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415 Cards in this Set
- Front
- Back
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Airway fine, but soon to be compromised Mgmt
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Orotracheal intubation w/ rapid sequence anesthetic
Pulse ox Paramedics – blind nasotracheal intubation Subcutaneous emphysema – fiberoptic bronchoscopy |
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Trauma + AMS Mgmt
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intubation
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poor airway w/ possible c-spine injury Mgmt
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orotracheal intubation w/ manual in-line cervical immobilization
over a flexible bronchoscope nasotracheal intubation |
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poor airway but cannot use orotracheal Mgmt
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cricothyroidotomy
percutaneous transtracheal ventilation |
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Shock – general Mgmt
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Big bore IV lines
Foley Catheter IV ABx Fluid/blood -going to surgery – done last -not going to surgery – done first |
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Shock – 2 miles away Mgmt
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Move the pt, don’t mess around
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Shock – squirting blood Mgmt
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Direct local pressure
Not a clamp/tourniquet Then volume restoration |
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Hypovolemic shock – don’t know where blood is coming from Mgmt
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2 large peripheral lines w/ Ringer lactate
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Shock – pedi, can’t use peripheral IVs Mgmt
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Intraosseous cannulation in proximal tibia
Ringer’s 20 ml/kg |
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Shock – 2 hrs from hospital Mgmt
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Ringer’s w/out sugar 2L in 20-30 min
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Pericardial Tamponade Mgmt – suspected
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Pericardiocentesis/tap/tube
If + - thoracotomy, ex-lap Fluids/blood NOT X-ray |
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Pericardial Tamponade – obv (SW) Mgmt
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Median sternotomy
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Tension Pneumothorax Mgmt
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Needle/catheter in pleural space
CT placement (high up?) Ex-lap NOT X-ray |
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Shock w/ head trauma mgmt
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Look for another source
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Cardiogenic shock from massive MI mgmt
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Verify – high CVP, ECG, enzymes
Thrombolytic Tx NOT drown in fluid |
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Vasomotor shock mgmt
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Vasoconstrictors
Volume replacement |
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Penetrating head wound mgmt
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Surgical repair
Don’t remove anything embedded while in ER |
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Skull Fx – closed, ASx mgmt
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Left alone
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Skull Fx – open mgmt
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Cleaned and closed
Possible craniotomy |
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Unconscious (at any point) mgmt
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CT scan – look for hematoma
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Basal Skull Fx mgmt
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CT
C-spine eval |
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Acute Epidural Hematoma mgmt
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CT – lens shape
Emergency craniotomy |
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Acute Subdural Hematoma mgmt
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CT – crescent-shape
Check cervical spine Emergency craniotomy, remove clot Control ICP |
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Diffuse Axonal Injury mgmt
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Control ICP
-ICP monitor -head elevation -hyperventilation -avoid fluid overload -mannitol, furosemide |
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Chronic Subdural Hematoma mgmt
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CT
craniotomy |
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Penetrating wound mgmt
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Immediate surgical exploration
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Penetrating wound – very high in neck mgmt
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angiography
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GSW to base of neck
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Angiography
Soluble-contrast esophagogram Esophagoscopy Bronchoscopy repair |
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SW to upper/middle neck and ASx mgmt
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Observe 12 hrs
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Persistent local pain of neck mgmt
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C-spine XR – lateral, AP, odontoid
CT if suspicious |
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Hemisection/Brown-Sequard mgmt
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MRI
High dose steroids soon after? |
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Anterior Cord Syndrome mgmt
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MRI
High dose steroids soon after |
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Central Cord syndrome mgmt
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MRI
High dose steroids soon after |
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Rib Fx mgmt
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Nerve block
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Pneumothorax mgmt
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CXR
CT placed high – underwater seal, suction |
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Hemothorax mgmt
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CXR
CT placed at base |
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Hemothorax – bleeding from systemic vessel mgmt
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Thoractomy – ligate the vessel
