Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
264 Cards in this Set
- Front
- Back
|
assesing the airway |
patient consious and speaking --> airway present
neck hematoma or emphysema --> patient will loose airway and should be secured patient unconsicous or noisy breathing --> need to secure airway |
|
|
airway procedures
|
in the field --> cricothyroidotomy
in the ER --> orotracheal intubation with pulse oxumetry cervical spine injury --> orotracheal or nasotracheal intubation maxillofacial injuries --> cricothyroidotomy or percutaneous tracheostomy |
|
|
signs of shock
|
systolic pressure < 90mmHg
fast feeble pulse low urinary output in patient who is cold, pale, shivering, sweating, thirsty |
|
|
traumatic causes of shock
|
bleeding
pericardial tamponade tension pneumothorax hypovolemic shock cannot happen from intracranial bleeding |
|
|
hemorrhagic shock Vs. pericardial tamponade Vs. tension pneumothorax
|
hemorrhage --> CVP is low (empty veins)
cardiac tamponade and tension pneumo --> CVP high (distended neck veins) pericardial tamponade --> no respiratory distress tension pneumo --> severe respiratory distress, unilateral loss of breath sounds, hyperresonance and mediastinum/tracheal deviation |
|
|
hemorrhagic shock in penetrating injuries management
|
surgical intervention first to stop the bleeding then volume replacement
|
|
|
non-hemorrhagic shock management
|
fluid replacement first with 2L of Ringer followed by packed red cells until urine is 0.5-2ml/kg/h and CVP does not exceed 15mmHg
|
|
|
pericardial tamponade shock management
|
clinical diagnosis, don’t order x-rays, if unclear order sonogram
prompt evacuation of pericardial sac by pericardiocentesis, tube, pericardial window or open thoracotomy fluids and red cells while evacuation is being done |
|
|
tension pneumothorax shock management
|
clinical diagnosis, don’t order x-rays or wait blood gases; big needle or IV catheter into pleural space; follow with chest tube connected to underwater seal
|
|
|
preferred route of lfuid resuscitation in shock
|
2 16-gauge peripheral IV lines
if not --> percutaneous femoral vein catheter or saphenous vein cut-down |
|
|
types of head trauma
|
penetrating
linear skull fracture base of skull fracture acute epidural and subdural hematoma diffuse axonal injury chronic subdural hematoma |
|
|
head trauma + loss of consiousness
|
CT of head required to rule out hematoma
if negative CT --> send home and wake up frequently in next 24 hours |
|
|
base of skull fracture
|
signs are racoon eyes, rinorrhea, otorrhea, echymosis behind ear
no antibiotics indicated cervical spine CT to assess integrity if has loss consciousness --> head CT if signs of base fracture --> neck CT also |
|
|
neurologic damage from trauma
|
from initial blow, or later hematoma or increased intracranial pressure
treat hematoma with surgery treat pressure with drugs (diuretics) |
|
|
acute epidural hematoma
|
sequence of trauma, unconsciousness, lucid interval, gradual coma, fixed dilated pupil, contralateral hemiparesis
CT shows biconvex, lens-shaped hematoma cure is emergency craniotomy |
|
|
acute subdural hematoma
|
sequence of trauma, unconsciousness, lucid interval, gradual coma mcuh more severe
CT shows semilunar hematoma if midline deviated --> craniotomy else --> treat increased intracranial pressure |
|
|
diffuse axonal injury from head trauma
|
CT shows blurring of gray-white matter interface and small punctate hemorrahges
if no hematoma, no surgery decrease ICP |
|
|
chronic subdural hematoma
|
in elderly or severe alcoholics
a tear in venous sinuses with hematoma over days or weeks CT and surgical evacuation is cure |
|
|
penetrating neck trauma exploration indications
|
expanding hematoma
deteriorating vital signs esophageal or tracheal injury (coughing, hemoptysis) gunshot to middle neck |
|
|
neck gunshot wounds
|
middle zone --> exploration
upper zone --> arteriogram base of neck --> arteriogram, esophagogram (barium), esophagoscopy, and bronchoscopy before surgery |
|
|
neck stab wounds
|
if upper and middle zones in asymptomatic patients --> observation
|
|
|
blunt neck trauma
|
if neurologic deficits or pain to local palpation of cervical spine --> cervical spine CT
|
|
|
types of chest trauma
|
rib fracture
pneumothorax hemothorax blunt trauma sucking chest wounds flail chest pulmonary contusion myocardial contusion traumatic rupture of diaphragm, aorta, trachea or bronchus air and fat embolism |
|
|
rib fracture
|
can be deadly in elderly
progression of pain --> hypoventilation --> atelectasis --> pneumonia treat with nerve block |
|
|
plain pneumothorax
|
penetrating trauma due to broken rib or weapon
moderate shortness of breath, unilateral absence of breath sounds and hyperresonance do chest x-ray, place chest tube, connect to underwater seal |
|
|
hemothorax
|
penetrating trauma due to broken rib or weapon
moderate shortness of breath unilateral absence of breath sounds and dullness to percussion do chest x-ray and evacuate blood by chest tube surgery indicated if --> recover 1.5L of blood with insertion of chest tube or 600ml in tube drainage over 6 hours |
|
|
blunt chest trauma
|
monitor hidden injuries --> blood gases, chest x-ray, cardiac enzymes, ECG
|
|
|
sucking chest wound
|
flap sucks air in with inspiration and closes in expiration
treat with occlusive dressing to allow air out but not in |
|
|
flail chest
|
multiple rib fracture with paradoxic breathing
treat lung contusion with fluid restriction, colloid solutionsa and diuretics |
|
|
pulmonary contusion
|
appears immediately or within 48 hours --> deteriorating blood gases and white-out of lungs on x-ray
treat with fluid restriction, colloids and diuretics |
|
|
myocardial contusion
|
suspect it in sternal fractures
do ECG and troponins treatment is to prevent complications (arrhythmia) |
|
|
traumatic rupture of diaphragm |
bowel in chest on left side by physical exam and x-ray
evaluate with laparoscopy surgical repair from abdomen |
|
|
traumatic rupture of aorta
|
hidden injury due to at junction of arch and descending aorta
due to deceleration injury asymptomatic until rupture occurs suspect it if first rib, scapula or sternum are fractured first procedure is x-ray if normal mediastinum --> transesophageal echo, CT or MRI angio if wide mediastinum --> aortogram if noninvasive tests are inconclusive needs prompt surgical repair |
