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200 Cards in this Set

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  • Back
Rx for adrenal crisis
IV steroids (dexamethasone), volume resuscitation
When should transfusion with FFP be given?
On call to the OR
Factors that predispose to fistula formation and may prevent closure
Foreign body
Epithelialization of the tract
Distal obstruction
Fever, chills, hypotension, oliguria, pain at IV site
Hemolytic tranfusion reactions (due to reaction of recipient Abs against transfused antigens)
Management of pt with hemophilia A who needs surgery
If severe disease: e-aminocaproic acid (AMICAR; inhibits fibrinolysis) and desmopressin (DDAVP, increases VIII and vWF)

If mild: DDAVP alone
Why can FFP not be used successfully in hemophiliacs?
Factor levels are too low; need cryo or recombinant factos
NSAIDs can cause ___ dysfunction
Potential vitamin deficiency syndromes from gastrectomy and Bilroth II procedure
Megaloblastic anemia (decreased intrinsic factor)
Microcytic anemia (iron deficiency from decreased uptake in duodenum)
Osteoporosis (decreased calcium absorption from duodenum/jejunum)
Steatorrhea (fat malabsorpion)
Diagnostic test for suspected ureteral injury (intraop and postop)
Intraop: methylene blue administration

Postop: CT to see hydronephrosis or fluid collection (urinoma), then IV pyelogram
Tingling sensation and muscle cramps after thyroid surgery
Hypocalcemia, likely short-term due to transient ischemia of parathyroid gland
Rx for symptomatic hypocalcemia
IV calcium infusion (or oral if only mild symptoms); Vitamin D if persistent
Massive transfusion is associated with what electrolyte abnormality?
Hypocalcemia 2/2 chelation with citrate in banked blood
Numbness, Chvostek's sign, and prolonged QT
Best fluid replacement for enteric losses
Ringer's lactate
Rx for hyperkalemia
Kayexalate (to bind it)
Sodium bicarb, dextrose, insulin (all to shift it intracellularly)
Calcium gluconate (to counteract myocardial effects)
Best drainage system and location to minimize wound infections
Closed drainage system that exits skin away from surgical incision
When epithelialization is delayed beyond 3 wks, the incidence of ? increases
Hypertrophic scarring
Ex of epidermal burn
Why are superficial partial thickness burns painful?
Exposed superficial nerves
What leads to healing of superficial partial thickness burns?
Regeneration of epidermis from keratinocytes w/in sweat glands and hair follicles (areas with more will heal more quickly)
Rx for superficial partial thickness burns and why?
Antimicrobial creams and occlusive dressings (epithelialization is faster in a moist environment)
Rx for deep partial thickness wounds
Excise to a viable depth and then skin graft, esp if in cosmetic location since healing is slow and associated with contraction
Rx for full thickness injuries
All should be excised and grafted unless <1cm and no compromise of function, b/c all regenerative elements have been destroyed
When is the best time to graft burns?
Within 5 days of injury to minimize blood loss
Ideal skin covering choice?
Split skin autograft from unburnt areas
Alopecia, poor wound healing, night blindness, anosmia, neuritis, skin rashes
Zinc deficiency
Excessive diarrhea may lead to a ___ deficiency
Cardiomyopathy may be due to a ___ deficiency
Pts on long-term TPN may develop this deficiency w/ hyperglycemia, peripheral neuropathy, and encephalopathy
Potential abnormality following administration of large volumes of normal saline
Non anion-gap metabolic acidosis (due to increased chloride concentrations)
Both LR and NS are both __ (acidic/alkalotic) w/ respect to plasma
pH of LR is 6.5
pH of NS is 4.5
Two good situations for NS and for LR
NS: vomiting or significant nasogastric suction losses (b/c pt will have tendency toward metabolic alkalosis)

LR: replacing GI losses and correcting ECF deficits
3 indications for a vena caval filter
- Anticoagulation contraindication/ failure
- Free-floating venous clot
- Chronic PE complicated by pulm HTN
Earliest signs of sepsis
Altered mental status, flushed skin, tachypnea --> respiratory alkalosis
Body's response to stress causes
Increased CO
Peripheral vasodilation
Decreased arteriovenous oxygen difference (from decreased peripheral use of O2)
Rx for hemolytic transfusion reaction
- Fluid resuscitation
- Foley for diagnosis and monitoring of Rx
- Mannitol to induce diuresis (so can clear hemolyzed red cell membranes and avoid renal damage)
- Alkalinization of urine to prevent Hb clumping
Surgery for C. diff colitis
Subtotal colectomy with end ileostomy
Caloric requirements for 70kg man who is:
Multiple trauma/ventilated
Major burn
Nml: 1450
Postop: 1500
Septic: 2000
Multiple trauma/ventilated: 2500
Major burn: 3000
Bleeding from trach
Bleeding from tracheoinnominate artery fistula
Management of tracheoinnominate artery fistula
If still bleeding: stop (inflate balloon or compress)