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Hemopneumothorax mgmt
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CT placed at base
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Sucking Chest wound mgmt
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Cover w/ Vaseline gauze
Tape dressing on 3 sides to make 1-way flap CT placed in hospital |
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Flail Chest mgmt
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R/o injuries – aortic rupture, abd injury
-CXR -spiral CT (if wide mediastinum) -aortogram (if wide mediastinum and poor CT) -US Tx Pulm contusion – fluid, respiratory support Bilateral CT if respirator or OR |
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Pulmonary Contusion mgmt
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Fluid restriction (colloid)
Diuretics Respiratory support -intubation -mechanical ventilation -PEEP |
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Tension pneumothorax – caused by rib Fx mgmt
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Needle through chest wall CT placed
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Sternal Fx mgmt
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Dx/Tx myocardial contusion, aortic rupture
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Myocardial contusion mgmt
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EKG
Troponin Control arrythmia |
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Traumatic rupture of aorta mgmt
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Spiral CT
CXR – wide mediastinum Aortagram – if poor spiral CT Emergency surgical repair |
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Truamatic diaphragmatic rupture mgmt
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Surgical repair
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Traumatic rupture of trachea/bronchus mgmt
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CXR – air in tissues
Fiberoptic bronchoscopy Surgical repair |
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Air Embolism mgmt
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Cardiac massage
thoracotomy |
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Fat Embolism mgmt
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Respiratory support
+/- heparin, steroids, LMW dextran |
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GSW abd mgmt
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Indwelling catheter
Large IV BSAbx Ex-lap |
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Injury to colon mgmt
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Primary repair
NOT colostomy? |
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GSW to abd/chest mgmt
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CXR
CT placed Ex-lap |
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SW abd w/ peritoneal penetration mgmt
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laparotomy
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SW abd w/out peritoneal penetration mgmt
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Digital exploration
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Acute abd after blunt trauma mgmt
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laparotomy
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Ruptured spleen mgmt
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Repair > remove
If removed – pneumovax, HITB, meningococcus vaccines |
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?Ruptured other abd organ/internal bleed mgmt
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DPL
If stable – CT If unstable – ex-lap |
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Coagulopathy during abd surgery mgmt
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FFP, plt packs
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Coagulopathy during abd surgery w/ hypothermia mgmt
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Close abd w/ towel clips
Pack bleeding surfaces |
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Abd compartment syndrome - perioperative mgmt
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Close wound w/ absorbable mesh/nonabsorbable plastic cover
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Abd compartment syndrome – POD 1 mgmt
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Open incision
Use temporary cover |
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Nonexpanding pelvic hematoma and hemodynamically stable mgmt
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Left alone
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Pelvic Fx and not responding mgmt
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External fixation v. argeriographic embolization
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Penetrating urologic injury mgmt
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Surgical repair
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Blood at meatus mgmt
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Retrograde urethrogram
NOT foley |
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Bladder injury – rupture at dome mgmt
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Retrograde cystogram
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Bladder injury – rupture at trigone mgmt
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Retrograde cystogram
Another film after bladder is empty |
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Posterior urethral injury mgmt
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Retrograde urethrogram
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Anterior urethral injury mgmt
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Retrograde urethrogram
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Kidney injury/bleed mgmt
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CT
Operate only if renal pedicle is avulsed/pt exanguinating |
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Traumatic microhematuria mgmt
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Nothing
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Traumatic microhematuria in children mgmt
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US
+/- IVP |
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Scrotal hematoma mgmt
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US (check testicular rupture)
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Testicular Rupture mgmt
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surgery
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Tunical Albuginea Fx mgmt
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Prompt surgical repair
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Bone shatter mgmt
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Clean wound
Tetanus prophylaxis |
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Bone shatter – likely vascular injury mgmt
