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388 Cards in this Set
- Front
- Back
|
arc of Riolan |
short direct connection between IMA and SMA |
|
|
blood supply of rectum |
superior rectal artery - branch of IMA middle rectal artery - branch of internal iliac inferior rectal artery - branch of internal pudendal artery |
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Griffith's point |
watershed area of splenic flexure at junction of SMA and IMA |
|
|
Sudak's point |
watershed area of rectum where superior rectal and middle rectal junction |
|
|
from anal verge distance |
0-5 cm anal canal 5-15 cm rectum 15-18 cm rectosigmoid junction |
|
|
main fuel for colonocytes |
short-chain fatty acids |
|
|
risk of colonic adenoma having invasive malignancy |
5% |
|
|
risk of villous adenoma harboring invasive malignancy |
40%
22% for tubulovillous |
|
|
colorectal cancer screening for moderate risk |
first degree with cancer < 60 or > 2 with CRC start at 40 yrs or 10 yrs prior with colonoscopy every 5 yrs
if > 60 then same as average risk with cscope every 10 yrs |
|
|
colorectal cancer screening for FAP |
initiate surveillance at 10-12 yrs |
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|
colorectal cancer screening for HNPCC |
start at age 20-25 yrs or 10 yrs prior with biennial colonoscopy until age 40 and then annually |
|
|
false-positive guaiac |
beef, vit C, iron, antacids, cimetidine |
|
|
surveillance after resection of single adenoma < 1 cm |
colonoscopy 5 yrs postpolypectomy, if normal then resume q10yrs |
|
|
surveillance after resection of > 1 cm adenoma or high-risk adenoma |
colonoscopy 3 yrs postpolypectomy, if normal then q5 yrs |
|
|
surveillance after curative resection for CRC |
cscope within 1 yr postoperatively, repeat in 3 yrs then q5 yrs |
|
|
surveillance for IBD |
cscope within 8 yrs of diagnosis and survery q1-2 yrs |
|
|
colon cancer associations |
correlation with meat intake, clostridium septicum, APC, DCC, p53, k-ras |
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|
FAP |
autosomal dominant, APC gene
total colectomy at age 20
proctocolectomy, rectal muosectomy, and ileoanal J-pouch
also get periampullary tumors of duodenum |
|
|
Gardner's syndrome |
FAP with desmoid tumors/osteomas |
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Turcot's syndrome |
FAP with brain tumors |
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|
Lynch Syndrome |
HNPCC a/w DNA mismatch repair gene (MSH, MLH, PMS)
Lynch 1 - just colon CA
Lynch 2 - inc risk of ovarian, endometrial, bladder, and gastric cancer |
|
|
woman with Lynch syndrome |
endometrial biopsy q3 yrs and annual pelvic exams, earlier mammograms
after childbearing years consider TAHBSO |
|
|
Sigmoid volvulus |
debilitated, psychiatric patients, neuro dysfunction, laxative abuse
peritoneal signs - OR for sigmoidectomy
Tx: decompress with colonoscopy, give bowel prep, sigmoidectomy in same admission |
|
|
cecal volvulus |
occurs in 20-30s
decompression successful only 20% of time
Tx: OR for right hemicolectomy, can try cecopexy if colon viable and patient is frail |
|
|
ulcerative colitis features |
involves only colon involves rectum and moves proximal
bleeding, friable mucosam, pseudopolyps
Tx: sulfasalazine, 5-ASA, steroids, MTX, azathioprine, infliximab, loperamide |
|
|
Crohn's disease features |
transmural, granulomas, fissures, skip lesions, involves entire GI tract, perianal disease, fistulization, aphthous ulcers, cobblestoning, creeping fat, longitudinal ulcer, rectal sparing |
|
|
what does not improve with colectomy in patient with UC |
primary sclerosing cholangitis, ankylosing spondylitis |
|
|
LaPlace Law |
tension = pressure x diameter |
|
|
diverticular bleed |
causes arterial bleeding, recurs in 25%
colonoscopy or angio if massive bleed
OR if hypotensive despite resuscitation --> subtotal colectomy |
|
|
angiodysplasia bleeding |
causes venous bleeding
80% recur |
|
|
anal fissure |
90% in posterior midline
can see sentinel pile
sitz baths, bulk agent, lidocaine jelly, stool softeners
lateral internal sphincterotomy if med mgmt fails |
|
|
Goodsall's rule |
anterior goes in straight line to rectum
posterior goes in curvilinear to rectum |
|
|
anal cancer a/w |
HPV and XRT |
|
|
#1 cause of rectal ulcer in AIDS |
HSV |
|
|
anal canal SCC |
Nigro protocol - 5-FU, mitomycin C, XRT
APR for persistent or recurrent cancer |
|
|
anal canal melanoma |
WLE |
|
|
perianal or anal margin SCC |
treat like skin cancer with WLE w 0.5 cm margins |
|
|
Bowen's disease of anal margin |
malignant intraepidermal squamous cell CA |
|
|
Paget's disease of anal margin |
intraepidermal apocrine gland CA |
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|
most common complication following hernia repair |
urinary retention |
|
|
most common cause for testicular atrophy after hernia repair |
thrombosis of spermatic cord veins 2/2 dissection of distal component of the hernia sac causing vessel disruption |