|
|
traumatic rupture of trachea or major bronchus
|
suggested by subcutaneous emphysema or large air leak from chest tube
look for air in x-ray bronchoscopy de detect lesion and secure airway then surgical repair |
|
|
air embolism
|
seen as sudden death in intubated trauma patients
also from supraclavicular node biopsy, central venous lines, CVP lines that disconnect do cardiac massage with left side down prevent with Trendelenburg position |
|
|
fat embolism
|
multiple trauma patient with long-bone fractures
petechial rash in axilla and neck fever, tachycardia and respiratory distress treatment is respiratory support |
|
|
types of abdominal trauma
|
gunshot wounds
stab wounds blunt trauma ruptured spleen complications are intraoperative coagulopathy and abdominal compartment syndrome |
|
|
gunshot wound to abdomen
|
any entry or exit below nipple line is considered to involve abdomen
exploratory laparotomy always to repair |
|
|
stab wound to abdomen
|
if penetration is evident (protruding viscera), hemodynamic instability or peritoneal irritation--> exploratory laparotomy
else --> digital exploration if equivocal --> CT scan |
|
|
signs of internal bleeding after blunt trauma
|
same as shock --> hypotension, fast pulse, low CVP and urine, pale, cold, anxious, shivering, sweating, thirsty
|
|
|
body compartments where internal bleeding can cause shock
|
needs apprix. 1,500ml loss of blood for shock
potential places --> abdomen, thighs, pelvis places easily detectable --> lungs, pericardium, neck, arms and legs not possbble --> head |
|
|
to determine abdominal internal bleeding after blunt trauma
|
suspect in multiple trauma patient with normal chest x-ray, no evidence of pelvic or femur fracture who develops signs of shock
|
|
|
intraabdominal bleeding diagnosis
|
CT scan determines presence, severity and site of bleeding
if hemodynamically unstable --> do diagnosis while resuscitating with peritoneal lavage or sonogram if positive --> exploratory laparotomy |
|
|
ruptured spleen
|
most common source of significant intraabdominal bleeding in blunt trauma
hints are ruptured lower left ribs try to repair, not remove if removal is needed --> postoperative immunization against encapsulated bugs |
|
|
intraoperative coagulopathy after abdominal trauma
|
treated with platelet packs and fresh-frozen plasma
if there's hypothermia and acidosis --> terminate laparotomy |
|
|
abdominal compartment syndrome
|
abdominal surgical wound cannot be closed in surgery or opens up in postoperative
treat with temporary cover (absorbable mesh or nonabsorbable plastic) |
|
|
pelvic fractures
|
pelvic hematomas are usually left alone if not expanding
have to rule out associated injuries (rectal exam, bladder, pelvic exam and urethra in men) diagnosis is with signs of shock in patient with pelvic fracture who is not bleeding elsewhere blood transfusions necessary but external fixation Vs. arteriographic embolization Vs. surgery is controversial |
|
|
urologic injuries
|
penetrating trauma
blunt trauma urethral injury bladder injury renal injury scrotal hematoma fracture of penis |
|
|
hallmark of urologic injuries
|
hematuria in trauma patient
microscopic hematuria in asymptomatic trauma patient does not need work-up |
|
|
urethral traumatic injury
|
usually result of pelvic fracture
almost exclusively in men with blood at the meatus, scrotal hematoma, not able to void, high-riding prostate on exam Foley catheter should not be inserted but retrograde urethegram done instead anterior injuries are repaired immediately, posterior are delayed |
|
|
bladder traumatic injury
|
associated with pelvic fracture, diagnosed by retrograde cystogram which must include postvoid film
surgical repair is done |
|
|
renal traumatic injury
|
usually associated with lower rib fracture
diagnosed by CT scan mostly managed without surgery complications are AV fistula with CHF or renal artery stenosis with hypertension |
|
|
scrotal hematoma
|
can attain alarming size but no specific intervention needed unless sonogram shows ruptured testicle
|
|
|
fracture of the penis
|
usually due to sex with woman on top
sudden pain, large shaft hematoma and normal glans emergency surgery required to prevent impotence |
|
|
penetrating injury to extremities considerations
|
determine whether theres vascular injury or not
if no major vessels in vicinity --> tetanus prophylaxis and debridement if near major vessels --> Doppler or arteriogram if obvious vascular injury --> surgery |
|
|
combined injuries of arteries, nerves and bone
|
first do bone, then vascular repair, then nerve, finally a fasciotomy (to prevent compartment syndrome)
|
|
|
crushing injury of extremities
|
risks --> hyperkalemia (do fluid correction), myoglobinemia, myoglobinuria, renal failure and compartment syndrome
|
|
|
chemical burns
|
massive irrigation to remove offending ageng
don’t try to neutralize |
|
|
electrical burns
|
always deeper than they appear
may involve myoglobinemia, myoglobinuria and renal failure orthopedic injuries due to massive muscle contraction |
|
|
respiratory burns
|
smoke inhalation in fires
soot or mouth burns are suggestive diagnose with bronchoscopy blood gases to determine if intubation is needed if carboxyhemoglobin is elevated --> 100% O2 reduces half-life |
|
|
rule of nines for adults
|
head and arms --> 9% each
legs --> 18% each trunk front --> 18% trunk back --> 18% |
|
|
rule of nines for babies
|
head --> 18%
2 legs --> 27% |
|
|
Parkland formula
|
kg X % of burn X 4cc RL + 2L D5W
first 1/2 in first 8h, the rest in next 16h; on day 2 --> half of day 1 |
|
|
burn care
|
topical silver sulfadiazine is agent of choice
burns around the eyes use triple antibiotic ointment IV analgesics enteric nuttrition |
|
|
tetanus prophylaxis
|
required for all bites
|
|
|
dog bites
|
considered provoked if dog was petted while eating or teased
no rabies prophylaxis needed just observation of the dog unprovoked dog bites require rabies immunoglobulin + vaccine |
|
|
snake bites
|
severe local pain, swelling and discoloration within 30 minutes
draw blood for typing and cross match, coagulation stdies and liver/renal function treat with antivenom don’t make cruciate cuts, suck out venom, wrap with ice or apply tourniquet |
|
|
