High Yield Surgery Shelf Exam Review Complete

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High Yield Surgery

Shelf Review

PRE-OP EVALUATION

Contraindications to surgery

– Absolute? Diabetic Coma, DKA

– Poor nutrition? albumin <3, transferrin <200, weight loss <20%.

– Severe liver failure? bili >2, PT >16, ammonia > 150 or encephalopathy

– Smoker? stop smoking 8wks prior to surgery

If a CO2 retainer, go easy on the O2 in the post-op period. Can suppress respiratory drive. Goldman Index: Who is at greatest risk for surgery

#1 = CHF

• Check? EF. If <35%, no surg.

#2 = MI w/in 6mo (ischemic disease)

• Check? EKG  stress test  cardiac cath  revasc.

#3 = arrhythmia

#4 = Old (age >70)

#5 = Surgery is emergent

#6 = Aortic stenosis, poor medical condition, surg in chest/abd

• Murmur of AS: Late systolic, crescendo-decrescendo murmur that radiatesto carotids. ↑ with squatting, ↓ with decr preload

Meds to stop

2 wks: Aspirin, NSAIDs, vit E

5 days: Warfarin – drop INR to <1.5 (can use vit K) !  Take thyroid meds morning of surgery

If CKD on dialysis

 Take ½ morning dose of insulin if IDDM  Dialyze 24 hours pre- & post-op

• Why check BUN/Cr? Increased risk of post-op bleeding 2/2

– If BUN > 100: Uremic platelet dysfunction.

– Coag panel: Normal platelets but prolonged bleeding time

VENT SETTINGS

• Assist-control: set TV and rate but if pt takes a breath, vent gives the volume. • Pressure support: pt rules rate but a boost of pressure is given (8-20).

*Important for weaning.*

• CPAP: pt must breathe on own but + pressure given all the time.

• PEEP: pressure given at the end of cycle to keep alveoli open (5-20).

*Used in ARDS or CHF*

• Best test to evaluate vent management? ABG

• LowPaO2? increase FiO2

• High PaO2? decrease FiO2

• Low PaCO2 (pH is high)? Decr RR or TV

• High PaCO2 (pH is low)? Incr rate or TV

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*Remember minute ventilation equation & dead space*

ACID-BASE DISORDERS

Respiratory: pH and PCO2 move in opposite directions Metabolic: pH and PCO2 move in same direction pH < 7.4 = acidotic.

High pCO2: Acute Respiratory Acidosis  High pCO2 and HCO3? Chronic

Low HCO3: Acute Metabolic Acidosis  Low HCO3 and pCO2? Chronic

• Anion gap: (Na – [Cl + HCO3]) Normal: 8-12

• Anion-gap acidosis = MUDPILES (Methanol, Uremia, Diabetic ketoacidosis, Propylene glycol, Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates)

• Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV) pH > 7.4 = alkalotic.

High HCO3: Acute Metabolic Alkalosis  High HCO3 and pCO2? Chronic

Low pCO2: Acute Respiratory Alkalosis  Low HCO3 and pCO2? Chronic  Decrease in serum K and ionized Ca

o Paresthesias, carpopedal spasm, and tetany.  Urine [Cl]

o [Cl] < 20: Vomiting/NG, antactids, diuretics  [Cl] > 20: Conn’s, Bartter’s, Gittleman’s

TRAUMA

ABCDE: Airway, Breathing, Circulation, Dysfunction (neurological), Exposure (examine whole body)

AB: Airway, Breathing

 Patient comes in unconscious or GCS </= 8: Intubate, Will Robinson! Intubate!

o Stung by a bee, developing stridor and tripod posturing: Intubate!

o Penetrating neck trauma, GCS = 15 BUT expanding mass/hematoma in lateral neck: Intubate!  Penetrating neck trauma, subcut. emphysema on palpation: Fiberoptic broncoscope/intubation  Huge facial trauma, blood obscuring/obliteration of oral/nasal airway: Cricothyroidotomy  Post-intubation: Check bilateral breath sounds

o If decr on left: Intubation of R mainstem bronchus  Pull back ET tube

 Check pulse ox, keep at > 90% Traumatic Aortic Injury

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Burns

American Burn Association Criteria for Referral to a Burn Center  Partial- or full-thickness burns of > 10% BSA in pts < 10 or > 50 y/oPartial- or full-thickness burns of > 20% BSA in pts of other ages

Partial- or full-thickness burns involving face, hands, feet, genitalia, perineum, or skin over major jointsFull-thickness burns of > 5% BSA at any age

Significant electrical (incl. lightning) & chemical burns

Lesser burn injury in conjunction with inhalational injury, trauma, or preexisting medical cond’nsPatients requiring special social, emotional, or rehabilitation assistance (i.e., child or elder abuse) Rule of 9s

Start resuscitation with 1L LR bolus adults, 20 mL/kg for children

 Parkland formula: 2-4mL/kg/%BSA burn (adults)  children, 3-4mL/kg/%BSA  Give ½ over 1st 8h, rest over next 16h

NO PO or IV abx; use topical tx

 Painless, but doesn’t penetrate eschar, var. gram-neg cov’g, can cause leukopenia: Silver sulfdiazine