|
|
pain after hernia |
usually from compression of ilioinguinal nerve
tx with local lidocaine |
|
|
ilioinguinal nerve injury |
loss of cremasteric reflex, numbness on ipsilateral penis, scrotum, and thigh |
|
|
most common nerve injury during laparoscopic hernia repair |
genitofemoral nerve
genital branch - cremaster (motor) and scrotum (sensory)
femoral branch - sensory to upper later thigh |
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|
spigelian hernia |
lateral border of rectus muscle through linea semilunaris |
|
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Littre's hernia |
incarcerated Meckel's diverticulum |
|
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Petit's hernia |
inferior lumbar hernia
external oblique, lat dorsi, and iliac crest |
|
|
Grynfeltt's hernia |
superior lumbar hernia
internal oblique, lumbodorsal aponeurosis, and 12th rib |
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|
most common retroperitoneal tumor |
#1 lymphoma
#2 liposarcoma |
|
|
CO2 pneumoperitoneum |
increase: pulmonary artery pressure, HR, SVR, CVP, mean airway pressure, peak inspiratory pressure, CO2
decrease: pH, venous return, renal flow, cardiac output |
|
|
testicular mass |
orchiectomy via inguinal incision |
|
|
seminoma testicular cancer |
#1 testicular tumor no AFP elevation 10% have bHCG elevation
Tx: XRT --> orchiectomy and XRT --> chemo (cisplatin, bleomycin, VP-16) for positive nodes, metastatic disease, or bulky retroperitoneal disease |
|
|
nonseminomatous testicular cancer |
90% have AFP and beta-HCG
hematogenous spread
Stage I = orchiectomy, retroperitoneal node dissection
Stage II = orchiectomy, XRT, and chemo |
|
|
most common complication after resection of prostate cancer |
impotence |
|
|
RCC with growth in IVC |
pull tumor thrombus out of IVC with radical nephrectomy (kidney, adrenal, fat, Gerota's, regional nodes)b |
|
|
bladder cancer |
intravesical BCG or TURB if T1
cystectomy if T2 (if muscle wall invaded) with ileal conduit, chemo, and XRTur |
|
|
ureteral trauma - if repairing end-to-end |
spatulate ends, use absorbable suture, stent ureter, and place drains |
|
|
post-TURP syndrome |
hyponatremia 2/2 irrigation with water, can precipitate seizures |
|
|
stress incontinence |
hypermobile urethra
Tx: Kegel exercises, alpha-adrenergic agents |
|
|
urge incontinence |
sense of urgency or frequency
Tx: anticholinergics, behavior modification |
|
|
treatment of ureteropelvic obstruction |
pyeloplasty |
|
|
treatment for vesicoureteral reflux |
reimplanation with long bladder portion |
|
|
treatment for ureteral duplication |
most common urinary tract abnormality
Tx - reimplantation |
|
|
treatment for ureterocele |
resect and reimplant |
|
|
hypospadias |
ventral
tx - repair at 6 months with penile skin |
|
|
epispadias |
dorsal
surgery |
|
|
SCC of penis |
penectomy with 2-cm margin |
|
|
endometriosis tx |
OCP |
|
|
PID diagnosis and tx |
increased risk of infertility and ectopic pregnancy
Dx: cervical cultures, cerbical motion tenderness, Gram stain
Tx: ceftriaxone, doxycycline |
|
|
gonococcus |
diplococci |
|
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chlamydia |
granuloma lymphadenopathy |
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HSV |
condylomata, vesicles |
|
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Syphilis |
+ dark-field microscopy, chancre |
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|
vulvar cancer |
< 2 cm WLE and inguinal node dissection ipsilateral
> 2 cm vulvectomy with bilateral inguinal node dissection, XRT if margins < 1 cm |
|
|
ovarian cancer treatment |
TAHBSO debulking omentectomy 4 quadrant washes chemo with cisplatin and paclitaxel |
|
|
ovarian cyst in postmenopausal patient |
if septated, has increase vascular flow, has solid components, or has papillary projections, oophorectomy with intraoperative frozen sections, TAH if ovarian CA
if none of above present, then f/u with US |
|
|
ovarian cyst in premenopausal patient |
if septated, has increase vascular flow, solid components, or has papillary projections, then oophorectomy with frozen sections |
|
|
incidental ovarian mass at time of laparotomy for another procedure |
postmenopausal - oopherectomy, frozen section, TAHBSO if cancer
premenopausal - partial oophorectomy and frozen section, if cancer removal of tube and ovary with GYN |
|
|
subdural hematoma |
higher mortality than epidural hematoma, torn bridging veins, crescent shape on head CT |
|
|
epidural hematoma |
injury to middle meningeal artery |
|
|
subarachnoid hemorrhage |
OR only if neurologically intact |
|
|
head trauma with decrease CPP |
elevate head of bed, sedate and paralyze, moderate hyperventilation (30-35), mannitol, +/- decompressive craniectomy |
|
|
Cushing's triad |
hypertension, bradycardia, and slow respiratory rate |
|
|
cord injury with deficit |
high-dose steroids |
|
|
complete cord transection |