bee stings |
wheezing and rash may occur with hypotension
give 0.3-0.5ml epinephrine 1:1,000 remove stingers without squeezing |
|
|
black widow spider bite
|
the spider is black with red hourglass on belly
nausea, vomitting, generalized muscle cramps treat with IV calcium gluconate |
|
|
brown recluse spider bite
|
skin ulcer with necrotic center surrounded by halo of erythema
dapsone may help |
|
|
human bites
|
bacteriollogically the dirtiest
require extensive irrigation and debridment may present on fist after punch in mouth |
|
|
orthopedic disorders in children
|
dysplasia of the hip
Legg-Perthes slipped capital femoral epiphysis septic hip acute hematogenous osteomyelitis genu varum genu valgus Osgood-Schlatter club foot scoliosis fractures |
|
|
developmental dysplasia of the hip
|
uneven gluteal folds
hip is easily dislocated with jerck-and-click and returned to normal with snap if physical is equivocal --> sonogram treat with abduction splinting with Pavlik harness for 6 months |
|
|
Legg-Perthes disease
|
avascular necrosis of capital femoral epiphysis occurs around age 6
limping, decreased hip motion, hip/knee pain, antalgic gait diagnose with AP/lateral hip x-rays treatment is controversial |
|
|
slipped capital femoral epiphysis
|
orthopedic emergency
chubby boy around 13, limping and with groin/knee pain, limited hip motion, flexed hip and thigh is externally rotated diagnose with x-rays and treat with surgical pinning of femoral head |
|
|
septic hip
|
orthopedic emergency in little toddlers with history of febrile illness and refusal to move the hip
elevated ESR diagnose by aspiration of hip under general anesthesia further drainage may be required |
|
|
acute hematogenous osteomyelitis in children
|
history of febrile illness with severe localized bone pain
x-rays don’t show anything for weeks do bone scan and treat with antibiotics |
|
|
genu varum
|
bow legs normal up to age 3
persistent varus is Blount disease and surgery can be done |
|
|
genu valgus
|
knock knee is normal between 4-8 years
no treatment needed |
|
|
Osgood-Schlatter disease
|
osteochondrosis of tibial tubercle seen in teenagers with persistent pain over tibial tubercle aggravated by contraction of quadriceps
immobilize the knee in extension for 4-6 weeks |
|
|
club foot
|
seen at birth with feet turned inward
plantar flexion of ankle inversion of foot adduction of forefoot internal rotation of tibia needs serial plaster casts or surgery if uncorrected after 6-8 months |
|
|
scoliosis in pediatrics
|
seen mostly in adolescent girls
look from behind while she bends forward noting hump (mostly over right thorax) bracing to arrest progression surgery may be needed |
|
|
osteogenic sarcoma
|
ages 10-25
persistend low-grade pain in lower femur or upper tibia sunburst pattern on x-ray |
|
|
Ewing sarcoma
|
ages 5-15 and grows at diaphyses
onin-skinning seen on x-rays |
|
|
metastatic bone tumors
|
seen min adults from breast (lytic lesions) or prostate (blastic lesions)
localized pain and pathologic fractures bone scan more sensitive but not more specific than x-rays |
|
|
multiple myeloma
|
CRAB --> hypercalcemia, renal failure, anemia, localized bone pain and lytic lesions on x-rays
increased total proteins with normal albumin Bence-Jones protein abnormal Igs by serum electrophoresis infections treat with chemo |
|
|
soft tissue sarcomas
|
firm, mass fixed to surrounding structures which metastasizes to lungs not lymph nodes
treat with wide local excision, radiotherapy and chemo |
|
|
general considerations about fractures
|
x-rays should include 2 views at 90 degrees to one another and include joints above and below fracture
if not badly displaced or angulated --> closed reduction else --> open reduction with internal fixation |
|
|
clavicular fractures
|
typically at junction of middle and distal third
treat with figure-of-eight-device 4-6 weeks |
|
|
anterior dislocation of the shoulder
|
most common dislocation
patient holds arm close to body but rotated outward numbness over deltoid from stretching axillary nerve AP/lateral x-rays are diagnostic |
|
|
posterior shoulder dislocation
|
occurs after seizures or electrical burns
arm is close to body and internally rotated needs axillary or scapular lateral view on x-ray |
|
|
Colles fracture
|
fall on outstretched hand results in painful and deformed wrist
fracture is of distal radius which is dorsally displaced and angulated treat with closed reduction and long arm cast |
|
|
Monteggia fracture
|
diaphyseal fracture of proximal ulna with anterior dislocation of radial head results from direct blow to ulna
broken bone often requires open reduction and internal fixation |
|
|
Galeazzi fracture
|
fracture of distal third of radius from direct blow with dorsal dislocation of distal radioulnar joint
broken bone required open reduction and internal fixation |
|
|
scaphoid fracture
|
fall on outstretched hand
wrist pain with localized tenderness to palpation usually x-ray is negative until 3 weeks later undisplaced fractures require spica cast |
|
|
metacarpal neck fractures
|
closed fist hits hard surface
hand is swollen and tender x-ray is diagnostic if mild --> closed reduction and ulnar gutter splint if severe --> Kirschner wire or plate fixation |
|
|
hip fractures
|
typically elderly who sustain fall
hip hurts affected leg is shortened and externally rotated diagnose with x-rays |
|
|
femoral neck fractures
|
can compromise vasculature of femoral head
prosthesis achieves faster healing and earlier mobilization |
|
|
intratrochanteric fractures
|
less likely to lead to avascular necrosis
treat with open reduction, pinning and anticoagulation to prevent DVT and pulmonary embolism |
|
|
femoral shaft fracture
|
treat with intramedullary fixation
may lead to shock from blood loss if open --> orthopedic emergency requiring OR cleaning and closure within 6 hours if multiple --> may lead to fat embolism |
|
|
knee injury
|
has swelling
if no swelling, unlikely to be serious MRI is best diagnosis |
|
|
collateral ligament injury
|
lateral blow displaces medial ligaments and vice versa
abduction demonstrates medial injuries and vice versa treat with hinged cast or surgical repair |
|
|
anterior cruciate ligament injury
|
more common than posterior