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doppler
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Bone shatter – obvious vascular injury mgmt
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Surgical exploration
No need for arteriogram? |
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Bone shatter – vascular and nerve injury mgmt
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Fx stabilization vascular repair nerve repair
Delay fasciotomy |
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Hunting rifle GSW mgmt
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Extensive debridement
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Crushing injury mgmt
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Correct Hyperkalemia
Correct myoglobinemia/uria -fliuds, -mannitol/osmotic diuretic -alkalinization of urine Correct compartment syndrome -fasciotomy |
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Alkalai/Chemical burn mgmt
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30 min tap water before ER visit
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Eletrical burn mgmt
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Extensive surgical debridement
Correct Mb – IVF, osmotic diuretic, alkalinzation of urine |
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Respiratory Burn/CO poisoning mgmt
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CoHb levels
100% O2 Bronchoscopy ABG Respiratory support |
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Circumferential Burn mgmt
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Monitor pulses
Escharotomies at bedside (if compromised circulation) +/- fasciotomy |
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Rule of 9s
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Head – 9
Arm – 9 Leg – 18 Trunk – 36 ~child head = 18, legs = 27 total |
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Burn victim initial fluid rate
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Ringer w/out sugar 1000 ml/h
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Burn victim total fluid needed
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4ml/Kg/% (up to 50%) + 2L D5W; colloids
-1/2 first 8 hrs -1/2 second 16 hrs -1/2 second day -brisk diuresis on 3rd day |
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Child burn fluid rates
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Initial – 20mg/kg
24hrs – 4-6ml/kg/% |
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Burn mgmt
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Tetanous prophylaxis
cleaning sulfadiazine eyes – triple ABx IV pain Rx Grafts if not regenerated NG suction nutritional support |
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Small 3rd degree burn (<20%) mgmt
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Early excision and graft
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Dog bite mgmt
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Observe pet for rabies
Tetanous prophylaxis |
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Coyote bite mgmt
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Examine brain for rabies
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Bat bite mgmt
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Rabies prophylaxis (Ig and vaccine)
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Rattlesnake bite mgmt
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Not envenomated (pain, swelling) – observe, tetanus prophylaxis
Envenomated – Type/cross, coags, BUN, LFTs, several vials antivenin |
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Bee sting mgmt
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Epinephrine
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Black widow bite mgmt
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IV Ca gluconate
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Brown recluse bite mgmt
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Dabsone
Excision/graft (wait 1 wk) |
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Human bite mgmt
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Surgical exploration
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DDH mgmt
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HxPE
US Pavlik harness (abduction splinting) |
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Legg-Perthes Dz mgmt
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XR – AP, lateral
Casting/crutches (contain femoral head in acetabulum) |
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Slipped capital femoral epiphysis mgmt
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XR – AP, lateral
Pin femoral head in place |
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Septic Hip mgmt
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Aspiration under general anesthesia
Open arthrotomy = drainage |
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Acute hmatogenous osteomyleitis mgmt
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Bone scan
ABx (XR won’t help for 2 wks) |
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Genu Varum mgmt
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Nl till 3yo
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Genu Valgus mgmt
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Nl 4-8yo
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Blount Dz mgmt
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surgery
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Osgood-Schlatter mgmt
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Knee immobilization (extension/cylinder cast 4-6 wks)
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Club foot/talipes equinovarus mgmt
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Serial plaster casts (neonatal)
Correction: adducted forefoot hindfoot varus equines If surgery needed – between 8mo and 2 yrs |
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Nl Fx of child mgmt
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Do nothing
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Supracondylar Fx of humerus mgmt
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Casting/traction
Monitor vascular/nerve – prevent volkmann Prevent compartment syndrome |
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Fx of growth plate mgmt
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Not Divided – closed reduction
Divided/2 pieces – ORIF |
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Osteogenic sarcoma mgmt
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No Bx, referral
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Ewing sarcoma mgmt
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No bx, referral
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Pathologic Fx mgmt
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XR – particular bone
Bone scan – rest of body (primary) |