areflexia, flaccidity, anesthesia, and autonomic paralysis |
|
|
spinal shock |
hypotension, normo/bradycardia, warm extremities (vasodilated)
tx with fluids initially, may need alpha agonist |
|
|
anterior spinal artery syndrome |
usually with acutely ruptured cervical disc
bilateral loss of motor, pain, and temp sensation
preservation of position, vibration, light touch |
|
|
Brown-Sequard syndrome |
loss of ipsilateral motor and contralateral pain and temperature
90% recover |
|
|
Central Cord syndrome |
most commonly occurs with hyperflexion of cervical spine
bilateral loss motor, pain, and temperature in upper extremities, lower extremities spared |
|
|
most common brain tumor in children |
medulloblastoma |
|
|
most common metastatic brain tumor in children |
neuroblastoma |
|
|
most common spine tumor |
neurofibroma
intradural benign more likely than extradural |
|
|
Salter-Harris III, IV, V |
cross epiphyseal plate and can affect the growth plate
need open reduction and internal fixation |
|
|
Salter-Harris I and II |
does not cross growth plate
closed reduction and casting |
|
|
L3 nerve (L2-3 disc) |
difficulty in hip flexion |
|
|
L4 nerve (L3-4 disc) |
difficulty in knee extension and weak patellar reflex |
|
|
L5 nerve (L4-5 disc) |
weak dorsiflexion (foot drop), decrease sensation in big toe web space |
|
|
S1 nerve (L5-S1 disc) |
weak plantar flexion, weak Achilles, decrease sensation in lateral foot |
|
|
ulnar nerve |
intrinsic musculature of hand, finger abduction, wrist flexion
back of hand, 5th and 1/2 of 4th digit sensation
injury results in claw hand |
|
|
median nerve |
thumb apposition, thumb abduction, finger flexors
most of palm and 1st 3.5 fingers sensation
carpal tunnel syndrome |
|
|
radial nerve |
wrist extension, finger/thumb extension, triceps
dorsal 1st 3.5 finger sensation |
|
|
musculocutaneous nerve |
motor to biceps, brachialis, coracobrachialis |
|
|
risk of what for scaphoid fracture |
avascular necrosis |
|
|
Volkmann's contracture |
a/w supracondylar humeral fracture, occluded anterior interosseous artery, reperfusion after reduction forearm compartment syndrome
Fasciotomy |
|
|
anterior leg compartment |
anterior tibial artery, deep peroneal nerve |
|
|
lateral leg compartment |
superficial peroneal nerve |
|
|
deep posterior compartment |
posterior tibial artery, peroneal artery, and tibial nerve |
|
|
superficial posterior leg compartment |
sural nerve |
|
|
most common mediastinal tumor in children |
neurogenic tumors (neurofibroma, neuroganglionoma, neuroblastoma) - usually located posteriorly |
|
|
most common anterior mediastinal mass in children |
T cell lymphoma, teratoma, or germ cell tumor |
|
|
overall survival in children with diaphragmatic hernia |
50% |
|
|
diaphragmatic hernias |
left side 80%, severe pulmonary HTN, 80% a/w anomalies |
|
|
most common diaphragmatic hernia |
Bochdalek's hernia, posterior and to left |
|
|
Morgagni's hernia |
rare, located anteriorly |
|
|
#1 solid abdominal malignancy in children |
neuroblastoma - HTN, adrenals, 1st 2 yrs of life, increased catecholamines/VMA/HVA/metanephrines, from neural crest cells, rarely metastasize
NSE, LDH, HVA, diploidy, N-myc = worse prognosis |
|
|
Wilm's tumor (nephroblastoma) |
mean age of diagnosis 3 yrs, prognosis based on tumor grade, frequent mets to bone and lung, a/w with Beckwith-Wiedemann syndrome, replacement of renal parenchyma on CT
Tx: nephrectomy
actinomycin, vincristine, doxorubicin, XRT |
|
|
#1 children's malignancy overall |
leukemia (ALL) |
|
|
#1 solid tumor class |
CNS tumors |
|
|
treatment for pyloric stenosis |
pyloromyotomy |
|
|
most common type of tracheoesophageal fistula |
type C (80-90%)
blind esophagus, distal TE fistula |
|
|
gastroschisis |
intrauterine rupture of umbilical vein, does not have peritoneal sac |
|
|
failure to pass meconium in 1st 24 hrs |
Hirschsprung's disease, absence of ganglion cells in myenteric plexus, failure of migration neural crest cells |
|
|
ABO blood-type antigens |
glycolipids on cell membrane
HLA-type antigens are glycoproteins |
|
|
protein kinase C |
activated by calcium and DAG |
|
|
protein kinase A |
activated by cAMP |
|
|
intrinsic pathway |
exposed collagen + prekallikrein + HMW kininogen + factor XII
convert prothrombin (factor II) to thrombin |
|
|
thrombin function |
converts fibrinogen to fibrin (which forms platelet plug) |
|
|
extrinsic pathway |
tissue factor and factor VII
converts prothrombin to thrombin |
|
|
response to vascular injury |
vascular vasoconstriction, platelet adhesion, thrombin generation |
|
|
heparin binds ? |
AT-III (binds and inhibits thrombin) |
|
|
plasmin |
degrades factors V and VIII, fibrinogen, and fibrin |
|
|
which factor has shortest half-life |
factor VII |
|
|
which factors are heat-labile |
factors V and VIII |
|
|
prostacyclin PGI2 |
from endothelium decrease platelet aggregation and promotes vasodilation |
|
|
thromboxane |
from platelets, increases platelet aggregation and promotes vasoconstriction