knee pain and swelling with flexed knee at 90 degrees, leg can be pulled anteriorly treat sedentary patients with immobilization and rehab treat athletes with arthroscopic reconstruction |
|
|
posterior cruciate ligament injury
|
knee pain and swelling
with flexed knee at 90 degrees, leg can be pulled posteriorly treat sedentary patients with immobilization and rehab treat athletes with arthroscopic reconstruction |
|
|
meniscal tears
|
presents with pain, swelling and click when knee is forcefully extended
best diagnosed with MRI arthroscopic repair is done complete meniscectomy leads to late development of degenerative arthritis |
|
|
tibial stress fractures
|
seen in young men subjected to forced marches
tenderness on palpation and x-ray is initially normal repeat x-ray in 2 weeks treat with cast or crutches |
|
|
tibia and fibula fractures
|
often when pedestrian is hit by car
physical shows angulation x-rays are diagnostic casting or intramedullary nailing is treatment watch out for compartment syndrome after long cast |
|
|
rupture of Achilles tendon |
seen in out-of-shape middle-aged men subjected to severe strain
loud popping noise is heard and there's loss of balance there's pain, swelling and limping and palpation reveals a gap cast in equinus or surgery |
|
|
fracture of ankle
|
falling on inverted foot
AP, lateral and mortise x-rays are diagnostic if displacement, open reduction and external fixation is needed |
|
|
compartment syndrome
|
orthopedic emergency frequently in forearm or lower leg precipitated by reperfusion after ischemia or crushing injury
there's pain and limited use of extremity, compartment is tight, tender and painful emergency fasciotomy is treatment |
|
|
pain under cast
|
orthopedic emergency requires removal of cast and examination of limb
|
|
|
open fracture
|
orthopedic emergency requires cleaning in OR and suitable reduction within 6 hours from injury
|
|
|
posterior hip dislocation
|
hip pain, leg is shortened, adducted and internally rotated
emergency reduction is needed to prevent avascular necrosis |
|
|
gas gangrene
|
penetrating dirty wounds
within 3 days patient looks ill wound is tender, swollen, discolored and has gas crepitation treat with IV penicillin, emergency surgical debridment, hyperbaric O2 |
|
|
radial nerve injury
|
dorsiflexion is affected
if nerve paralysis remains after reduction of fracture --> surgery |
|
|
popliteal artery injury
|
due to posterior dislocation of knee
check pulses, Doppler and arteriogram delayed restoration of lfow requires prophylactic fasciotomy |
|
|
carpal tunnel syndrome
|
numbness and tingling in distribution of median nerve reproduced by tapping or pressing median nerve over carpal tunnel
clinical diagnosis + wrist x-ray (carpal tunnel view) to rule out other things initial treatment is splints and antinflammatories if surgery is needed --> electromyography first |
|
|
trigger finger
|
finger is acutely flexed and patient is unable to extend it
painful snap when extended with other hand treat with steroid injections or surgery as last resort |
|
|
DeQuervain tenosynovitis
|
due to holding baby's head with wrist flexion and thumb extension
pain over radial distribution can be reproduced by holding thumb inside closed fist then forcing wrist into ulnar deviation treat with steroid injection surgery is rarely needed |
|
|
felon
|
abscess in pulp of fingertip due to neglected penetrating injury
presents with throbbing pain and signs of inflammation can lead to necrosis so surgical drainage is necessary |
|
|
gamekeeper thumb
|
injury of ulnar collateral ligament due to forced hyperextension of thumb
painful and can lead to arthritis treat with cast |
|
|
jersey finger
|
injury to flexor tendon when finger is forcefully extended
when making a fist, the distal phalanx does not flex manage with splinting |
|
|
mallet finger
|
extended finger is forcefully flexed and extensor tendon is ruptured
tip of the finger remains flexed when hand is extended splinting |
|
|
traumatically amputated digits
|
surgically reattached when possible; clean with sterile saline, wrapp in saline moistured gauze and place in sealed plastic bag on bed of ice; do not put antiseptic solutions, alcohol, dry ice or allow finger to freeze
|
|
|
lumbar disk herniation presentation
|
at L4-L5 or L5-S1
months of vague aching discogenic pain (pressure on anterior spinal ligament) followed by neurogenic pain precipitated by forced movement, coughing, sneezing, defecating neurogenic pain feels like electric shock down leg |
|
|
lumbar disk herniation diagnosis
|
straight leg raising gives excrutiating pain
MRI is confirmatory |
|
|
lumbar disk herniation management
|
initially bed rest for 3 weeks
pain control with nerve blocks surgery if progressive muscle weakness emergency surgery if cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia) |
|
|
cauda equina syndrome
|
distended bladder
flaccid rectal sphincter perineal saddle anesthesia requires emergency surgical decompression |
|
|
ankylosing spondylitis
|
progressive chronic back pain and morning siffness worse at rest
bamboo spine on x-ray antinflammatories and physical therapy HLA-B27 is also associated with uveitis and inflammatory bowel disease |
|
|
metastatic malignancy
|
progressive back pain worse at night and unrelieved by rest or position
lytic lesions (breast) or blastic lessions (prostate) on x-rays bone scan for early metastases MRI is best diagnostic tool |
|
|
diabetic ulcers
|
indolent and located at pressure points
due to neuropathy and microvasculature disease keep clean or amputate |
|
|
arterial insufficiency ulcers
|
at the tip of the toes usually
they look dirty with a pale base devoid of granulation tissue associated with absent pulses, trophic changes, claudication, rest pain initial test is Doppler, then arteriogram treat with surgical revascularization |
|
|
venous stasis ulcers
|
develops in chronically edematous indurated hyperpigmented skin of legs
painless and associated with varicose veins and cellulitis use support stockings and surgery may be required |
|
|
foot ulcers
|
need work up for diabetes and arteriosclerotic disease
|
|
|
Marjolin ulcer
|
is a squamous cell carcinoma of the skin that develops in chronic leg ulcer from burns or osteomyelitis
biopsy to diagnose wide local excision and skin graft to cure |
|
|
plantar fasciitis
|