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Multiple Myeloma mgmt
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XR > bone scan
Immunoelectrophoresis – Bence-jones protein in urine, abnl Ig in blood |
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Soft Tissue sarcoma mgmt
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MRI
referral |
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Clavicle Fx mgmt
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Figure 8 4-6 wks
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Anterior Shoulder dislocation mgmt
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XR – AP, lateral
reduce |
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Posterior Shoulder dislocation mgmt
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XR – axillary, scapular lateral
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Colles Fx mgmt
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Close reduction (long arm cast)
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Monteggia Fx mgmt
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Radial head – close reduction
Ulnar Fx – ORIF |
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Galeazzi Fx mgmt
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Radius – ORIF
Dislocated joint – supination casting |
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Schaphoid Fx mgmt
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Thumb spica cast
Repeat XR in 3 wks (take 2-3 to show up) |
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If angulated – ORIF
Metacarpal neck Fx mgmt |
Mild – closed reduction, ulnar gutter splint
Severe – kirschner-wire or plastic fixation |
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Displaced femoral neck Fx mgmt
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Metal prosthesis
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Intertrochanteric Fx mgmt
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Preop anticoagulation
Open reduction and pinning |
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Femoral shaft Fx (closed) mgmt
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Intramedullary rod fixation
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Fx hypovolemic shock mgmt
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Fixation
Fluids/blood |
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Fat embolism mgmt
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Respiratory support
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MCL injury mgmt
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Hinged cast
Several ligaments – surgical repair |
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LCL injury mgmt
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Hinged cast
Several ligaments – surgical repair |
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ACL injury mgmt
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MRI
Sedentary – immobilization, rehab Athlete – arthroscopic reconstruction |
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Meniscal tear mgmt
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MRI
Arthroscopic repair – save as much meniscus as possible |
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Stress Fx mgmt
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Cast/crutches
XR in 2 wks (won’t show up till then) |
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Tib/Fib Fx mgmt
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Easily reduced – casting
Not allignable – intramedullary nailing |
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Compartment Syndrome mgmt
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fasciotomy
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Achilles rupture mgmt
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Equinous casting or surgical repair (quicker)
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Displaced Fx of both malleloi mgmt
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XR – AP, lateral, mortise
ORIF |
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Compartment syndrome mgmt
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fasciotomy
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Open Fx mgmt
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Clean in OR/reduce w/in 6 hrs
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Posterior dislocation of Hip mgmt
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XR
Emergency reduction |
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Gas gangrene mgmt
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IV PCN
Immediate surgical debridement Hyperbaric O2 |
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Humeral Shaft Injury/radial N. injury mgmt
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Hang arm in cast/coaptation splint
Paralysis after closed reduction – surgery |
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Posterior knee dislocation/popliteal A. injury mgmt
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Pulses
Arteriogram reduction |
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Fall on feet mgmt
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Look for Fx of thoracic/lumbar spine
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Knees strike dashboard mgmt
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Look for femoral heads driving
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Facial Fx w/ closed head injury mgmt
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Look for C-spin Fx (XR, CT)
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Carpal Tunnel mgmt
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Clinical Dx, but XR (Carpal tunnel)
Splint Anti-inflammatory Rx EMG before surgery (if needed) |
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Trigger finger mgmt
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Steroid injections
Surgery if needed |
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De Quervain tenosynovitis mgmt
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Steroid injection
Surgery if needed |
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Dupuytren contracture mgmt
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surgery
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Felon mgmt
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Urgent drainage
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Gamekeeper’s thumb/Ulnar collateral ligament mgmt
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casting
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Jersey finger mgmt
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splinting
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Mallet finger mgmt
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splinting
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Traumatic amputation of digit mgmt