triggers release of calcium and activates PIP system, exposing GpIIb/IIIa receptor |
|
|
cryoprecipitate |
VIII and vWF and fibrinogen |
|
|
FFP |
high levels of all factors |
|
|
acute hemolytic reaction |
ABO incompatibility, antibody mediated |
|
|
delayed hemolysis |
antibody-mediated against minor antigens |
|
|
febrile nonhemolytic transfusion reaction |
recipient antibody against donor WBC |
|
|
anaphylaxis |
IgG against IgA in IgA-deficient recipient |
|
|
TRALI |
antibodies against recipient WBC |
|
|
what causes B-cell maturation into plasma cells |
IL-4 |
|
|
what causes maturation of cytotoxic T cells |
IL-2 |
|
|
clean surgery |
2% risk of wound infection |
|
|
clean-contaminated |
3-5% risk of wound infection (elective colon resection in prepped bowel) |
|
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contaminated |
5-10% risk of wound infection |
|
|
dirty |
30% risk of wound infection |
|
|
MOA of penicillins, cephalosporins, carbapenems, monobactams, vancomycin |
inhibitors of cell wall synthesis |
|
|
MOA of tetracycline, ahminoglycosides, linezolid |
inhibitors of 30s ribosome and protein synthesis |
|
|
MOA of erythromycin, clindamycin, chloramphenicol, Syndercid |
inhibitors of 50s ribosome subunit and protein synthesis |
|
|
MOA of quinolones |
inhibitors of DNA gyrase/helicase |
|
|
rifampin MOA |
inhibitor of RNA polymerase |
|
|
flagyl MOA |
produces oxygen radicals that breakup DNA |
|
|
sulfonamides |
PABA analogue, inhibit purine synthesis |
|
|
trimethoprim |
inhibits dihydrofolate reductase, inhibits purine synthesis |
|
|
bacteriostatic agents |
chloramphenicol, tetracycline, clindamycin, erythromycin, Bactrim |
|
|
aminoglycosides |
irreversible binding to ribosome, bactericidal |
|
|
penicillin resistance |
plasmids for beta-lactamase |
|
|
most common method of antibiotic resistance |
plasmid transfer |
|
|
MRSA mechanism of resistance |
mutation of cell-wall binding protein |
|
|
VRE |
mutation in cell wall-binding protein |
|
|
gentamicin resistance (aminoglycoside) |
resistance due to modifying enzymes leading to decrease in active transport |
|
|
how many half-lives of drug to reach steady state |
5 |
|
|
volume of distribution |
amount of drug in body divided by amount of drug in plasma or blood
drugs with high volume of distribution have higher concentrations in extravascular components (fat tissue)
|
|
|
ED50 |
drug level at which desired effect occurs in 50% of patients |
|
|
LD50 |
drug level at which death occurs in 50% of patients |
|
|
Phase I drug metabolism |
demethylation, oxidation-reduction, hydrolysis
P450 |
|
|
Phase II drug metabolism |
glucuronic acid and sulfates attached to form water-soluble metabolite |
|
|
polar drugs or non-polar drugs more water soluble? |
polar drugs more water soluble and more likely to be eliminated in unaltered form
non polar drugs more fat soluble and more likely to be metabolized before excretion |
|
|
digoxin |
Na/K ATPase inhibitor and increase myocardial calcium
inotrope
implicated in mesenteric ischemia due to decrease blood flow to intestine
not cleared with dialysis
|
|
|
inhibit adrenal steroid synthesis |
aminoglutethimide and metyrapone
used for adrenocortical carcinoma |
|
|
indomethacin |
inhibits PGE production
used to close PDA and in patients with gout |
|
|
side effect of gadolinium |
nausea |
|
|
nitrous oxide |
fast, minimal myocardial depression |
|
|
halothane |
slow
highest degree of cardiac depression and arrhythmias
can effect liver (hepatitis) |
|
|
enflurane |
can cause seizure |
|
|
isoflurane |
good for neurosurgery |
|
|
sevoflurane |
less myocardial depression
fast onset/offeset
less laryngospasm |
|
|
sodium thiopental |
fast acting
decrease cerebral blood flow and metabolic rate |
|
|
propofol |
fast on/off and rapid distribution
do not use with egg allergy
metabolized in liver and by plasma cholinesterases |
|
|
ketamine |
dissociative agent
no respiratory depression
can cause tachycardia, hallucinations, increase cerebral blood flow
contraindication in head injury
good for children |
|
|
etomidate |
few hemodynamic changes
fast acting
can lead to adrenocortical suppression |
|
|
diaphragm |
last to go and first to come back from paralytic |
|
|
the only depolarizing paralytic |
succinylcholine |
|
|
succinylcholine |
fast, short-acting, fasciculations
side effects: malignant hyperthermia (increased end-tidal CO2 - give dantrolene), prolonged paralysis in patients with atypical pseudocholinesterases, open-angle glaucoma can become closed-angle, hyperkalemia
do not use in burn patients, neuro injury, nm disorders, spinal cord injury, massive trauma, ARF |
|
|
nondepolarizing paralytics |
inhibit NMJ by competing with acetylcholine
prolongation of these agents with hypothermia, hypercarbia, antibiotics, electrolyte abnormalities, myasthenia gravis |
|
|
which non depolarizing agent undergoes Hoffman degradation |
Cis-atracurium - can be used in liver and renal failure |