sharp heel pain when stepping, worse in the morning
bony spur on x-ray and tenderness to palpation resolves in 12-18 months no surgery, just sumptomatic treatment |
|
|
preop assessment: cardiac --> ejection fraction
|
below 35% poses too much risk
|
|
|
preop assessment: cardiac --> JVD
|
worst factor indicating cardiac risk
|
|
|
preop assessment: cardiac --> MI
|
next worst predictor of cardiac complications; perform surgery after 6 months
|
|
|
preop assessment: cardiac risk factors
|
JVD
MI premature ventricular contractions rhythm other than sinus age over 70 emergency surgery aortic valve stenosis poor medical condition |
|
|
preop assessment: pulmonary risk factors
|
smoking (high PCO2) --> quit smoking 8 weeks prior to surgery with intensive respiratory therapy
do FEV1 and if abnormal, blood gases |
|
|
preop assessment: hepatic risk factors
|
40% mortality --> bilirubin > 2, albumin < 3, PT > 16, encephalopathy
80% mortality --> bilirubin > 4, albumin < 2, ammonia > 150mg/dL |
|
|
preop assessment: nutritional risk factors
|
20% weight loss in 2 months
albumin < 3 anergy to skin antigens transferrin < 200 treat with 7-10 days of preoperative nutritional support |
|
|
preop assessment: diabetic coma
|
absolute contraindication to surgery
|
|
|
postoperative fever causes
|
high fever --> malignant hypertehermia, bacteremia
usual range fever --> atelectasis, day 1 pneumonia, day 3 UTI, day 3 deep venous thrombophlebitis, day 5 wound infection, day 7 deep abscess, 2 weeks |
|
|
postop complications
|
fever
chest pain aspiration tension pneumothorax disorientation/coma oliguria abdominal distention wounds fluid and electrolyte imbalance |
|
|
postop bacteremia
|
30-45 minutes of invsive procedures
fever > 104 + chills do blood cultures x 3 start empiric antibiotics |
|
|
postop atelectasis
|
MCC in first day
rule out malignant hyperthermia and bacteremia treat with --> deep breathing and coughing, postural drainage, and if needed bronchoscopy if uncorrected --> pneumonia |
|
|
postop deep abscess
|
fever 2 10-15 days postop
diagnose with CT percutaneous guided drainage |
|
|
periop MI
|
chest pain only in 30%, the rest present with MI complications
treatment directed at complications cannot use thrombolytic therapy |
|
|
postop PE
|
ABGs --> hypoxemia, hypocapnia
diagnosis --> MC is CT +- contrast (angio CT); gold standard is angiogram use heparin |
|
|
intraop aspiration
|
leads to chemical acid injury
prevent with NPO and antacids before induction treat with bronchoscopy lavage, bronchodilators and respiratory supprt |
|
|
intraop tension pneumothorax
|
from positive pressure breathing
decreased BP, increased CVP if abdomen is open --> decompress through diaphragm else --> needle through anterior chest with chest tube later |
|
|
causes of disorientation/coma postop
|
hypoxia --> first thing to check with ABGs
ARDS --> treat with PEEP, careful of barotrauma delirium tremens --> in alcoholics, treat with benzos or alcohol hyponatremia --> from high ADH and free water; may use hypertonic and osmotic diuretics hypernatremia --> from unreplaced water loss ammonium --> in cirrhotic patients with bleeding varices who goest for portocaval shunt |
|
|
postop oliguria/anuria
|
urinary retention --> feels need to void but can't; do in-out catheter at 6 hours; after 2nd or 3rd then Foley
oliguria --> from dehydration (responds to 500ml saline bolus) or ARN (high urinary and fractional Na) anuria --> usually mechanical; look for plugged or kinked catheter |
|
|
postop paralytic ileus
|
after abdominal surgery
mild distention, no pain, absent bowel sounds prolonged by hypokalemia |
|
|
early mechanical bowel obstruction
|
due to postop adhesions
paralytic ileus does not resolve x-ray --> dilated small bowel loops and air fluid levels confirm with CT --> proximally distended, distally collapsed bowel surgical correction |
|
|
Ogilvie syndrome
|
paralytic "ileus" of the colon
follows surgery other than abdominal large abdominal distention x-ray --> massively dilated colon colonoscopy to suck out gas leave rectal tube in cecostomy of colostomy may be needed |
|
|
postop wound complications
|
wound dehiscence
evisceration wound infections fistulas of GI tract |
|
|
wound dehiscence
|
after open laparotomy
wound is intact but salmon-colored peritoneal fluid leaks out tape the wound, bound the abdomen and careful mobilization and coughing eventual reoperation for ventral hernia prevention or correction (not emergency) |
|
|
evisceration
|
complication of wound dehiscence
skin opens and abdominal content rush out cover with sterile dressings and emergency closure |
|
|
GI fistula
|
bowel content leaks
sepsis if drains to cesspool fluid/electrolyte loss, nutritional depletion and erosion of belly wall if they drain freely treat with electrolyte replacement, nutrition beyond the fistula and ostomy bags until nature heals it nature heals it if FETID not present --> foreign body, epithelilization, tumor, infection, irradiation, IBD or distal obstruction |
|
|
postop hypernatremia
|
if gradual --> rapid volume repletion with slow tonicity --> use D51/2 NS
if rapid --> from osmotic diuresis or DI --> produces CNS symptoms --> correct with D51/3 NS or D5W |
|
|
water intoxication
|
CNS symptoms of hyponatremia
carefully use hypertonic saline |
|
|
hypokalemia
|
from GI loss, loop diuretics, increased aldosterone, correction of DKA
correct at < 10mEq/h |
|
|
hyperkalemia
|
from renal failure, aldosterone antagonists, crush injuries, dead tissue, acidosis
treat with calcium (neutralize effects on membrane, fastest); dextrose/insulin; exchange resins; dyalisis |
|
|
mechanical intestinal obstruction
|
caused by adhesions in those with prior laparotomy
colick pain, vomiting, abdominal distention, noo pasage of gas or feces x-ray --> distended small bowel loops, air fluid levels treatment --> NPO, NG suction, IV fluids wating for spontaneous correction watch for strangulation --> fever leukocytosis, peritonitis, sepsis |
|
|
mechanical intestinal obstruction by hernia
|
from incarcerated hernia
emergent surgery if strangulation elective surgery if manual reduction is possible |
|
|
appendicitis
|
anorexia followed by vague paeriumbilical pain
then severe sharp constant pain in right lower quadrant guarding and rebound tenderness mild leukoxytosis and fever emergency appendicectomy doubtful presentation --> CT |
