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60 Cards in this Set

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  • Back
Which patients are at high risk of VTE during hospital admission?
ischaemic stroke
history of VTE
Active cancer
decompensated heart failure
acute on chronic lung disease
acute inflammatory disease
> 60
Which surgeries require post operative VTE prophylaxis?
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
When should warfarin be stopped prior to surgery?
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
Is aspirin effective in preventing VTE in surgical patients?
no
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?
Change them to insulin
Should oral antidiabetic drugs be stopped prior to surgery?
Short term fasting not too much of an issue
Sulfonylreas and other insulin sensitisers stop on day of fasting and monitor BG closely
How do you manage someone on insulin who goes for surgery?
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
When should you consider prophylactic antibiotics?
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
Are most post surgical infections due to the patient's own organisms or ones introduced during the surgery?
own organisms
How do you manage post operative DVT?
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
Duration of anticoagulation for VTE
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
How do you calculate maintenance fluids?
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%
How do you calculate how much fluid to give in someone with hypovolaemia?
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
How does someone with atelectasis present post surgery?
Low grade fever day 0-2
tachycardia
crackles
decreased breath sounds
bronchial breathing
tachypnoea
How does someone with post op pneumonia present?
productive cough
fever
tachycardia, cyanhosis, respiratory failure, decreased LOC
usually occurs day 0-2
How do you prevent atelectasis?
Smoking cessation > 6 weeks pre-op
Minimise use of resp depressant drugs
good pain control
incentive spirometry - deep breathing and coughing
early ambulation
When do the majority of post operative MIs occur?
on operative day or first 4 days post op
How do post operative MIs present?
Often silent, without chest pain
May only present with new onset CHF, arrhythmias, hypotension
What day post op does leakage at bowel anastomosis usually occur?
POD 5+
What day do post operative intra-abdominal abscesses usually occur?
5-10 days
When does DVT/PE usually occur post op?
can occur at any time but most commonly day 7-10
What are the most common organisms involved in operative wound infections
S. aureus
E Coli
Enterococcus
Strep
Clostridium
Which 2 bacterial organisms can present as wound infection within 24 hours?
Strep and Clostridium
Which operations require post operative antibiotics
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
How long should you give post operative antibiotics for?
No evidence supporting more than 24 hours post-op prophylaxis
How to you treat wound infections?
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
How would a wound haematoma present?
pain, swelling, discolouration of wound edges, leakage
How do you manage a wound haematoma?
pressure dressing
may need to re-operate if significant bleeding
What is wound dehicence?
breakdown of the wound
disruption of fascial layer, abdominal contents contained by skin
What days post op does wound dehicence usually occur?
1-3
How does wound dehicence present?
Serosangounas drainage from the wound +/- evisceration (disruption of all abdominal layers and extrusion of abdominal contents)
Management of wound dehiscence?
can consider conservative management
BUT if evisceration - surgical emergency - take back to theatre
RF for wound dehiscence?
Increased intra-abdominal pressure
haematoma
inbfection
poor blood supply
radiation
smoking
CT diseases
IMmunosuppression
DM, Sepsis, uraemia
How do you treat intra-abdominal abscess?
IR percutaneous drainage
debridement of infected soft tissue around infection
antibiotics - amp/gent/metronidazole
How many days/hours should warfarin and LMWH heparin be discontinued pre-op?
Warfarin - 3-5 days
LMWH - 4-6 hours
Which wounds should be healed by secondary intention?
Deep stab or puncture wounds that cannot be adequately irrigated
contaminated wounds
small noncosmetic animal bites
abscess cavities
presentation after a significant delay
What is the ratio of fluid replacement to blood volume lost?
3x estimated blood loss because only 30% of infused isotonic cystalloids remains in intravascular space
When replacing blood at what stage do you need to give FFP?
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
What are contraindiations to an NG tube?
base of skull fracture
significant mid face trauma
How much blood loss is required in a 70kg patient to produce hypotension?
> 2L
What are the signs of a basal skull fracture?
battle's sign (bruised mastoid process)
haemotympanum
Raccoon eyes (periorbital bruising)
CSF rhinorrea/otorrhea
When can you clear a c-spine?
no posterior midline cervical tenderness
no evidence o intoxication
oriented to person, place, time and event
no focal neurological deficits
no painful distracting injuries
What pharmagolocal management should you give in a suspected spinal cord injury?
Start methylprednisolone within 6-8 hours of injury
What is a pulmonary contusion?
Interstitial oedema impaires compliance and gas exchange usually due to blunt trauma to the chest
What do you see on CXR with pulmonary contusion?
areas of opacification of lung within 6 hours of trauma
When is a lapartomy mandatory with penetrating trauma?
If penetrating trauma AND
shock
peritnoitis
evisceration
free air in abdomen
blood in NG tube, foley catheter or on rectal exam
How do you manage gun shot wounds?
ALWAYS require a laparotomy
What is the most sensitive test for imaging in abdominal trauma?
Diagnostic peritoneal lavage
BUT results can take up to 1 hr so not regularly used
Cannot test for retroperiteonal bleeds
If colles fracture involves the articular surface do you need emergent orthopaedic referral?
yes
What should you add to the fluid resuscitation in eletrical burns?
NaHCO3
To alkalinise urine and reduce pigment precipitation in renal tubules
What signs of PE can you see on CXR?
Westermark's sign - abrupt tapering of a vessel on chest film
Hamptom's hump - a wedge shaped infiltrate that abuts the pleura
Do you get a narrow or wide complex ECG in LBBB?
wide complex
What does digitalis toxicity look like on ECG?
downward curve of ST
How do you treat an open pneumothorax?
i.e. air entering chest from wound rather than trachea
Air tight dressing sealed on 3 sides
chest tube
surgery
Is hereditary telangiectasia autosomal dominant or recessive?
dominant
mutation in TGF-beta
What are the symptoms and signs of hereditary telangiectasia?
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
How much maintenance K is required each day?
90 mmol
Are crystalloids or colloids extravascular/intravascular
crystalloids - extravascular
colloids - intravascular
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
What are some causes of obstructive shock?
PE
tension pneumothorax
severe asthma
cardiac tamponade