|
|
which non depolarizing agents is degraded by plasma cholinesterases |
mivacurium |
|
|
rocuronium - metabolism? |
hepatic metabolism, fast, intermediate duration |
|
|
pancuronium - metabolism? |
renal metabolism, long-lasting, slow-acting
most common side effect is tachycardia |
|
|
reversing drugs for non depolarizing agents |
neostigmine, edrophonium, atropine or glycopyrrolate
|
|
|
neostigmine and edrophonium |
acetylcholinesterase inhibitors, indirectly increase Ach
atropine or glycopyrrolate (acetylcholine receptor antagonists) - given to counteract overdose of Ach |
|
|
infected tissues hard to anesthetize secondary to ? |
acidosis
local works by increasing action potential threshold thus preventing Na influx |
|
|
length of action of local anesthestic |
bupivacaine > lidocaine > procaine |
|
|
opiods |
metabolized by liver and excreted by kidney
morphine - histamine release
demerol - no histamine release, don't give in renal failure b/c active metabolite build up can cause seizures |
|
|
BZD |
hepatically metabolized |
|
|
midazolam |
short-acting, don't give in pregnancy, crosses placenta |
|
|
lorazepam |
long acting |
|
|
diazepam |
long acting |
|
|
epidural anesthesia |
causes sympathetic denervation and vasodilation
Tx for acute hypotension and bradycardia: turn down epidural, give IVF, phenylephrine and atropine |
|
|
morphine in epidural can cause? |
respiratory depression |
|
|
lidocaine in epidural can cause? |
decreased heart rate and blood pressure |
|
|
spinal anesthesia |
injection into subarachnoid space, spread determined by basicity and patient position |
|
|
complications of epidural and spinal anesthesia |
hypotension, headache, urinary retention, abscess/hematoma, neurologic impairment
resp depression in high spinal |
|
|
spinal headaches |
rest, IVF, caffeine, analgesics
blood patch if persists > 24 hrs |
|
|
NS composition |
Na and Cl 154 |
|
|
LR composition |
Na 130 K 4 Ca 2.7 Cl 109 bicarb 28 |
|
|
plasma osmolarity |
2xNa + glucose/18 + BUN/2.8
normal 280-295 |
|
|
stomach secretion amount |
1-2 L per day
replace with D5 1/2 NS w 20 K |
|
|
biliary system secretion amount |
500-1000 cc per day
LR w bicarb |
|
|
pancreas |
500-1000 cc per day
LR w bicarb |
|
|
duodenum |
500-1000 cc per day
LR w bicarb |
|
|
normal K requirement and Na requirement |
Na 1-2 mEq/kg/day
K 0.5-1 mEq/kg/day |
|
|
large intestine fluid loss replacement |
LR w K |
|
|
free water deficit |
0.6 x wt in kg x (Na/140 - 1) |
|
|
total body water |
TBW = 0.6 x wt in kg |
|
|
correction of hyponatremia |
water restriction diuresis NaCl replacement |
|
|
pseudohyponatremia |
for every 100 above normal glucose, add 2 points to Na value |
|
|
FeNa |
(urine Na/Cr)/(plasma Na/Cr) |
|
|
burn nutrition |
25 kcal/kg/day + (30 kcal/day x % burn)
protein: 1-1.5 g/kg/day + 3g x % burn |
|
|
Harris-Benedict equation |
calculations basal energy expenditure
uses age, height, weight, and gender |
|
|
fuel for colonocytes |
SCFA |
|
|
fuel for small bowel enterocytes |
glutamine, most common AA in bloodstream and tissue |
|
|
primary fuel for neoplastic cell |
glutamine |
|
|
acute indicators of nutritional status |
retinal binding protein, prealbumin, transferrin, total lymphocyte count |
|
|
glycogen stores depleted in ? |
24-36 hrs of starvation, body then switches to fat |
|
|
primary substrate for gluconeogenesis |
alanine |
|
|
protein-conserving mechanisms |
occur with starvation, not after trauma or surgery 2/2 catecholamines and cortisol |
|
|
fuel for brain after starvation |
ketones |
|
|
mediator of cachexia |
TNF-alpha |
|
|
preferential source of energy for liver, heart, and skeletal muscle |
saturated fatty acids (ketones = acetoacetate and beta-hydroxybutyrate) |
|
|
essential fatty acids |
linolenic and linoleic |
|
|
omega-3 fatty acids |
thought to have antioxidant properties |
|
|
carb digestion begins with ? |
salivary amylase |
|
|
protein digestion begins with ? |
pepsin in stomach |
|
|
chromium deficiency |
hyperglycemia, encephalopathy, neuropathy |
|
|
cardiomyopathy, weakness, hair loss |
selenium |
|
|
pancytopenia - which deficiency |
copper |
|
|
hair loss, poor healing, rash |
zinc |
|
|
weakness (failure to wean vent), encephalopathy, decreased phagocytosis |
phosphate |
|
|
peripheral neuropathy, cardiomyopathy, Wernicke's encephalopathy |
B1 (thiamine) |
|
|
glossitis, peripheral neuropathy, sideroblastic anemia |
B6 (pyridoxine) |
|
|
peripheral neuropathy, beefy tongue, megaloblastic anemia |
B12 (cobalamin) |
|
|
pellagra (diarrhea, dermatitis, dementia) |
niacin |
|
|
dermatitis, hair loss, thrombocytopenia |
essential fatty acids |
|
|
night blindness |
vitamin A |
|
|
coagulopathy |
vitamin K |
|
|
rickets, osteomalacia |
vitamin D |
|
|
tumor marker for small cell lung cancer and neuroblastoma |
neuron-specific enolase |
|
|
most vulnerable stage of cell cycle for XRT |
mitosis, most damage done by formation of oxygen radicals, need high oxygen levels |