Once bleeding stopped: fiberoptic exploration in the OR
Criteria for extubation
Negative inspiratory force >-20
Weaned to 5cm H2O PEEP
Minute ventilation <10L/min
RR <20/min
Rapid shallow breathing index btwn 60 and 105
What is the rapid shallow breathing index?
Ratio of RR to tidal volume
Anesthetic not to use in SBO operations and why
Nitrous oxide, b/c is less dense than air so may cause distension of air-filled spaces
Changes in ARDS
Decreased compliance
Decreased FRC
Alveolar collapse from leakage of protein-rich fluid
Oxygen dissociation curve shifts (right/left) indicate?
Right: increased tissue oxygen uptake
Left: decreased tissue oxygen uptake
Do the following conditions shift the oxygen dissociation curve R or L?
Increased PaCO2
Increased temp
Increased 2,3-DPG
Chronic lung diseases
Banked blood
All right except banked blood (b/c low in 2,3-DPG)

Chronic lung diseases shift it right via an increase in 2,3-DPG due to chronic hypoxia
Dopamine at low doses
Vasodilation of renal/mesenteric vessels and peripheral vasoconstriction, redirecting blood to kidneys/bowels
Dopamine at high doses
Increases HR, CO, BP and causes peripheral vasoconstriction
Dopamine at all doses
Increases diastolic BP and coronary blood flow
Best pressor choice for cardiogenic shock
Dobutamine (positive inotrope and vasodilates, but minimal chronotropic effect so only mild increase in O2 demand)
Reversal of epidural opiates
IV (not epidural) maloxone
Cardiac index =
Rx for acalculous cholecystitis
Percutaneous drainage
Hemodynamics in postop septic shock (early)
Increased CO, decreased SVR, normal central pressures
Rx for postop septic shock
Fluids, pressors, Abx (against gram negative rods and anaerobes, esp after bowel surgery), laparotomy and drainage of intraabdominal abscess when identified/ if pt stable
Indications for cholecystectomy in asymptomatic pts
Porcelain gallbladder (calcified)
Gallstones >3cm (associated w/ dev't of gallbladder carcinoma)
Why is an intraop cholangiogram often performed in cholecystectomies?
To r/o common bile duct stones
2 major complications of a cholecystectomy
Injury to the common duct (--> chronic biliary strictures, infection, and cirrhosis)
Injury to hepatic artery (--> hepatic ischemia or bile duct ischemia and stricture)
Most common bacteria in cholecystitis
E coli, enterobacter, klebsiella, enterococcus
Antibiotics for cholecystitis
2nd generation cephalosporin preop and for 24hrs postop
When is lap chole indicated in cholecystitis?
Within 48-72hrs
Symptomatic cholelithiasis + elevated bili or elevated LFTs
Suspect common bile duct obstruction
When is removal of common duct stones not necessary?
If they're smaller than 3mm
Management of symptomatic cholelithiasis or gallstone pancreatitis in pregnancy
Pain meds and hydration

If needed, cholecystectomy (ideally in 2nd trimester) or ERCP
Management of cholecystitis + elevated amylase
Cholangiogram (and cholecystectomy) is mandatory with biliary pancreatitis
Cholecystitis + severe symptomatic pancreatitis
Delay cholecystectomy
Ddx for very high fever, gallstones, and hypotensive
Acute cholecystitis, cholangitis, empyema of gall bladder, or pericholecystic abscess
Management of suppurative cholangitis
Emergent ERCP with sphincterotomy, decompression of biliary tree, stone removal
What causes a palpable gallbladder?
Inflamed gallbladder with omentum attached
Management of palpable gallbladder?
Emergent cholecystectomy due to high rupture risk
What is an emphysematous gallbladder?
Air in the wall due to gas-forming organism that has invaded the tissues
Management of emphysematous gallbladder
Urgent surgery
Jaundice, fever, and RUQ pain/tenderness
Acute (or ascending) cholangitis
Management of acute cholangitis
Resuscitation, Abx, US of biliary tree