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Clean w/ sterile saline
Wrap in saline-soaked gauze Place in plastic bag Place on ice NO alcohol, antiseptics, dry ice, freezing |
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Lumbar disk herniation mgmt
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MRI
Bed rest Progressive weakness, sphincter problem – surgery |
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Cauda Equina syndrome mgmt
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Emergency surgery
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Ankylosing spondylitis mgmt
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XR – bamboo spine
Anti-inflammatory Rx, PT |
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Metastatic malignancy mgmt
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XR, bone scan
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Leg Ulcers
DM pressure ulcer mgmt |
Control DM
Keep ulcer clean Keep leg elevated Prep mind for ampuation |
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Ischemic ulcer mgmt
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Doppler, arteriogram
+/- revascularization |
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Venous stasis ulcer mgmt
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Unna boot, support stockings
+/- varicose vein surgery |
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SCCA of irritation site/Marjolin ulcer mgmt
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Bx
WLE w/ skin grafting |
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Plantar fasciitis mgmt
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Tx of Sx (12-18 mo)
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Morton Neuroma mgmt
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Conservative mgmt (shoe Δ)
excision |
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Gout mgmt
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Joint aspiration – uric acid crystals
Acute attack – indomethacin, colchicines Long term – allopurinol, probenecid |
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Malignant Hyperthermia mgmt
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IV dantrolene
Support – 100% O2, correct acidosis, cooling blankets, watch Mb |
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Bacteremia mgmt
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BCx x3
ABx |
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Atelectasis mgmt
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R/o other sources – CXR, look at wound, IVs, ask about Urinary Sx
Improve ventilation – deep breathing, coughing, postural drainage, incentive spirometry Major/recalcitrant - bronchoscopy |
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Pneumonia mgmt
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CXR
Sputum Cx ABx |
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UTI mgmt
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UA
UCx |
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Thrombophlebitis mgmt
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Doppler
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Wound infection mgmt
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Physical exam
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Deep abscess mgmt
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CT
Percutaneous drainage |
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Perioperative MI mgmt
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troponin
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PE mgmt
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ABG – hypoxia, hypocapnia
VQ scan Pulm angiography – gold std Spiral CT Heparinization If recur – IVC filter |
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Aspiration mgmt
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Prevention – empty stomach, antacids before
Tx – remove particular matter/bronchoscopy, bronchodilators, respiratory support Too late for steroids |
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Intraoperative tension pneumothorax mgmt
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Make hole in diaphragm
CT placed later |
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Hypoxia/metabolic problems mgmt
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ABG
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ARDS mgmt
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PEEP (allow significant hypercapnia)
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DTs mgmt
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IV alcohol (5% alcohol, 5% dextrose)
Psyc – med mgmt |
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Water intoxication/hyponatremia mgmt
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Careful hypertonic saline
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Surgically induced DI/hypernatremia mgmt
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1/3-1/4 NS
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Inability to void mgmt
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In/out catheter
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Low UOP – low fluid replacement/dehydrated mgmt
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Fluid challenge – diuresis
Urinary Na - <10-20 mEq/L FeNa - <1 |
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Low UOP – renal failure mgmt
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Fluid challenge – no diuresis
Urinary Na - > 40 mEq/L FeNA - > 1 |
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Paralytic ileus mgmt
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NPO, NG suction
If not coming along -r/o SBO – small barium tag -r/o hypokalemia |
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Ogilvie syndrome mgmt
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Colonoscopy – suck gas, r/o SBO/cancer, leave in rectal tube
If cecum is about to blow – cecostomy, colostomy |
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Wound dehiscence mgmt
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Tape wound
Bind abdomen No mobilization, coughing |
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Evisceration mgmt
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Cover bowel w/ WARM,MOIST dressing
Emergent OR closure |
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Wound infection mgmt
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No pus – US
Pus – ABx Questionable pus - US |
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GI fistula mgmt
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Close eventually on own
Febrile, sick – drainage +/- diverting colostomy |
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Hypernatremia – quick mgmt
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½ or 1/3 NS
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Hypernatremia – slow mgmt