|
|
high-energy radiation has skin-preserving effect |
maximal ionizing potential not reached until deeper structures |
|
|
very radiosensitive tumors |
seminomas, lymphomas |
|
|
radioresistant tumors |
sarcomas, epithelial |
|
|
taxol (paclitaxel) |
promotes microtubule and stabilizes them so that they cannot be broken down, cells rupture |
|
|
bleomycin, busulfan |
cause pulmonary fibrosis |
|
|
cisplatin (platinum alkylating agent) |
nephrotoxic, neurotoxic, ototoxic |
|
|
carboplatin |
bone suppression |
|
|
vincristine/vinblastine |
microtubule polymerization inhibitors
peripheral neuropathy
vinblastine - bone suppression |
|
|
5-FU |
inhibits thymidylate synthesis |
|
|
tumor suppressor genes |
Rb1, p53, APC, DCC, bcl, BRCA |
|
|
protooncogenes |
ras - G protein defect src - tyrosine kinase defect sis - PDGF receptor defect erb B - EGF receptor defect myc - transcription factors |
|
|
predictors of mortality and survival after resection of hepatic colorectal metastases |
disease-free survival < 12 months, tumor number > 3, CEA > 200, size > 5 cm, node positive primary |
|
|
cyclosporin (CSA) MOA |
binds cyclophilin and inhibits cytokine synthesis
hepatic and biliary excretion |
|
|
FK-506 (prograf) |
binds FK-binding protein, similar action to CSA but more potent |
|
|
ATGAM |
induction therapy, polyclonal antibodies directed against antigens on T cells |
|
|
OKT3 |
monoclonal antibodies that block antigen recognition function of T cells by binding CD3
for severe rejection |
|
|
Zenapax |
human monoclonal antibody against IL-2 |
|
|
Hyperacute rejection |
occurs within minutes to hours
caused by preformed antibodies that should have been picked up by crossmatch
Tx: emergent retransplant |
|
|
Accelerated Rejection |
< 1 week
sensitized T cells to donor antigens, produces secondary immune response
Tx: increase immunosuppression, pulse steroids, possibly OKT3 |
|
|
Acute rejection |
1 week to 1 month
via T cells
Tx: immunosuppression, pulse steroids, OKT3 |
|
|
Chronic rejection |
months to years
by sensitized T cells (delayed type IV)
leads to graft fibrosis and vascular damage |
|
|
chronic rejection for lung transplant |
bronchiolitis obliterans |
|
|
nitric oxide |
arginine precursor
activates guanylate cyclase and increases cGMP
vascular smooth muscle dilation |
|
|
endothelin |
vascular smooth muscle constriction |
|
|
main initial cytokine response to injury and infection |
TNF-alpha and IL-1 |
|
|
largest producers of TNF |
macrophages |
|
|
IL-1 |
responsible for fever
also released by alveolar macrophages with atelectasis |
|
|
IL-6 |
increases hepatic acute phase proteins
lymphocyte activation |
|
|
interferons |
released by lymphocytes
activate macrophages, NKC, cytotoxic T cells
inhibit viral replication |
|
|
increased hepatic acute proteins |
CRP, amyloid A/P, fibrinogen, haptoglobin, ceruloplasmin, alpha-1 antitrypsin, C3 |
|
|
decreased hepatic acute phase proteins |
albumin and transferrin |
|
|
Selectins |
on leukocytes, bind to E- and P- selectins
rolling adhesion |
|
|
Beta-2 integrins |
bind ICAMS
anchoring adhesion |
|
|
PGI2 and PGE2 |
vasodilation, bronchodilation, increase permeability
inhibits platelets |
|
|
PGD2 |
vasodilation, bronchoconstriction, increase permeability |
|
|
catecholamines |
peak 24-48 hrs after injury |
|
|
neuroendocrine response to injury |
afferent nerves from site of injury stimulate CRF, ACTH, ADH, growth hormone, epinephrine, and norepinephrine release |
|
|
primary mediator of reperfusion injury |
PMNs |
|
|
wound healing phases |
inflammation - PMNs and macrophages proliferation - fibroblasts remodeling - type III replaced by type I collagen |
|
|
order of cell arrival in wound |
platelets PMN macrophages fibroblasts lymphocytes |
|
|
chemotactic for macrophages and anchors fibroblasts |
fibronectin |
|
|
predominant cell type 0-2, 3-4, 5 and on |
0-2 PMN 3-4 macrophages then fibroblasts |
|
|
platelet granules |
alpha granules - PF4, beta-thrombomodulin, PDGF
dense granules - adenosine, serotonin, calcium |
|
|
strength of small bowel |
submucosa
weakest time point for anastomosis is 3-5 days |
|
|
myofibroblasts |
involved in wound contraction and healing by secondary intention |
|
|
collagen |
I - most common type, skin, bone, tendons II - cartilage III - healing wound, blood vessels, skin IV - basement membranes V - widespread, cornea |
|
|
required for hydroxylation of proline and subsequent cross-linking of proline residues |
alpha-ketoglutarate, vitamin C, oxygen, iron |
|
|
collagen has __________ every 3rd amino acid |
proline
also has abundant lysine |
|
|
tensile strength |
never equal to prewound, but 80%
Type III for days 1-2, then type I
type III replaced by type I by 3 weeks
6 weeks - 60% of original, 80% of final
8 weeks - 80% of original, maximum strength |
|
|
what inhibits collagen cross-linking |
d-Penicillamine |
|
|
essential for wound healing |
moist, oxygen (TCOM > 25 mm Hg), avoid edema, remove necrotic tissue |