If obstruction or dilation of CBD seen, then ERCP and biliary decompression
Name for a common duct stone occurring w/in 2yrs of a cholecystectomy
Retained stone
Management of biliary stricture
Surgical exploration and bypass of stricture usually w/ choledochojejunostomy
What two tests should be done in a pt with fever or pain after a lap chole?
Abdominal ultrasound and hepatobiliary nuclide scan (HIDA scan: hepatoiminodiacetic acid) looking for infection or biliary leak
How does the gallbladder look on a HIDA scan in a pt with acute cholecystitis?
Doesn't visualize
Management of postop biliary leak identified on HIDA scan
ERCP to define anatomy

If large collection: biliary drainage w/ temporary stent placed during ERCP
Tender lymph nodes in the groin
Lymphadenitis (or, lower likelihood, malignancy)
Tender testicle (acte vs. gradual)
Acute: torsion of testis
Gradual: viral ochitis or epididymitis
Hernia pt with N/V/abdominal distention
Incarcerated/ strangulated hernia
Hernia pt w/ fever, leukocytosis, and acidosis
Strangulated segment of bowel
Most hernia repairs involve attaching which two structures?
Transversalis fascia to either inguinal ligament or periosteum of pubic ramus
Most common hernia repair type
Lichtenstein repair (prosthetic mesh approximates superior abdominal wall structures to inguinal ligament)
Advtg of mesh?
Avoids creating tension on fascial structures, lessening postop pain and recurrence
Nerves at risk of injury in hernia repair
Genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous
Pediatric hernias represent a
Persistent patent processus vaginalis, NOT an abdominal wall defect/ defect in floor of inguinal canal
Sliding hernias may involve which other structures herniating?
Bladder, cecum, or sigmoid colon
When are ventral hernias difficult to repair?
Inadequate tissue strength, insufficient tissue, infection, or poor nutrition
Management of a perforated duodenal ulcer
Emergent celiotomy and ulcer closure

If no Hx of PUD, can close ulcer w/ omental patch; if long-standing disease, antrectomy w/ truncal vagotom
Postop postprandial weakness, sweating, lightheadedness, crampy abdominal pain, diarrhea
Dumping syndrome
When should dumping syndrome symptoms abate?
Within 3mo of surgery
Mechanism of omeprazole
Irreversabily inhibits H+/K+ ATPase in gastric parietal cells
Management of ITP w/:
Plts >30,000
Plts <30,000
Active bleeding
Prednisone (+/- IVIG)
Plt transfusion
Management of appendical adenocarcinoma
R hemicolectomy
Management of achalasia
Calcium channel blockers or long-acting nitrates; endoscopic dilation; Botox injection
Pts with achalasia are at increased risk of
Squamous cell carcinoma
Which symptoms improve in UC pts after total proctocolectom?
Peripheral arthritis, ankylosing spondylitis
Indications for UC surgery
Toxic megacolon, fulminant colitis, high grade dysplasia/carcinioma, definitive management of intractable disease (need end ileostom yas well)
Pancreatic fluid collection 4-6wks after acute pancreatitis
Pancreatic pseudocyst
Rx for pancreatic pseudocyst or pancreatic abscess
Percutaneous catheter drainage w/ Abx
CEA and amylase levels in pancreatic malignancy
High and low
Conditions associated w/ familial autonomous polyposis
Colon cancer
Fundic gland hyperplasia in stomach
Premalignant polyps in duodenum and perampullary region
Extraintestinal malignancies
Retroperitoneal and abdominal wall desmoid tumors
Benign osteomas
Most frequent serious complication of end colostomes
Parastomal herniation
Cause of parastomal herniation
Stoma placed lateral to, rather than thru, rectus muscle
Management of parastomal herniation
If symptomatic, needs operative relocation
Prolapse occurs most frequently w/ what type of colostomy?
Transverse loop colostomy
Management of transverse loop colostomy prolapse
Restoration of intestinal continuity or converstion to end colostomy
Contraindication for pancreatic cancer excision
Involvement of superior mesenteric artery
Management of variceal bleed
Fluisd, octreotide or vasopressin to decrease splanchnic blood flow, beta-blockers for long term prevention
Surgical option for recurrent bleeding varices
TIPS (transjugular intrahepatic portosystemic shunt)
2 classes and 4 types of ulcers
Acid associated (II: body of stomach + duodenum; III: prepyloric)
Not acid associated (I: body or lesser curvature; IV: GE junction)
Surgical indications for ulcers
Hemorrhage, perforation, refractory to medical Rx, inability to r/o malignancy
What surgery is required for ulcers?
Billroth I or II, + vagotomy if ulcer is a Type II or III (i.e. acid-associated)
Billroth I reconstruction
Distal gastrectomy w/ gastroduodenostomy
Billroth II reconstruction
Distal gastrectom w/ gastrojejunostomy
What is a Klatskin tumor?
DDx of biliary obstruction (5)
Pancreatic head cancer, periampullary carcinoma, cholangiocarcinoma, stricture of CBD, CBD stone impacted in ampulla
2 types of pts who often get CBD strictures
Chronic alcoholics w/ chronic pancreatitis

