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60 Cards in this Set
- Front
- Back
Which patients are at high risk of VTE during hospital admission?
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ischaemic stroke
history of VTE Active cancer decompensated heart failure acute on chronic lung disease acute inflammatory disease > 60 |
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Which surgeries require post operative VTE prophylaxis?
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5-10 days
knee arthroplasty Major trauma Other surgery with prior VTE and/or active cancer major surgyer AND over age 40 years 28-35 days hip arthroplasy or hip fracture |
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When should warfarin be stopped prior to surgery?
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Omit warfarin for 4 doses prior to surgery
In most cases can recommence on day of surgery or within next few days Can give heparin during this time - depends on specific situation |
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Is aspirin effective in preventing VTE in surgical patients?
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no
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If someone is taking diet or an oral antidiabetic drug and devleop a major illness or have extensive surgery with prolonged post operative fasting how should they they be managed?
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Change them to insulin
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Should oral antidiabetic drugs be stopped prior to surgery?
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Short term fasting not too much of an issue
Sulfonylreas and other insulin sensitisers stop on day of fasting and monitor BG closely |
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How do you manage someone on insulin who goes for surgery?
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Require insulin even though fasting
Continue insulin treatment and start IV glucose from time of first missed meal If complex may require IV infusion of insulin + glucose If non-major - procedure early in morning and withold insulin until after surgery BUT if later in the day give 2/3 of morning and lunchtime doses with extra short acting if required |
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When should you consider prophylactic antibiotics?
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When there is a significant risk of infection (e.g., colonic resection) or where postoperative infection would have severe consequences e.g., infection associated with a prosthetic implant
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Are most post surgical infections due to the patient's own organisms or ones introduced during the surgery?
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own organisms
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How do you manage post operative DVT?
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Graduated compression stockings - 30-40mmHg pressure
Anticoagulation - LMWH - enoxaparin 1.5mg/kg SC daily + start warfarin on same day Give LMWH for 5 days and until INR has 2 on 2 consecutive days Duration of anticoagulation depends on risk |
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Duration of anticoagulation for VTE
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VTE provoked by a transient major RF or unprovoked distal DVT - 3 months
First unprovoked proximal DVT or PE - 6 months Recurrenc unprovoked VTE or first unprovoked VTE and cancer, thrombophilias, antiphospholipid antibody sydnrome - indefinite |
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How do you calculate maintenance fluids?
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100ml/kg/24 hours for first 10 kg
50ml/kg/24 hours for next 10 kg 20ml/kg/24 hours for remaining kg At leasg half give as NaCl 0.9%, the rest as glucose 5% |
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How do you calculate how much fluid to give in someone with hypovolaemia?
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Deficit assess based on acute loss of body weight
2L or 20ml/kd NS in 1st hour 1/2 remaining deficit + maintenance over 8 hr 1/2 remaining deficit + maintenance over following 16 h |
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How does someone with atelectasis present post surgery?
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Low grade fever day 0-2
tachycardia crackles decreased breath sounds bronchial breathing tachypnoea |
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How does someone with post op pneumonia present?
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productive cough
fever tachycardia, cyanhosis, respiratory failure, decreased LOC usually occurs day 0-2 |
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How do you prevent atelectasis?
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Smoking cessation > 6 weeks pre-op
Minimise use of resp depressant drugs good pain control incentive spirometry - deep breathing and coughing early ambulation |
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When do the majority of post operative MIs occur?
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on operative day or first 4 days post op
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How do post operative MIs present?
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Often silent, without chest pain
May only present with new onset CHF, arrhythmias, hypotension |
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What day post op does leakage at bowel anastomosis usually occur?
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POD 5+
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What day do post operative intra-abdominal abscesses usually occur?
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5-10 days
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When does DVT/PE usually occur post op?
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can occur at any time but most commonly day 7-10
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What are the most common organisms involved in operative wound infections
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S. aureus
E Coli Enterococcus Strep Clostridium |
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Which 2 bacterial organisms can present as wound infection within 24 hours?
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Strep and Clostridium
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Which operations require post operative antibiotics
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Contaminated
nonpurulent inflammation, gross spillage from GI, entry into biliary or GU tracts with infected bile/urine, penetrating trauma < 4 hours) Dirty purulent inflammation, pre-op perforation of resp/GI/biliary/GU tracts, penetrating trauma > 4 hours |
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How long should you give post operative antibiotics for?
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No evidence supporting more than 24 hours post-op prophylaxis
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How to you treat wound infections?
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Re-open affect part of incision
Culture wound Pack Heal by secondary intention If cellulitis or immunodeficieny - antibiotics Debride necrotic and non-viable tissue intraoperatively |
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How would a wound haematoma present?