|
|
impediments to wound healing |
bacteria > 100000, devitalized tissue and foreign bodies, cytotoxic drugs, diabetes, albumin < 3, steroids (vitamin A 25 K IU qd), wound ischemia |
|
|
osteogenesis imperfecta |
type I collagen defect |
|
|
Ehlers-Danlos syndrome |
collagen disorders |
|
|
Marfan's syndrome |
fibrillin defect |
|
|
Epidermolysis bullosa |
excessive fibroblasts
Tx with phenytoin |
|
|
what does FAST scan miss |
retroperitoneal bleeding, hollow viscus injury |
|
|
CT scan following blunt trauma in patients with ? |
abd pain, need for general anesthesia, closed head injury, intoxicated, paraplegia, distracting injury, hematuria |
|
|
CT scan misses what in trauma? |
hollow viscus injury, diaphragm injury |
|
|
epidural hematoma |
operate if significant neurologic deterioration or significant mass effect > 5 mm |
|
|
most common site of facial nerve injury |
geniculate ganglion
FN injuries need repair |
|
|
anterior vs posterior nosebleeds treatment |
anterior - packing
posterior - try balloon tamponade, may need angioembolization of internal maxillary artery or ethmoidal artery |
|
|
asymptomatic blund trauma to neck |
neck CT scan |
|
|
symptomatic blunt or penetrating trauma to neck |
need neck exploration |
|
|
tracheobronchial injury |
Dx with bronchoscopy
Tx: repair if large air leak or resp compromise or after 2 weeks of persistent air leak
left thoracotomy for distal left mainstem injuries otherwise right thoracotomy |
|
|
esophageal injury |
rigid esophagoscopy and esophagogram |
|
|
diaphragm injury |
more likely on left and from blunt trauma
transabdominal approach if < 1 week
chest approach if > 1 week |
|
|
signs of aortic transection |
widened mediastinum, 1st rib fractures, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to right
head on car crash > 45 mph or fall > 15 ft need aortogram or CT angio |
|
|
most common cause of death with myocardial contusion |
v-tach and v-fib
highest risk in 1st 24 hrs
SVT most common arrhythmia overall in these patients |
|
|
penetrating "box" injury to chest |
need pericardial window, bronchoscopy, esophagoscope, barium swallow
if blood found on pericardial window, need sternotomy to fix cardiac injury and place pericardial drains |
|
|
penetrating chest wound outside of "box" without pneumo/hemothorax |
chest tube if patient required intubation
otherwise follow CXRs |
|
|
penetrating injury anterior-medial to midaxillary line and below nipples |
need laparotomy or laparoscopy |
|
|
pelvic fracture and HD unstable with negative DPL/CXR and no other reason for shock |
pelvic stabilization and angioembolization |
|
|
anterior pelvic fractures |
more likely to have venous bleeding
posterior pelvic fractures have arterial bleeding |
|
|
penetrating injury pelvic hematomas |
open
blunt - leave unless expanding or patient unstable (stabilize, pack if in OR, angio) |
|
|
most common area of injury in duodenal trauma |
2nd portion, can also get tears at ligament of Treitz
most can be treated with debridement and primary closure
fistulas are major source of morbidity |
|
|
paraduodenal hematomas |
usually in 3rd portion overlying spine
if in OR -- need to open these up |
|
|
missed duodenal hematomas |
can present as high SBO 12-72 hrs after injury
stacked coins or coiled spring appearance
conservative treatment (TPN and NGT) - cures 90% |
|
|
most common organ injury with penetrating trauma |
small bowel |
|
|
mesenteric hematomas |
open if expanding or > 2 cm |
|
|
paracolonic hematomas |
both blunt and penetrating need to be opened |
|
|
portal triad hematoma |
need to be explored |
|
|
common bile duct injury |
< 50% - repair primary over stent
> 50% - choledochojejunostomy
may need IOC |
|
|
portal vein injury |
need to repair
ligation of portal vein 50% mortality |
|
|
conservative mgmt of blunt liver injury |
failed if > 4 units PRBC or to keep hct > 25, active blush on CT or pseudo aneurysm (angio if posterior, OR if anterior)
bed rest x 5 days |
|
|
conservative mgmt of blunt splenic injury |
has failed if > 2 units price, active blush or pseudo aneurysm, bedrest for 5 days |
|
|
pancreatic trauma |
distal pancreatic duct injury - distal panc
pancreatic head injury not reparable - drain initially, delayed Whipple if necessary
open pancreatic hematoma |
|
|
whipple vs distal panic based on duct injury in relation to ? |
SMA/SMV
to the right require drains initially instead of whipple initially |
|
|
IVC injury |
< 50% stenosis then primary repair
otherwise use saphenous vein graft or synthetic patch |
|
|
orthopaedic emergencies |
unstable patient with pelvic fracture, spine injury with deficits, open fractures, dislocation/fracture with vascular compromise, compartment syndrome |
|
|
left renal vein ligation |
must be ligated near IVC as it has adrenal and gonadal collaterals |
|
|
anterior to posterior renal hilum structures |
vein, artery pelvis |
|
|
indications of operation for renal trauma |