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Dextrose in ½ NS
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Hyponatremia – rapid mgmt
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Hypertonic saline 100ml at a time
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Hyponatremia – slowly; ADH production mgmt
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Water restriction
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Hyponatremia + volume depleted mgmt
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Isotonic fluids
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Hypokalemia mgmt
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10-20 mEq/h Potassium
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Hyperkalemia mgmt
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Improve BP
Insulin w/ 50% dextrose Exchange resins IV calcium Ultimate weapon – hemodialysis |
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Metabolic Acidosis w/ AG mgmt
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Bicarbonate, bicarbonate precursors (lactate , acetate)
Fluid resuscitation – Ringer |
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Metabolic Acidosis w/out AG mgmt
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Bicarbonate, precursors
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Metabolic alkalosis – hypochloremic, hypokalemic mgmt
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Saline > Ringer
Potassium chloride (10 mEq/hr) |
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GERD mgmt
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Esophageal pH monitoring
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Barrett’s Esophagus mgmt
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Med mgmt
Continued Sx – fundoplication Dsyplasia – resection |
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Nissen Fundoplication preop
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pH monitoring – Dx GERD
manometry – good motility endoscopy/Bx – severe enough esophagitis isotope gastric emptying study – empyting is ok barium swallow – show anatomy |
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Achalasia mgmt
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Barium swallow
manometry |
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Esophageal Adenocarcinoma mgmt
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Barium swallow (first)
Endoscopy/bx CT |
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Esophageal SCCA mgmt
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Barium swallow (first)
Endoscopy/Bx CT |
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Mallory-Weiss tear mgmt
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Endoscopy
Self-limiting/photocoagulation |
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Boerhaave syndrome mgmt
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Gastrografin swallow
Emergency surgical repair |
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Instrumental perforation of Esophagus mgmt
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Gastrografin swallow
Emergency surgical repair |
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Cancer of stomach mgmt
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Endoscopy/Bx
CT Surgery – cure or palliation |
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Mechanical SBO – adhesions mgmt
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NG suction, IVF, observation
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Strangulated obstruction mgmt
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Emergency surgery
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Mechanical SBO – incarcerated hernia mgmt
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Fluid replacement
Urgent surgical intervention |
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Carcinoid syndrome mgmt
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24hr urinary 5-hydroxy-indolacetic acid
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Acute appendicitis mgmt
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Emergency appendectomy
CT if atypical |
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R. colon cancer mgmt
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Blood transfusion
R. hemicolectomy |
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L. colon cancer mgmt
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Endoscopy/Bx (flex P full colon)
surgery |
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Polyp mgmt
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Excise pre-malignant ones
(FAP, villous, adenomatous NOT juvenile, Peutz-jeghers, inflammatory, hyperplastic) |
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CUC/Toxic megacolon mgmt
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Emergency Surgery – remove colon and rectal mucosa
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Pseudomembranous colitis mgmt
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d/c clinda/ABx
metronidazole alternate ABx – Vancomycin |
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Internal hemorrhoids mgmt
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r/o cancer – proctosig, DRE, anoscopy, flex sig
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External hemorrhoids mgmt
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r/o cancer – proctosig, DRE, anoscopy, flex sig
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Anal fissure mgmt
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r/o cancer – exam under anesthesia
stool softners, topical agents paralyze/botox sphincter if surgery – lateral internal sphincterotomy |
|
|
Chron’s Dz mgmt
|
r/o cancer – exam w/ Bx
|
|
|
Ischiorectal abscess mgmt
|
r/o cancer – exam under anesthesia
I&D If DM – close f/u in hospital |
|
|
Fistula in ano mgmt
|
r/o cancer – proctosig
elective fistulotomy |
|
|
Anal SCCA mgmt
|
Bx of mass
Nigro protocol – ChTx/XRT |
|
|
Meckel Diverticulum mgmt
|
Technetium scan (gastric mucosa)
|
|
|
Stress ulcer mgmt
|
Prevention – keep stomach pH <4 (antacids, h2 blockers)
Dx – endoscopy Tx – endoscopic laser, angiographic embolization of L. gastric A. |
|
|
Perforated peptic ulcer mgmt
|
Ex-lap
r/o Dz -CXR – LLP -EKG - MI |
|
|
Primary peritonitis mgmt
|
Ascites Cx
ABx |
|
|
Perforated duodenal ulcer mgmt
|
Ex-lap
|
|
|
Acute pancreatitis mgmt
|
Serum amylase/lipase
Urinary amylase/lipase CT NPO, NG suction, IVF |
|
|
Acute cholecystitis mgmt
|
US
HIDA Med mgmt surgery |
|
|
Ureteral Colic mgmt
|
KUB
US or IVP |
|
|
Acute Diverticulitis mgmt
|
CT
ABx, NPO Recurrent - Elective sigmoid resection Does not respond – emergency surgery |
|
|
Sigmoid Volvulus mgmt
|
Proctosigmoidoscopy or rectal tube
Recurrent – elective surgery |
|
|
Mesenteric Ischemia – embolus mgmt
|
Angiogram embolectomy
|
|
|
Primary Hepatoma/HCC mgmt