|
|
colonic polyps
|
most malignant --> familial polyposis, villous adenoma, adenomatous polyp
not premalignant --> juvenile, Peutz-Jeghers, inflammatory and hyperplastic |
|
|
indications for surgery in ulcerative colitis
|
disease > 20 years
nutritional compromise multiple hospitalizations need for high-dose steroids or immunosuppresants toxic megacolon (abdominal pain, fever, leukocytosis, distended colon) also need to remove all rectal mucosa |
|
|
hemorrhoids
|
internal --> painless bleed, rubber band ligation
external --> painful prolapsed internal --> pain and itching rule out cancer in all anorectal diseases |
|
|
anal fissure
|
exquisite pain with defecation with blood
constipation from fear of bowel movement may require physical exam under anesthesia relax the tight sphincter with stool softener, topical nitroglycerin, botulin toxin or surgery rule out cancer in all anorectal disease |
|
|
ischiorectal perirectal abscess
|
fever, perirectal pain, no bowel movements
local inflamation signs surgical drainage if diabetic --> necrosis --> watch closely rule out cancer in all anorectal disease |
|
|
fistula in ano
|
drainning tract lateral to anus after ischiorectal abscess drainage
rule out necrotic drainning tumor treat with fistulotomy rule out cancer in all anorectal disease |
|
|
GI bleeding stats
|
75% upper GI, 25% colon or rectum
if young person with GI bleed --> suspect upper if elderly --> can be from anywhere |
|
|
GI bleed work-up
|
hematemesis or melena --> start work-up with upper endoscopy
blood per rectum --> NG tube if blood retrieved --> upper GI bleed --> endoscopy if no blood retrieved + white fluid --> follow with endoscopy to exclude duodenum bleed if no blood retrieved + billous fluid --> no upper endoscopy needed once upper GI bleed is excluded --> exclude hemorrhoids --> if excluded --> if high volume --> angiography if low volume --> wait for bleeding to stop then colonoscopy alternative --> tagged RBC scan if child --> Meckel --> technetium scan looking for ectopic gastric mucosa |
|
|
acute abdominal pain from perforation
|
sudden onset severe constant generalized abdominal pain
antalgic position peritoneal irritation signs free air under diaphragm in upright chest-xray |
|
|
acute abdominal pain from obstruction
|
sudden onset colicky pain that is localized
patient moves constantly |
|
|
acute abdominal pain from inflamation
|
gradual onset constant that starts as ill-defined and then localizes
peritoneal irritation signs are localized systemic signs fever and leukocytosis |
|
|
acute abdominal pain from ischemia
|
severe sudden abdominal pain with blood in the lumen
|
|
|
primary peritonitis
|
ascites along with mild generalized acute abdomen and equivocal findings
culture the ascitic fluid and treat with antibiotics |
|
|
acute abdomen management
|
exploratory laparotomy after ruling out -->
primary peritonitis --> ascites myocardial ischemia --> ECG lower lobe pneumonia --> chest xray PE --> immobilized patient pancreatitis --> amylase urinary stones --> xray or CT |
|
|
mesenteric ischemia
|
acute abdomen in patient with Afib or recent MI
clot lodges in superior mesenteric there's pain and blood in lumen |
|
|
pyogenic liver abscess
|
complication of billiary tract disease, acute ascending cholangitis
fever, leukocytosis, tender liver ultrasound or CT are diagnostic treat with percutaneous drainage |
|
|
amebic abscess of liver
|
mexico connection
treat with metronidazole if no improvement --> drainage |
|
|
types of jaundice
|
hemolytic --> unconjugated bilirubin < 6 or 8, no bilirubin in urine
hepatocellular --> both fractions elevated, very high transaminases, modest AP obstructive --> both fractions elevated, modest transaminases and very high AP --> do ultrasound |
|
|
billiary obstruction from stone
|
ultrasound may not find common duct stone, but stones in a nondistended gallbladder are seen
high alkaline phosphatase after ultrasound, do ERCP for confirmation and stone removal after ERCP --> cholecystectomy |
|
|
Courvoisier-Terrier sign
|
large thin-walled distended gallbladder by ultrasound in malignant obstruction
|
|
|
causes of obstructive jaundice
|
stone in common duct
malignant obstructive jaundice --> adenocarcinoma of head of pancreas adenocarcinoma of ampulla of Vater cholangiocarcinoma of common bile duct |
|
|
obstructive jaundice by tumor work-up
|
first ultrasound --> dilated gallbladder -->
CT --> adenocarcinoma of head of pancreas if positive --> percutaneous biopsy if negative --> ERCP ERCP endoscopy shows ampulla of Vater cancers ERCP cholangiogram show cholangiocarcinoma of common duct or small pancreatic cancers |
|
|
ampulla of Vater cancer
|
malignant obstructive jaundice
anemia positive occult blood test endoscopy ERCP is first test |
|
|
gallstone disease spectrum
|
asymptomatic gallstone -->
billiary colic --> acute cholecystitis --> acute ascending cholangitis --> obstructive jaundice --> biliary pancreatitis |
|
|
biliary colic
|
stone temporarily obstructs cystic duct
colicky pain in RUQ radiates to right shoulder and back trigered by fatty food, associated with nausea and vomit no signs of peritoneal irritation or systemic inflammation self-limited diagnose with ultraound elective cholecystectomy is indicated |
|
|
acute cholecystitis
|
starts as biliary colic until inflammation of gallbladder occurs
pain becomes constant with fever and leukocytosis and peritoneal signs in RUQ liver function tests mildly affected ultrasound --> gallstones, thick gallbladder, pericholecystic fluid supportive and antibiotics to cool down then elective cholecystectomy if doesnt respond --> emergency surgery |
|
|
acute ascending cholangitis
|
stone partially obstructs common bile duct with ascending infection
fever with chills, high WBCs with sepsis some hyperbilirubinemia and markedly increased AP treat with ERCP decompression or percutaneous transhepatic cholangiogram then do cholecystectomy |
|
|
biliary pancreatitis
|
stone obstructs bile and pancreatic ducts at ampulla
stone often pass spontaneously elevated amylase ultrasound confirms gallstones in the gallbladder conservative treatment with elective cholecystectomy if unresponsive --> ERCP |
|
|
acute edematous pancreatitis
|
due to alcohol or gallstones