Penetrates eschar, but hurts like hell, can cause acidosis via c. anhydrase inhib, poor Candida cov’g:

Mafenide acetate

Painless, but doesn’t penetrate eschar, stains black, causes hypoK and hypoNa: Silver nitrate

Circumferential burns: Consider escharotomy (bedside, no anesthesia needed) Inhalational burn: Singed nose hairs, wheezing, soot in mouth/nose

 Low threshold for intubation

 Pt w/confusion, HA, cherry-red skin: Check/monitor carboxyHb (pulse ox = worthless)

o Treatment: 100% O2 (hyperbaric if CO-Hb is ↑↑↑) Chemical burn: Irrigate > 30min prior to ER

Electrical burn: EKG first!

 If LOC or abnormal EKG: 48 hours of telemetry

 If urine dipstick + for blood but microscopic exam negative for RBCs: Myoglobinuria  ATNCheck for hyperkalemia due to RBC lysis!

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Chest Trauma

 Inward mvmt of ribcage on inspiration: Flail chest > 3 consec. rib fx

o Tx: O2 and pain control

Acute SOB, confusion, petechial rash on chest/axilla/neck after long bone fx (esp. femur): Fat embolism

 Patient dies suddenly after removal of central line: Air embolism

o Suspect during: Lung trauma, vent use, major vascular surgery

Hypotensive/tachycardic/cool skin: Shock  Hypovolemic, cardiac tamponade, tension pneumo  Flat neck veins and normal CVP: Hypovolemic

o Next step: 2 large-bore (14-16 gauge) periph. IV- 2L LR over 20min

o Follow with blood transfix

o Do not exceed CVP of 15mmHg

 Muffled heart sounds, JVD, pulsus paradoxus: Pericardial tamponade

o Confirmation: FAST scan

o Treatment: Needle decompression, pericardial window or median sternotomy  Decr. unilateral BS w/ tracheal deviation AWAY: Tension pneumo

o Next step: Needle decompression, followed by 26-French chest tube—NOT CXR!

Types of Shock Physical Exam Swann-Ganz Catheter

Treatment

Hypovolemic

Loss of circ. blood vol.

(hemorrhage, interstit. d/t bowel obstr., excessive vom./diarrhea,

polyuria, burn)

Hypotensive, tachycardic, diaphoretic, cool, clammy extremities

RAP/ Pulm. capill.WP↓ Systemic vasc. resist.↑ Cardiac output↓

Crystalloid resuscitation

Vasogenic

Decreased periph. vasc. resistance sepsis (LPS) and

anaphylaxis (histamine)

Early: AMS, hypotn, warm/dry

extrem.

Late: Resembles hypovolemic

RAP/Pulm. capill.WP ↓ Systemic vasc. resist.↓ Cardiac output↑ (EF↓)

Fluid resuscitation (may cause edema), tx offending organism, epinephrine/antihist. Neurogenic

Vasogenic d/t spinal cord

injury/anesthesia, adrenal insuff.

(susp. in pts on steroids w/acute stressors) acute loss of sympathetic vascular tone

Hypotensive, bradycardic, warm, dry extremities, absent reflexes and flaccid tone.

Adrenal insuff.: hypoNa, hyperK

RAP/Pulm. capill.WP ↓ Systemic vasc. resist.↓ Cardiac output↑

Tx adrenal insuff w/ dexamethasone; taper over several wks.

Cardio-compressive Cardiac tamponade (pressure

preventing it fulfilling role as pump)

Hypotensive, tachycardic, JVD, decreased HS, norm. BS, pulsus paradoxus (10-pt PP drop w/inspir.)

FAST scan shows fluid in pericardial space

Needle pericardiocentesis, pericardial window, sternotomy

Cardiogenic

Failure of heart as pump, as in

arrhythmia or acute MI

SOB, clammy extrem., bilat. rales/decr. BS, S3, pleural effusion, ascites, periph. edema

RAP/ Pulm. capill.WP↑ Systemic vasc. resist.↑ Cardiac output↓

Diuretics, raise HR to 60-100, rhythm control; vasopressors if necess. Head Trauma

GLASGOW COMA SCALE (GCS): Classification of head injury

 Severe: 8 or less

 Moderate: 9–13  Mild: 14 or 15.ir

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Eyes 4, verbal 5, motor 6

GLASGOW COMA SCALE

1 2 3 4 5 6

Eye Does not open eyes Opens eyes to pain Opens eyes to voice Opens eyes spontaneously

Verbal No sounds Incomprehensible sounds Inappropriate words Confused, disoriented Converses normally

Motor No movements Decerebrate posturing Decorticate posturing Withdraws from pain Localizes pain Obeys commands

Increased ICP: Hematoma, edema, tumor

 Symptoms: Headache, vomiting, altered mental status

 Treatment: Elev. head, hyperventil. to pCO2 28-32, diuresis (furosemide, mannitolwatch renal fxn)  Surgical: Burr hole, ventriculostomy

Neck Trauma

Penetrating trauma vs. GSW

Zone 3 = ↑ angle of mandible

 Aortography and triple endoscopy

Zone 2 = Angle of mandiblecricoid  2D doppler +/- exploratory surgery

Zone 1 = ↓ cricoid

 Aorto/angiography Abdominal Trauma

Penetrating Abdominal Trauma: Do not pass go! Go directly to exploratorylaparotomy.