|
CT w/ contrast
Resection if free segment Monitor w/ aFP |
|
|
Liver met mgmt
|
CT w/ contrast
Resection if no other mets Monitor w/ CEA (i.e. colon) |
|
|
Ruptured hepatic adenoma mgmt
|
CT
surgery |
|
|
Pyogenic liver abscess mgmt
|
Percutaneous drainage
|
|
|
Amebic liver abscess mgmt
|
Metronidazole
Serology – don’t wait CANNOT Cx from pus |
|
|
Hemolytic jaundice mgmt
|
Figure out what’s chewing RBCs
|
|
|
Hepatocellular jaundice/Hepatitis mgmt
|
serologies
|
|
|
Obstructive jaundice – general mgmt
|
US
|
|
|
Obstructive jaundice – gallstones mgmt
|
US
ERCP – remove stones cholecystectomy |
|
|
Malignant obstructive jaundice mgmt
|
US
CT ERCP if poor CT |
|
|
Cholangiocarcinoma mgmt
|
Brushings of CBD
Whipple/pancreatoduodenectomy |
|
|
Ampullary carcinoma mgmt
|
Endoscopy
Radical surgery |
|
|
Cancer of head of pancreas mgmt
|
CT
ERCP if poor |
|
|
Gallstones w/ colic mgmt
|
US
Elective cholecystecomy |
|
|
Acute cholecystitis mgmt
|
US
Med surgery |
|
|
Acute ascending cholangitis mgmt
|
US
IV ABx Emergency decompression – ERCP or PTC (percutaneous transhepatic cholangiogram) |
|
|
Transient cholangitis + biliary pancreatitis mgmt
|
US
Gets well – elective cholecystectomy Deteriorates/stone at ampulla vater – ERCP/sphincterotomy |
|
|
Acute edematous pancreatitis mgmt
|
NPO, NG suction, IVF
|
|
|
Hemorrhagic pancreatitis mgmt
|
Serial CT scans for abscess
|
|
|
Pancreatic abscess mgmt
|
CT
drainage |
|
|
Pancreatic pseudocyst mgmt
|
US, CT
Present after 6 wks – CT drainage, endoscopic cystogastrostomy |
|
|
Chronic pancreatitis mgmt
|
Stop EtOH
Replace pancreatic enzymes Control DM ERCP |
|
|
Umbilical hernia – <2yo mgmt
|
observe
|
|
|
Inguinal hernia – ASx mgmt
|
Elective surgical repair (extraperitoneal)
|
|
|
Incarcerated hernia mgmt
|
Elective repair
|
|
|
Strangulated hernia mgmt
|
Emergent repair
|
|
|
Fibroadenoma mgmt
|
FNA, US
Optional excision |
|
|
Giant juvenile fibroadenoma mgmt
|
resection
|
|
|
Cystosarcoma phyllodes mgmt
|
Tissue Dx
Margin-free resection |
|
|
Fibrocystic Dz (w/ palpable cyst) mgmt
|
MMG
Aspiration of cyst (NOT FNA) -Clear fluid – nothing -bloody – cytology Recurs – Bx |
|
|
Intraductal papilloma mgmt
|
MMG
Optional resection (guided by galactogram or retroaereolar exploration) |
|
|
Breast abscess/Mastitis mgmt
|
I&D
Bx of abscess wall |
|
|
Breast cancer mgmt
|
MMG guided multiple core Bx
Axillary mass – Bx node Operable – lumpectomy/segmental w/ axillary node sampling, XRT to same breast Less operable – modified radical mastectomy, axillary sampling Confined to 1 quadrant – axillary sampling is not needed Multicentric lesions all over breast – simple total mastectomy Inoperable - ChTx |
|
|
ChTx protocol for breast cancer
|
Premenopause – ChTx hormonal
Postmenopause – anastrozole |
|
|
Pregnancy protocol for breast cancer mgmt
|
No XRT during pregnancy
No ChTx during 1st Trimester |
|
|
Brain Mets mgmt
|
CT
High dose steroids, XRT |
|
|
Bone mets mgmt
|
Bone scan
XR – r/o benign causes Local XRT Orthopedic supports |
|
|
ASx thyroid nodule mgmt
|
US
Radioiodine scan FNA!!! |
|
|
Malignant/indeterminate FNA of thyroid nodule mgmt
|
surgery
|
|
|
Hot adenoma mgmt
|
Free T4, TSH
Radioactive iodine scan Surgery (b-block first) |
|
|
Parathyroid adenoma mgmt
|
PTH
Sestamibi scan surgery |
|
|
Cushing mgmt
|
Overnight dex
24hr urine cortisol High dose suppression MRI head If positive – transnasal transsphenoidal resection CT/MRI adrenals |
|
|
Gastrinoma/Zollinger-Ellison mgmt
|
Serum gastrin
CT (vascular/GI contrast) pancreas Surgical removal |
|
|
Exogenous insulin OD mgmt
|
Psych eval
|
|
|
Insulinoma mgmt
|
CT
Surgical removal |
|
|
Nesidoblastosis mgmt
|
95% pancreatectomy
|
|
|
Glucagonoma mgmt
|
Glucagon level
CT Surgery Inoperable – somatostatin, streptozocin |
|
|
Hyperaldosteronism – adenoma mgmt
|
Aldo, renin levels
Lying down, sitting up Hyperplasia – aldactone Adenoma – CT/MRI, surgery |
|
|
Pheochromocytoma mgmt
|
24hr urinary metanephrine, VMA
CT adrenals Surgery (a-blocker prep) |
|
|
Coarctation of Aorta mgmt
|
CXR
Spiral CT or MRI angiogram surgery |
|
|
Renovascular HTN mgmt
|
Duplex, possible aortogram
Fibromuscular dysplasia – angiographic balloon w/ stent or surgery Arteriosclerosis – no Tx unless arteriosclerosis will not kill him |
|
|
Tracheoesophageal Fistula – proximal blind esophageal pouch, distal TE fistula mgmt
|
R/o VACTER – XR, echo, US, physexam
surgery |
|
|
VACTER acnronym
|
Vertebral
Anal Cardiac TE Renal/radial |
|
|
Imperforate anus mgmt
|
r/o VACTER
look for fistula primary repair vs. colostomy repair later |
|
|
Congenital diaphragmatic hernia mgmt
|
Wait 36-48 hrs – allow fetalnewborn circulation
-endotracheal intubation, lowP hyperventilation, sedation, NG suction surgery |
|
|
Gastroschisis mgmt
|
Look for atresias
Intestines back in belly Vascular access for IV nutrition |
|
|
Omphalocele mgmt
|
Look for multiple defects
Intestines back in belly Silicon silo if no room |
|
|
Extrophy of urinary bladder mgmt
|
Make arrangements that day
|
|
|
Duodenal Atresia mgmt
|
Look for anomalies
Surgery +/- contrast enema, EGD |
|
|
Annular pancreas mgmt
|
Look for anomalies
Surgery +/- contrast enema, EGD |
|
|
Malrotation mgmt
|
Look for anomalies
Emergency surgery +/- contrast enema, EGD |
|
|
Necrotizing enterocolitis mgmt
|
Stop feedings, BSAbx, IVF, IVN
surgery |
|
|
Meconium ileus mgmt
|
Gastrografin enema
Surgery if unsuccessful CF mgmt |
|
|
Malrotation mgmt
|
Urgent Dx studies
|
|
|
Hypertrophic pyloric stenosis mgmt
|
Check electrolytes
Correct alkalosis, rehydrate Ramstedt pyloromyotomy |
|
|
Biliary atresia mgmt
|
HIDA 1 wk after Phenobarbital
Surgery Liver transplant |
|
|
Hirschsprung Dz mgmt
|
Barium enema
Full-thickness Bx |
|
|
Intussusception mgmt
|
Barium/air enema
surgery |
|
|
Child Abuse mgmt
|
CPS
|
|
|
Meckel Diverticulum mgmt
|
Technetium scan – gastric mucosa in lower abd
|
|
|
Vascular ring mgmt
|
Barium swallow – extrinsic compression
Bronchoscopy Surgical repair – divide smaller of double aortic arch |
|
|
ASD mgmt
|
Echo
Closure – open surgery or cardiac cath |
|
|
VSD mgmt
|
Echo
Surgical correction Spontaneous closure if small and low |
|
|
PDA mgmt
|
Echo
Full-term – intraluminal coils, surgery Premature – indomethacin Heart failure – surgical closure |
|
|
Tetralogy of Fallot mgmt
|
Echo
Surgical correction |
|
|
Aortic Stenosis mgmt
|
Echo
Valve replacement (gradient > 50mm or CHF/angina/syncope) |
|
|
Chronic aortic insufficiency mgmt
|
Valve replacement
|
|
|
Chronic aortic insufficiency – endocarditis mgmt
|
Emergency valve replacement
ABx for a long time |
|
|
Mitral stenosis mgmt
|
Echo
Valve repair (commissurotomy) |
|
|
Mitral regurgitation mgmt
|
Echo
Repair (annuloplasty) > replacement |
|
|
MI risk mgmt
|
Cardiac cath – eval for revascularization
|
|
|
Triple vessel Dz mgmt
|
Coronary bypass
|
|
|
Chronic constrictive pericarditis mgmt
|
Surgery
|
|
|
Lung Cancer mgmt
|
Find older CXR