acutely - ongoing hemorrhage with instability
after acute phase - major collecting system disruption, unresolving urine extravasation, severe hematuria |
|
|
bladder trauma |
Dx: cystogram
extraperitoneal - starbursts on cystogram, treat with foley for 7-14 days
intraperitoneal - shows leak, operation and repair of defect with foley drainage |
|
|
ureteral trauma |
IVP and RUG best tests |
|
|
if large ureteral segment > 2 cm missing and cannot perform reanastamosis |
upper 1/3 and middle 1/3 - if unstable perc nephrostomy and ligate, otherwise transureteroureterostomy
lower 1/3 (below pelvic brim) - reimplant in bladder, may need posts hitch |
|
|
if small < 2 cm missing of ureter |
can try to mobilize and primarily repair over stent if in upper 2/3 and reimplant if in lower 1/3
leave drains for all ureter trauma |
|
|
urethral trauma |
urethrogram best test
significant tears - suprapubic cystotomy and repair in 2-3 months (stricture and impotence if repair early)
small tear - may bridge with catheter and delayed repair |
|
|
testicular trauma |
repair if ultrasound shows violation of tunica albuginea |
|
|
uterine rupture |
most likely in posterior fundus |
|
|
management of hematomas |
organ - penetrating, blunt pelvic - open, leave paraduodenal, open, open portal triad - open, open retrohepatic - leave, leave mesenteric - open, open pericolonic - open, open perirenal - open, leave |
|
|
MAP = CO x SVR
CI = CO/BSA |
SVRI = SVR x BSA |
|
|
Anrep effect |
automatic increase in contractility 2/2 to increased afterload |
|
|
Bowditch effect |
automatic increase in contractility 2/2 to increase HR |
|
|
O2 delivery |
O2 delivery = CO x arterial O2 content = CO x [(Hb x 1.34 x O2 sat) + (PO2 x 0.003)] |
|
|
right shift on oxygen-Hb dissociation curve |
increase temp, (2,3)-DPG, CO2, ATP production
decrease pH |
|
|
primary determinants of myocardial O2 consumption |
increase ventricular wall tension and HR |
|
|
blood with lowest venous saturation |
coronary venous blood |
|
|
first sign of cardiac tamponade |
impaired diastolic filling of right atrium
treat with fluid resuscitation, then pericardial window or pericardiocentesis |
|
|
initial alteration in hemorrhagic shock |
increased diastolic pressure |
|
|
neurogenic shock |
loss of sympathetic tone, everything decreased
Tx with volume first, then phenylephrine, steroids for blunt spinal trauma with deficit |
|
|
early sepsis triad |
hyperventilation, confusion, respiratory alkalosis |
|
|
gram-negative sepsis (early and late) |
early - decreased insulin, increased glucose 2/2 to impaired utilization
late - increased insulin, increased glucose 2/2 to insulin resistance |
|
|
fat embolus |
sudan red stain
petechia, hypoxia, confusion
long bone fractures |
|
|
PE findings |
RV strain on echo
PA systolic pressures > 40, decreased PO2 and PCO2, respiratory alkalosis, chest pain, cough, dyspnea, increase HR |
|
|
IABP |
inflates on T wave (diastole) and deflates on P wave or start of Q (systole)
decreases afterload
improves SBP which improves coronary perfusion |
|
|
dopamine |
low - dopamine receptors (renal) medium - beta-adrenergic (heart contractility) high - alpha-adrenergic (vasoconstriction) |
|
|
nitroprusside |
arterial and venous dilator
tx cyanide toxicity with amyl nitrite, then sodium nitrate |
|
|
nitroglycerine |
venodilator, decreases preload |
|
|
PEEP |
alveolar recruitment, improves FRC |
|
|
ventilation for bronchopleural fistula and children with TE fistula |
high-frequency jet ventilation |
|
|
ARDS |
acute onset bilateral pulmonary infiltrates PaO2/FiO2 < 200 PAOP < 18 and no clinical evidence of LAH |
|
|
mediators of SIRS |
TNF-alpha and IL-1
T > 38 or < 36 RR > 20 or PCO2 < 32 WBC > 12K or < 4K or > 10% bands HR > 90 |
|
|
most potent stimulus for SIRS |
endotoxin (lipopolysaccharide - lipid A) |
|
|
sepsis |
SIRS with clinical evidence of infection |
|
|
severe sepsis |
sepsis with organ dysfunction |
|
|
septic shock |
sepsis and hypotension despite adequate volume resuscitation |
|
|
pulmonary vasodilation |
bradykinin, PGE1, PGI2, NO |
|
|
pulmonary vasoconstriction |
histamine, serotonin, TXA2, epinephrine, norepinephrine, hypoxia, acidosis |
|
|
most common cause of postoperative renal failure |
hypotension |
|
|
prerenal cause of ARF |
FeNa < 1%, urina Na < 20, BUN/Cr ratio > 20, urine osmolality > 500 |
|
|
indications for HD |
acidosis, fluid overload, hyperkalemia, uremia, toxins |
|
|
renin release |
in response to decreased pressure sensed by JGA
response to hypernatremia sensed by MD cells |
|
|
where does aldosterone act |
distal convoluted tubule |
|
|
atrial natriuretic peptide |
released from atrial wall with atrial distention
inhibits sodium and water resorption in collecting ducts
also a vasodilator |
|
|
ADH |
acts on collecting ducts
secreted by posterior pituitary in response to high osmolality |
|
|
responsible for forming toxic oxygen radicals with reperfusion |
xanthine oxidase from endothelial cells |