Pts w/ prior biliary surgery
What is a "double duct" sign?
Dilated CBD and pancreatic duct due to narrowing of distal CBD
Option for surgical palliation in pts w/ unresectable pancreatic cancer, and what it helps avoid
Biliary and gastric bypass

Prevents gastric outlet or duodenal obstruction and bile duct obstruction
Dilated intrahepatic ducts (intrahepatic obstruction) but no dilation of the CBD (extrahepatic obstruction)
Where are cholangiocarcinomas located?
At the bifurcation of the hepatic ducts
ERCP or this alternative test can be used to identify the tumor especially if high in the bile duct
Percutaneous transhepatic cholangiography
Rx for cholangiocarcinoma
If primary tumor only, excision (5 yr survival still only 15%)

If unresectable, palliative stenting (5% 5yr survival)

No role for chemo/radiation
Biliary cancer with best cure rate
Ampullary adenocarcinoma
Resection method for ampullary adenocarcinoma
Why is lap chole not a suitable option for malignant gallbladder adenocarcinoma?
Need open to remove hepatic tissue (common direct spread to the liver)
Management of calcified (porcelain) gallbladder and why
Chole b/c of 50% association with adenocarcinoma
What test is necessary to ensure not missing other potential diagnoses in a pt with suspected pancreatitis
Obstructive abdominal series (rule out perforated ulcer w/ free air, etc.)
Pancreatitis + severe deterioration and hypotension
Severe necrotizing pancreatitis
Two criteria systems for pancreatitis
Ranson criteria or APACHE II
Pt recovering from percutaneous pancreatic abscess drainage when suddenly becomes hypotensive and drainage becomes bloody
Erosion of cathether or abscess into a major artery (diagnose w/ angiography; control w/ embolization)
Management of elderly pt with suspected pancreatitis
Abdominal CT b/c of concern for other pathologies (mesenteric ischemia and volvulus)
Management of hepatic mets found during colectomy for colon cancer?
Wedge resection
Hernias are defects in what?
Transversalis fascia
Air in biliary tract of nonseptic pt?
Biliary enteric fistula
Complication of biliary enteric fistula
Gallstone ileus (stone into duodenum causes SBO at distal ileum)
Colonic syndrome w/o malignant potential and why not
Peutz-Jeghers (intestinal polyposis and melanin spots on oral mucosa), b/c are hamartomas
Management of gallstone ileus
Ileotomy, removal of stone, cholecystectomy (or interval chole if too inflamed at time of op)
Surgical indications for diverticular disease
Hemorrhage, recurrent diverticulitis, intractable to medical Rx, complicated diverticulitis (perforated +/- abscess and fistula)
Rx for diverticular abscess
Percutaneous drainage then definitive resectional therapy
Rx for perforated diverticulitis
Hartmann's procedure (sigmoid resection w/ end colostomy and rectal stump) or sigmoid resection, anastomosis, and diverting loop ileostomy
Rx for biliary dyskinesia
Rx for gallbladder polyp
<1cm: observe w/ serial US
Suspected carcionma: chole w/ intraop frozen section
Management of acalculous cholecystitis
Abx and perc chole tubes until inflammation has resolved, then lap chole
Appendicitis presentation in the elderly (+anticoag, trauma, or sudden muscular exertion) plus mass on CT
Hematoma of rectus sheath: conservative management
Acute pancreatitis that won't resolve
Pancreatic pseudocyst
Diagnostic test and management of pancreatic pseudocyst