high amylase or lipase key finding is high hematocrit treat with NPO, rest and fluids |
|
|
acute hemorrhagic pancreatitis
|
alcohol or gallstones
lower hematocrit high amylase or lipase Ranson criteria --> leukocytosis, hyperglycemia, hypocalcemia increased BUN, metabolic acidosis, ARDS do daily CTs to find abscesses and drain them |
|
|
pancreatic abscess
|
acute supurative pancreatitis seen in CT after days of persistent fever and leukocytosis
percutaneous drainage required |
|
|
pancreatic pseudocyst
|
late sequela of acute pancreatitis or pancreatic trauma
collection of pancreatic secretions outside the ducts seen in CT or ultrasound cysts < 6cm or < 6 weeks --> conservative management for resolution cysts > 6cm or > 6 weeks --> percutaneous, surgical or endoscopic drainage |
|
|
glucagonoma
|
hyperglycemia
anemia glossitis stomatitis migratory necrolytic dermatitis measure glucagon and do a CT to localize |
|
|
esophageal atresia
|
excessive salivation shortly after birth with choking on first feed
coiled NG tube on xray rule out VACTER MC is blind upper esophagus and tracheoesophageal fistula if surgery is delayed --> do gastrostomy |
|
|
imperforated anus
|
may be VACTER presentation
look for fistula to vagina or perineum if present --> can delay surgery if absent --> colostomy for high rectal pouches or inmediate surgery for low level of pouch with upside-down x-ray |
|
|
congenital diaphragmatic hernia
|
always on the left
problem is lung hypoplasia with respiratory distress intubate, ventilate, wait 3-4 days for lung maturation then surgery |
|
|
gastroschisis Vs. omphalocele
|
gastroschisis defect is to the right of the normal cord with loose bowels; requires parenteral nutrition
omphalocele defect has membrane covering with cord going through it small defects --> immediate correction large defects --> construct protective Silastic silo and squeeze the contents a little every day |
|
|
double bubble sign
|
air-fluid level in stomach to the left
air-fluid level in first portion of duodenum to the right nor air in distal bowels present in duodenal atresia, annular pancreas and malrotation |
|
|
intestinal atresia
|
multiple air-fluid levels throughout abdomen
|
|
|
necrotizing enterocolitis
|
premature infant
first feeding causes intolerance, abdominal distention, thrombocytopenia and sepsis treat with broad-spectrum antibiotics indications for surgery --> abdominal wall erythema, air in portal vein, pneumatosis, pneumoperitoneum |
|
|
meconium ileus
|
babies with cystic fibrosis
feeding intolerance and bilious vomiting x-ray --> multiple dilated loops of small bowel gastrofin enema --> microcolon, meconium pellets diagnose and treat with gastrografin enema |
|
|
hypertrophic pyloric stenosis
|
nonbilous projectile vomiting after feeding at 3 weeks
visible peristaltic waves and palpable mass in RUQ if no clinical diagnosis --> sonogram |
|
|
biliary atresia
|
persistent progressive jaundice in 6-8 week baby
do sweat test and serology to rule out CF diagnosis --> HIDA scan after 1 week of phenobarbital; if no bile reaches duodenum --> laparotomy |
|
|
Hirchsprung
|
chronic constipation
x-ray --> distended proximal good colon with distal normal-looking aganglionic colon diagnosis --> full-thickness biopsy |
|
|
Meckel
|
lower GI bleed in kid
do radioisotope scan for gastric mucosa in bowel |
|
|
vascular rings
|
pressure on tracheobronchial tree and esophagus
stridor and respiratory distress and dyshpagia barium swallow shows extrinsic compression bronchoscopy shows segmental tracheal compression |
|
|
atrial septal defect
|
faint pulmonary flow systolic murmur
fixed split of second heart sound history of frequent colds |
|
|
ventricular septal defect
|
failure to thrive
loud pansystolic murmur at left sternal border increased pulmonary vasculature |
|
|
patent ductus arteriosus
|
bounding pulses
continous machinery murmur if no CHF --> indomethacin if CHF --> surgery or coil embolization |
|
|
tetralogy of Fallot
|
right to left shunt with cyanosis
bluish hue, clubbing and relieved by squatting systolic ejection murmur, right ventricular hypertrophy |
|
|
transposition of great vessels
|
kept alive by ASD, VSD or PDA
immediate cyanosis |
|
|
coin lesion and lung cancer work-up
|
check previous x-ray
then do sputum cytology and CT then bronchoscopy+biopsy for central OR percutaneous biopsy for peripheral |
|
|
operability of lung cancer
|
need aminimum FEV1 of 800
small cell is treaated with radio and chemo hilar metastases can be operated by node metastases not |
|
|
subclavian steal syndrome
|
atherosclerotic stenotic plaque at origin of subclavian
blood reaches the arm in normal activity but not in excersice in exercise the arm reverses blood from vertebrals and brain presentation --> arm claudication + posterior neurologic signs (visual and balance) diagnosis --> arteriogram claudication alone suggests thoracic outlet syndrome |
|
|
abdominal aortic aneurysm
|
pulsatile mass between xiphoid and umbilicus
coincidental finding on x-ray, ultrasound or CT < 4cm --> observation > 5-6 cm --> repair if tender --> will rupture soon --> repair |
|
|
arteriosclerotic disease of lower extremities
|
presentation --> intermittent claudication, shiny atrophic skin, no hair, no peripheral pulses, rest pain, ulceration and gangrene
if doesn't interfere with daily activities --> cessation of smoking, exercise and cilostazol if severe --> Doppler for pressure gradient if no gradient --> not amenable to surgery if gradient --> arteriogram looking for areas of stenosis and good distal vessels if short stenotic segments --> stents if large stenotic segments --> bypass graft of sequential stent |
|
|
atrial embolization
|
from atrial fibrillation or recent MI (mural thrombus)
pain, pale, poikilothermic, pulseless paresthetic, paralytic lower extremity do Doppler if incomplete obstruction --> thrombolytics if complete --> embolectomy with Fogarty catheter + fasciotomy |
|
|
dissecting aortic aneurysm of thoracic aorta
|
due to hypertension
do CT if ascending --> surgery if descending --> control hypertension |
|
|
amblyiopia
|
interference with processing of images in first 6-7 years of life most commonly by strabismus
produces cortical blindness |
|
|
strabismus
|
surgically correct to prevent amblyiopia
if acquired in childhood --> exagerated convergence --> glasses |
|
|
