprine, 6MP and methotrexate for severe dz

TRANSPLANT Hyperacute Rejection  Vascular thrombosis in minutes  Caused by preformed antibodies Acute Rejection  Organ dysfunction (incr. GGT or Cr depending on organ) in 5days/3mos o Due to T-lymphocytes

o Tx w/steroid bolus and antilymphocyte agent (Muromonab, anti-CD3)  Technical problems common in liver: o 1st, US check for biliary obstruction o Then check for thrombosis by Doppler  Cardiac sxs come late periodic ventricular bx Chronic Rejection  Occurs after years  Due to T-lymphocytes  Untreatable need re-transplantation

ANESTHESIA Local  Lidocaine, etc.: Give with epi to prevent systemic absorption  numb tongue, seizures, hypotension, bradycardia, arrhythmias  NO epi: Fingers, nose, penis, toes Spinal/subarachnoid  Bupivicaine, etc.: Pts who can’t be intubated o Can’t give if incr ICP or hypotensive  Epidural (local + opioid): If “high block,” blocks cardiac SNS/phrenic nerve General  Meperidine: Norperidine metabolite can lower seizure threshold, esp. in pts w/renal failure  Succinylcholine: Can cause malignant hyperthermia, hyperK (do not use in burn or crush victims)  Rocuronium, etc.: Sometimes allergic rxn in asthmatics  Halothane, etc.: Can cause malignant hyperthermia (tx w/dantrolene Na), liver toxicity

UROLOGY  BPH: Anticholinergics worsen  foley for acute urinary retention  Medical tx 1st : Tamsulosin or finasteride  Surgical tx: TURP (hyponatremia, retro-ejac) Prostate Cancer  Nodules on DRE or elevated/rising PSA: Transrectal ultrasound and bx.  Bone scan looks for blastic lesions.  Tx w/surgery, radiation, leuprolide or flutamide Kidney Stones  CT is best test  Stone 5mm: Shockwave lithotripsy  >2cm: Surgical removal Scrotal Mass  Transilluminate (cystic = hydrocele/hernia; solid = tumor)



U/S & excision o Don’t bx!  Know hormone markers! Testicular Torsion  Acute pain and swelling w/ high riding testis  STAT Doppler U/SNo flow (contrast w/ epididymitis)  Can surgically salvage if