Sputum cytology CT upper abd (liver mets) Bx -central – bronchoscopy -peripheral – percutaneous Peripheral – thoracotomy, wedge resection Central lesion – pneumonectomy Cannot tolerate – ChTx/XRT Small cell – ChTx/XRT |
|
|
Subclavian steal syndrome mgmt
|
Angiogram – vertebral retrograde flow
Surgical bypass |
|
|
Abdominal aortic aneurysm mgmt
|
US – size
Elective surgical repair Leaking – consult today Rupturing now – emergency surgery |
|
|
Claudication mgmt
|
Doppler
Arteriogram Bypass/angioplastic stent – palliative only |
|
|
Rest pain mgmt
|
Studies for candidacy
|
|
|
Embolization? mgmt
|
Doppler
Fogarty catheter embolectomy Fasciotomy (if several hours) If incomplete – clot busters |
|
|
Thoracic aorta dissection (aneurysm) mgmt
|
Spiral CT
Arteriogram w/ b-blockers, IV nitrates Ascending – emergency surgery Descending – ICU for HTN |
|
|
Basal cell carcinoma mgmt
|
Full thickness Bx at edge (punch or knife)
Excision w/ conservative width |
|
|
Squamous cell carcinoma (skin) mgmt
|
Full thickness Bx at edge (punch or knife)
Excision w/ 1cm margins |
|
|
Melanoma mgmt
|
Full thickness Bx at edge (punch or knife)
Superficial – local excision Deep – WLE w/ 2-3 cm margins |
|
|
Malignant melanoma mgmt
|
Aggressive in resecting mets
|
|
|
Amblyopia mgmt
|
Surgical correction of problem
|
|
|
Retinoblastoma mgmt
|
See ophtho
|
|
|
Acute Glaucoma mgmt
|
Systemic CA inhibitors
Topical b-blockers A2 agonists Mannitol, pilocarpine |
|
|
Orbital cellulitis mgmt
|
CT
Surgical drainage |
|
|
Chemical Burn of eye mgmt
|
Cold water tap at home
ER irrigation Remove solid matter Recheck pH |
|
|
Retinal Detachment mgmt
|
Spot welding
|
|
|
CRAO mgmt
|
Breathe into paper bag
Press hard on eye and release |
|
|
DM retinopathy mgmt
|
Regular ophtho f/u
|
|
|
Thyroglossal duct cyst mgmt
|
Radioisotope scanning
Sistrunk operation |
|
|
Branchial cleft cyst mgmt
|
Elective removal
|
|
|
Cystic hygroma mgmt
|
CT
Surgical removal |
|
|
Inflammatory neck mass mgmt
|
Recheck in 3 wks
|
|
|
Lymphoma mgmt
|
FNA
Node Bx |
|
|
Met from primary tumor below neck mgmt
|
Look for primary tumor
Node Bx |
|
|
Met (Jugular Chain)from primary cancer of head/neck mucosa mgmt
|
Don’t bx
FNA Triple Endoscopy (w/ Bx?) CT XRT/platinumChTx/surgery |
|
|
Acoustic Nerve neuroma mgmt
|
MRI
|
|
|
Parotid Pleomorphic adenoma mgmt
|
FNA
NOT Bx in office Formal superficial parotidectomy (ENT surgeon) |
|
|
Parotid cancer mgmt
|
Expert mgmt
|
|
|
Foreign body mgmt
|
XR, phys exam, endoscopy
Extraction under anesthesia |
|
|
Ludwig angina mgmt
|
I&D
Intubation/tracheostomy maybe needed |
|
|
Bell Palsy mgmt
|
Antivirals
steroids |
|
|
Facial N. paralysis by edema mgmt
|
Nothing
|
|
|
Cavernous sinus thrombosis mgmt
|
Emergent IV ABx
Surgical drainage CT |
|
|
Anterior Septal Epistaxis mgmt
|
Phenylephrine spray
Local pressure |
|
|
Septal Perforation (cocaine abuse) mgmt
|
Posterior packing
|
|
|
Posterior juvenile nasopharyngeal angiofibroma mgmt
|
Surgical removal
|
|
|
Epistaxis 2/2 HTN mgmt
|
Anti-HTN Rx
ENT consult Posterior packing +/- emergency arterial ligation |
|
|
Neurologic dizziness mgmt
|
Neuro workup
|
|
|
Vestibular dizziness mgmt
|
Tx of Sx – meclizine, phenergan, diazepam
ENT workup |
|
|
TIA – carotid mgmt
|
Duplex
CEA (if 70% stenois) arteriogram |
|
|
TIA – vertebral mgmt
|
Duplex
Arteriogram (aortic arch study) Vascular surgery |
|
|
Stroke – vascular occlusive mgmt
|
Prevention – vascular surgery in neck
CT Supportive Tx/rehab Duplex – second preventable stroke If w/in 90 min - TPA |
|
|
Stroke – vascular hemorrhagic mgmt
|
CT
Supportive Tx/rehab |
|
|
Subarachnoid bleed/Intracranial aneurysm mgmt
|
CT
Angiogram Clip aneurysm |
|
|
Brain Tumors
Brain Tumor – general mgmt |
MRI > CT
Decrease ICP – mannitol, hyperventilation, Decadron (high dose steroids) |
|
|
Cushing Reflex mgmt
|
Brain tumor protocol, but emergency
|
|
|
Frontal lobe tumor/Foster-Kennedy syndrome mgmt
|
MRI
neurosurgery |
|
|
Craniopharyngioma mgmt
|
MRI
craniotomy |
|
|
Prolactinoma mgmt
|
UPT, TFTs
Prolactin level MRI Bromocriptine Want to be pregnant – surgery Nonresponsive – surgery |
|
|
Acromegaly mgmt
|
Somatomedin C level
MRI Surgery or radioablation |
|
|
Nelson syndrome mgmt
|
MRI
Transnasal, trans-sphenoidal resection |
|
|
Pituitary apoplexy mgmt
|
MRI or CT
Urgent steroid replacement Eventual other hormone replacement |
|
|
Pineal gland tumor/Parinaud syndrome mgmt
|
MRI
Neurosurgery consult |
|
|
Pedi – Tumor of posterior Fossa mgmt
|
MRI
neurosurgery |
|
|
Brain abscess mgmt
|
CT
resection |
|
|
Spinal cord tumor mgmt
|
XR
MRI Neurosurgery consult |
|
|
Lumbar disk herniation mgmt
|
MRI
Bed rest Weakness/sphincter issue – neurosurgical intervention |
|
|
Spinal stenosis mgmt
|
MRI
Surgical decompression of cauda equina |
|
|
Autonomic dysreflexia mgmt
|
Empty bladder
a-blockers CCBs |
|
|
Trigeminal neuralgia/tic douloureux mgmt
|
MRI
Anti-convulsants |
|
|
Causalgia/reflex sympathetic dystrophy mgmt
|
Symphathetic block – successful
Surgical sympathectomy |
|
|
Testicular torsion mgmt
|
Emergency surgery
|
|
|
Acute Epididymitis mgmt
|
US – r/o torsion
ABx |
|
|
UTI + obstruction mgmt
|
Massive IVAbx
Relieve obstruction – ureteral stent, percutaneous nephrostomy |
|
|
Pyelonephritis mgmt
|
Hospital
IVAbx US – r/o obstruction |
|
|
Acute Bacterial Prostatitis mgmt
|
IVAbx
NO MORE DREs |
|
|
UTI in a male mgmt
|
Urine Cx, ABx
Urologic workup – IVP or US not cystoscopy |
|
|
Acute urinary retention – BPH mgmt
|
Indwelling catheter 3d
a-blockers 5a reductase inhibitors |
|
|
Acute urinary retention + overflow incontinence mgmt
|
Indwelling catheter
|
|
|
Stress incontinence mgmt
|
Kegels
Surgical reconstruction if large cystocele |
|
|
Ureteral Colic
|
<3mm – watch, wait
>7mm – SWL |
|
|
SWL contraindications
|
Pregnancy
Bleeding diathesis Stone > 2cm |
|
|
Colovesicular Fistula mgmt
|
CT
Sigmoid exam surgery |
|
|
Psychogenic impotence mgmt
|
Prompt psychotherapy
|
|
|
Organic impotence – vascular injury mgmt
|
Vascular reconstruction
Sildenafil, tadalafil, vardenafil |
|
|
Organic impotence – nerve injury mgmt
|
Prosthetic device
|
|
|
Posterior urethral valves mgmt
|
Catheter
Voiding cystourethrogram Endoscopic fulguration or resection |
|
|
Hypospadias mgmt
|
Don’t circumcise
Eventual surgical correction |
|
|
Pediatric hematuria mgmt
|
US
IVP |
|
|
Pediatric UTI mgmt
|
Tx infxn
IVP Voiding cystogram – look for reflux |
|
|
Reflux (vesicourethral reflux?) mgmt
|
Long term ABx
|
|
|
Low implantation of one ureter mgmt
|
Phys exam
IVP surgery |
|
|
Uretopelvic jxn obstruction mgmt
|
US
repair |
|
|
Renal cell carcinoma mgmt
|
IVP
CT |
|
|
Bladder cancer mgmt
|
IVP
cystoscopy |
|
|
Prostate Cancer mgmt
|
Transrectal needle Bx
Surgical resection/radiotherapy Mets/palliation – orchiectomy, LH agonists, antiandrogens ASx not Tx’d after 75yo |
|
|
Testicular cancer mgmt
|
Radical orchiectomy
LN dissection Platinum ChTx f/u – AFP, bHCG (draw before surgery) same if mets |
|
|
Acute transplant rejection mgmt
|
Bx
Steroids OKT3 if refractory |
|
|
Chronic transplant rejection mgmt
|
Bx – check if late actue
|