acute angle closure glaucoma
|
severe eye pain or frontal headache typically in the evening
halos around lights pupil is dilated and does not respond to light cloudy cornea eye is very hard emergency treatment with acetazolamide, topical betablockers, alpha2 agonists then emergency laser surgery |
|
|
orbital cellulitis
|
eyelids are inflammed
pupil is dilated and fixed eye has limited motion pus in the orbit emergency CT and drainage |
|
|
retinal detachment
|
flashes of light and floaters in the eye
emergency laser reattachement |
|
|
embolic occusion of retinal artery
|
unilateral sudden loss of vision
have the patient breathe in a paper bag and press/release the eye |
|
|
thyroglosal duct cyst
|
midline
pulling tongue out retracts the mass surgical removal of cyst, middle segment of hyiod bone and track to base of tongue |
|
|
brachial cleft cyst
|
anterior edge of sternocleidomastoid
may have little opening and blind tract in the skin |
|
|
cystic hygroma
|
at the base of neck
large, mushy, ill-defined mass occupies entire supraclavicular area often extend into chest and mediastinum CT before surgery is mandatory |
|
|
recently discovered enlarged lymph node
|
complete history and physical + follow-up 3-4 weeks
if mass persists --> work-up |
|
|
persistent enlarged lymph node
|
could be inflammatory but cancer has to be ruled out
for lymphoma or lymph node metastasis --> removal of node and pathologic exam could also be squamous cell carcinoma of mucosa of head and neck |
|
|
squamous cell carcinoma of mucosa of head and neck
|
smokers, drinkers, rotten teeth, AIDS
persistent hoarseness persistent painless ulcer at floor of the mouth persistent unilateral earache do triple panendoscopy FNA may be done but not open biopsy treatment --> resection, radical neck dissection, radio, chemo |
|
|
facial nerve tumor
|
unilateral facial peripheral paralysis that is insidious
do gadolinium MRI |
|
|
parotid tumor
|
most are adenomas but predispose to malignant; don’t produce facial paralysis
hard painful parotid mass with facial paralysis is carcinoma FNA may be done but open biopsy is absolutely contraindicated treat with parotidectomy |
|
|
cavernous sinus thrombosis
|
diplopia in patient with sinusitis
emergency IV antibiotics, CT and drainage is required |
|
|
epistaxis
|
in children, may be from nose picking; treat with phenylephrine and local pressure
in adolescents --> cocaine abuse (posterior packing needed) or nasopharyngeal angiofribroma (surgical excision) in elderly or hypertensives --> can be life-threatening; control BP and posterior packing |
|
|
parinaud syndrome
|
tumor of pineal gland
loss of upper gaze and sunset eyes |
|
|
neurogenic claudication
|
back pain worsened by back extension or standing up, releived by flexion or sitting down
diagnosis is spinal stenosis do MRI |
|
|
reflex sympathetic dystrophy
|
causalgia develops after crushing injury
constant burning pain does not respond to analgesics extremity is cold, cyanotic and moist diagnosis --> succesful sympathetic block management --> surgical sympathectomy |
|
|
testicular torsion
|
adolescents with testicular pain of sudden onset
no fever, pyuria or history of mumps testicle is tender but cord is not clinical diagnosis, don’t do tests emergency surgery required |
|
|
acute epididymitis
|
severe testicular pain of sudden onset
fever and pyruia is present cord is tender do sonogram to rule out testicular torsion treat with antibiotics |
|
|
combined obstruction and infection of urinary tract
|
urologic emergency because it can lead to kidney destruction in hours
suddenly develops fever, chills and flank pain treat with IV antibiotics and decompression above the obstruction |
|
|
urologic diagnostic procedures
|
IV pyelogram; looks at kidneys, ureters and some bladder; contraindicated if creatinine >2
CT --> renal tumors and stones sonogram --> to look for dilation and obstruction cytoscopy --> to look at bladder mucosa for cancer |
|
|
posterior urethral valves
|
MCC for a newborn not urinating in first day
do catheterization diagnosis --> voiding cystourethrogram treatment --> endoscopic fulguration or resection |
|
|
hypospadia
|
urethral opening on ventral side of penis
do not do circumsision because prepuce is needed for correction |
|
|
vesicouretheral reflux
|
signs of peylonephritis in a child
do IVP and voiding cystogram looking for the reflux if found --> long term antibiotics |
|
|
low implantation of urether
|
normal voiding plus wet with urine all the time in girls but asymptomatic in boys
do IVP then surgery |
|
|
ureteropelvic junction obstruction
|
normal diuresis is ok but large volume cannot handle it (teenage goes drinking)
colicky flank pain |
|
|
renal cell carcinoma
|
hematuria, flank pain, flank mass
hypercalcemia, erythocytosis, elevated liver enzymes work-up --> IVP shows mass; US shows solid, not cystic mass; CT may be first study shows heterogenous solid mass |
|
|
cancer of bladder
|
smoking predisposes
hematuria, irritative voiding symptoms work-up --> first IVP; best test is cytoscopy |
|
|
prostatic cancer
|
rock hard nodule on rectal exam and high PSA
diagnosis --> transrectal needle biopsy guided by sonogram; CT for extent of involvement widespread bone metastasis --> androgen ablation, orchiectomy, flutamide |
|
|
testicular cancer
|
painless testicular mass
do AFP and bHCG first for basal levels and follow-up diagnose and treat with radical orchiectomy radio and chemo may be given |
|
|
urether stone
|
< 3mm can pass spontaneously with analgesic and fluids
> 7mm needs intervention with shock wave lithotripsy or more invasive such as basket extraction, sonic probes, laser |
|
|
psychogenic impotence
|
does not interfere with nighttime erections
diagnose with roll of postage stamps |
|
|
hyperacute transplant rejection
|
vascular thrombosis within minutes
caused by preformed antibodies prevented by ABO matching and lymphocytotoxic crossmatch |
|
|
acute transplant rejection
|
5 days - 3 months
signs of organ dysfunction even on immunosupressants confirmed by biopsy treatment is steroid bolus +- OKT3 liver --> more often due to mechanical problems; do Doppler heart --> do serial ventricular biopsies |
|
|
chronic transplant rejection
|
years after the transplant with insidious loss of function
irreversible and no treatment available |