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pain, swelling, discolouration of wound edges, leakage
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How do you manage a wound haematoma?
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pressure dressing
may need to re-operate if significant bleeding |
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What is wound dehicence?
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breakdown of the wound
disruption of fascial layer, abdominal contents contained by skin |
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What days post op does wound dehicence usually occur?
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1-3
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How does wound dehicence present?
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Serosangounas drainage from the wound +/- evisceration (disruption of all abdominal layers and extrusion of abdominal contents)
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Management of wound dehiscence?
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can consider conservative management
BUT if evisceration - surgical emergency - take back to theatre |
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RF for wound dehiscence?
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Increased intra-abdominal pressure
haematoma inbfection poor blood supply radiation smoking CT diseases IMmunosuppression DM, Sepsis, uraemia |
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How do you treat intra-abdominal abscess?
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IR percutaneous drainage
debridement of infected soft tissue around infection antibiotics - amp/gent/metronidazole |
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How many days/hours should warfarin and LMWH heparin be discontinued pre-op?
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Warfarin - 3-5 days
LMWH - 4-6 hours |
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Which wounds should be healed by secondary intention?
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Deep stab or puncture wounds that cannot be adequately irrigated
contaminated wounds small noncosmetic animal bites abscess cavities presentation after a significant delay |
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What is the ratio of fluid replacement to blood volume lost?
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3x estimated blood loss because only 30% of infused isotonic cystalloids remains in intravascular space
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When replacing blood at what stage do you need to give FFP?
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After 2u RBCs - toronoto
Oli - after 5 u of RBC give 2 u FFP and 1 u of platelets for every 5 u after that |
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What are contraindiations to an NG tube?
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base of skull fracture
significant mid face trauma |
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How much blood loss is required in a 70kg patient to produce hypotension?
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> 2L
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What are the signs of a basal skull fracture?
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battle's sign (bruised mastoid process)
haemotympanum Raccoon eyes (periorbital bruising) CSF rhinorrea/otorrhea |
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When can you clear a c-spine?
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no posterior midline cervical tenderness
no evidence o intoxication oriented to person, place, time and event no focal neurological deficits no painful distracting injuries |
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What pharmagolocal management should you give in a suspected spinal cord injury?
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Start methylprednisolone within 6-8 hours of injury
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What is a pulmonary contusion?
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Interstitial oedema impaires compliance and gas exchange usually due to blunt trauma to the chest
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What do you see on CXR with pulmonary contusion?
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areas of opacification of lung within 6 hours of trauma
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When is a lapartomy mandatory with penetrating trauma?
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If penetrating trauma AND
shock peritnoitis evisceration free air in abdomen blood in NG tube, foley catheter or on rectal exam |
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How do you manage gun shot wounds?
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ALWAYS require a laparotomy
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What is the most sensitive test for imaging in abdominal trauma?
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Diagnostic peritoneal lavage
BUT results can take up to 1 hr so not regularly used Cannot test for retroperiteonal bleeds |
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If colles fracture involves the articular surface do you need emergent orthopaedic referral?
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yes
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What should you add to the fluid resuscitation in eletrical burns?
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NaHCO3
To alkalinise urine and reduce pigment precipitation in renal tubules |
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What signs of PE can you see on CXR?
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Westermark's sign - abrupt tapering of a vessel on chest film
Hamptom's hump - a wedge shaped infiltrate that abuts the pleura |
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Do you get a narrow or wide complex ECG in LBBB?
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wide complex
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What does digitalis toxicity look like on ECG?
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downward curve of ST
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How do you treat an open pneumothorax?
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i.e. air entering chest from wound rather than trachea
Air tight dressing sealed on 3 sides chest tube surgery |
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Is hereditary telangiectasia autosomal dominant or recessive?
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dominant
mutation in TGF-beta |
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What are the symptoms and signs of hereditary telangiectasia?
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recurrent bleeds and anaemia
Telangiectasia and small aneurysms on fingertips, fae, nasal passages and tongue, lung and GIT NB: can develop largery pulmonary arteriovenous malformations that cause arterial hypoaemia due to R-L shunt Thisese predispose to paradoxical embolism causing stroke or cerebral abscess Can also have brain AVMs |
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How much maintenance K is required each day?
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90 mmol
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Are crystalloids or colloids extravascular/intravascular
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crystalloids - extravascular
colloids - intravascular |
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What's the highest flow L/min that can be used for
nasal prongs simple mas non-rebreather venturi |
Nasal prongs - 4L/min
simple mask - 10L/min Non-rebreather 15L/min Venturi - varies according to setting on mask |
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What are some causes of obstructive shock?
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PE
tension pneumothorax severe asthma cardiac tamponade |