NPO, TPN, observe; if not improved w/in 6wks, cystogastrostomy to drain fluid into GI tract (+biopsy to r/o cancer)
Management of simple hepatic cyst
Observe; if persistently symptomatic, aspiration and then sclerosant or excision
Multilocular cyst in liver w/ calcifications (and management)
Suspect echinoccal cyst from GI parasite: need operative sterilization and excision
Hepatic abscess
IV antibiotics and CT-guided drainage
Amebic hepatic abscess
Metronidazole, no surgery
DDx for solid liver lesion
Hemangioma, focal nodular hyperplasia, hepatic adenoma, mets, HCC
Pts with hepatic adenoma usually have a history of?
OCP use
How to diagnose a hemangioma?
Labeled RBC scan
Indications for surgical removal of benign liver mass
Symptomatic, risk of spontaneous rupture, uncertainty of diagnosis
Why is biopsy not performed when hemangioma or hepatadenoma are suspected but uncertain diagnoses?
High risk of bleeding
Management of hepatic adenoma?
Stop OCPs
Why must persistent or large hepatic adenomas be resected?
Risk of rupture or of development into HCC
When do hepatic adenomas have the highest risk of rupture?
During pregnancy
What is Bowen's disease?
Squamous cell carcinoma in situ
Melanoma location with worst prognosis
Face or trunk
Additional primary melanomas occur in what percentage of pts?
Which melanoma pts need adjuvant therapy, and what does it consist of?
Stage III and IV
Interferon or dacarbazine
Possibly radiation
Management of large macular brown lesion on cheek
Lentigo maligna (Hutchinson freckle): monitor closely, remove if changing b/c is a precursor to lentigo malignant melanoma
Management of subungal melanoma
Biopsy requires excision of portion of nail in continuity w/ lesion; reexcision following diagnosis involves amputation at DIP
Prognosis for anal melanoma
As with other mucosal melanomas, mortality is near 100% at 5 years
Firm, painless mass that is larger than most benign tumors
Fibrosarcoma and lymphangiosarcoma are associated w/ what two exposures?
Fibrosarcoma: therapeutic radiation

Lymphangiosarcoma: axillary lympadenectomy
Management of suspected sarcoma
Excision biopsy if <3cm
Incisional biopsy if >3cm
Poor prognostic indicators in sarcoma
Mitoses, degree of necrosis, >15cm, symptomatic
Which pts need met workup, what does it consist of, and most common locations for mets
All! (22% have mets at presentation)
Liver, lung, bone, brain
Surgical option for sarcoma
Extensive: often total resection of tissue compartment or amputation of extremity
Best adjuvant therapy for sarcoma
Management of sarcoma recurrence in the lung
Thoracic wedge resection (one of the whom tumors in which excision of pulmonary mets can result in long-term disease-free survival)

Same with liver mets
7 factors that slow wound healing
Why can pts not do heavy lifting for 6wks postop?
Collagen production and cross-linking are still occurring, so not yet at full tensile strength, prone to injury/disruption
Hard knot-like structure underneath surgical wound
Likely a suture knot: should resolve if was absorbable suture, otherwise can be removed under local anesthesia once wound is fully healed
What is healing by third intention?
Delayed primary closure
Erythema and some pus drainage around wound 3mo postop
Stitch abscess
Management of a stitch abscess
Explore opening w/ hemostat and remove suture under local anesthesia
Management of postop ventral hernia thru wound
How long should a wound be observed for before considering revision for its appearance?
Management of hypertrophic scar
Steroid injections and local pressure dressings

Revision usually not appropriate as are likely to recur
Raised hypertrophic scar that is spreading outside immediate area of incision
Keloid (same as treatment for hypertrophic)
Management of wound infection
Drainage and debridement; usually don't require Abx (only if cellulitis spreading despite drainage)
2 types of wounds that heal by secondary intention
Wounds that are intentionally left open

Wounds that become infected and require opening in immediate postop period
What is the process of a graft revascularizing from granulation tissue called?
What is the advantage of split thickness skin grafts for wounds?
Reduce wound contraction by 60%
Disadvantage of skin grafts
More susceptible to trauma than normal skin
What is required for the skin graft to attach successfully?
Bacterial count on granulation bed must be <10^5 bacteria/gram of tissue
Four categories of wounds
Clean, clean-contaminated, contaminated, infected
Management of contaminated wound
Leave open to heal by secondary infection, treat with saline-soaked gauze
Definition of a clean wound
No entry made into GI, respiratory, or GU tracts and no active infection
Definition of clean-contaminated wound
There is entry into GI, resp, or GU tract but it is prepared both mechanically and antibacterially (e.g. bowel prep before surgery)
Need for prophylactic Abx for clean, clean-contaminated, and contaminated
Clean: none
Clean-contaminated: single preop and postop dose
4 situations in which prophy Abx are indicated
Exposure to bacteria
Prosthetic material
Poor bloody supply
When should prophy Abx be given?
1 hr preop
Postop: multiply half-life of drug by 1-2.5