 GSW to abdomen: Ex-lap. (plus tetanus prophylaxis)

 Stab wound w/unstable ptrebound tenderness & rigidity OR evisceration: Ex-lap. (plus tetanus prophylaxis)

o Stab wound w/stable pt: FAST exam; diag. peritoneal lavage (DPL) if FAST is equivocal  Ex-lap if either are positive.

Blunt Abdominal Trauma: w/hypotn/tachycardia, Ex-lap. If stable OR stable w/epigastric pain: Abdominal CT

 Lower rib fx + abd. bleed: Spleen or liver lac.  Lower rib fx + hematuria: Kidney lac.

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 Kehr sign (mult. air/fluid levels) + viscera in thorax on CXR: Diaphragmatic rupt.  Handlebar sign: Pancreatic rupt.

 Fluid found in retroperitoneum: Consider duodenal rupt. Pelvic Trauma

If hypotensive, tachycardic: FAST and/or DPL to r/o bleeding in abd. cavity

Can exsanguinate into abdomen, pelvis, & thigh: Stop bleeding by fixing fxinternal fix’n if stable, external if not

 Blood at urethral meatus and/or high-riding prostate: Consider urethral/bladder injury

o Test: Retrograde urethrogram (NOT FOLEY!)  If normal: Retrograde cystogram to evaluate bladder

o Check for extravasation of dye; 2 views (full/empty) to ID trigone injury  Extraperitoneal extravasation: Ex-lap and surgical repair

 Intraperitoneal extravasation: Bed rest + foley Orthopedics

XRs at 90° angles, including joints above and below

Fractures that go to the OR:

Depressed skull fx

Severely displaced or angulated fx

Open fx (w/in 6h)

Femoral neck or intertrochanteric fx (risk of necrosis) Common fractures:

 Shoulder pain s/p seizure/electrical shock: Post. shoulder dislocation  Arm ext. rotated/numbness over deltoid: Ant. shoulder dislocation

 Old lady fell on outstretched hand (FOOSH) distal radius displaced: Colle’s fracture

 Young person FOOSH, anatomic snuff box tenderness: Scaphoid (carpal navicular) fracture o Initial XRs NEGATIVE unless displaced (surgery indic.); will show on XR 2-3wks. PI  “I swear I just punched a wall…”: Metacarpal neck fracture (‘Boxer’s fracture’)

o May need K wire

 Clavicle: Most commonly broken between middle and distal 1/3s o Need figure-of-8 device

Extremity extremely tender, numb, white, cold (pulse may or may not be attenuated): Compartment syndrome  Compartment pressure >30mmHg

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Depressed skull fx

Colle’s fx

Scaphoid fx

Femoral neck fx Intertrochanteric fx Bone malig. in adults = mets from lung, prostate, breast

 4-5 y/o w/ a painless limp: Avascular necrosis o Adultssteroid use, s/p femoral head/neck fx  12-13 y/o w/knee or hip pain: SCFE

 Most common primary bone malig. (us. peds): Osteosarcoma o Distal femur, proximal tibia @ metaphysis, around the knee o Codman’s triangle (raised periosteum), sunburst appearance  Night pain, fever, elevated ESR: Ewing sarcoma

o Diaphysis of long bones

o Lytic bone lesions, “onion skinning” o Neuroendocrine (small blue) tumor

HERNIAS

Umbilical: Peds close spontaneously by age 2 o In adults: 2/2 obesity, ascites or pregnancy

Indirect inguinal: MCthrough inguinal ring (lateral to epigastric vessels) in spermatocord o R > L, more often congenital (patent proc. vaginalis)

Direct inguinal: through Hasselbeck’s triangle (medial to epigastrics), more often acq. weakness  Femoral: More common in women

 Treatment: Emergent surgical repair if incarcerated (to avoid strangulation) o Elective if reducible

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CARDIAC MURMURS

Systolic ejection murmur (SEM) cresc/decresc, louder w/squatting, softer w/valsalva + parvus et tardus: Aortic stenosis

SEM louder w/valsalva, softer w/squatting or handgrip: Hypertrophic cardiomyopathy

Late systolic murmur w/click; louder w/valsalva and handgrip, softer w/squatting: Mitral prolapseHolosystolic murmur radiates to axilla: Mitral regurgitation

Holosystolic murmur w/late diastolic rumblepeds: VSDContinuous machine-like murmur: PDA

Wide, fixed splitting in S2: ASD

Rumbling diastolic murmur w/opening snap, LAE and A-fib: Mitral stenosisBlowing diastolic murmur w/widened pulse pressure: Aortic regurgitation

INFLAMMATORY BOWEL DISEASE

 Involves terminal ileum: Crohn’s

o Mimics appendicitis, Fe deficiency  Continuous involving rectum: UC

o Rarely, ileal backwash, but never higher  Incr. risk for Primary Sclerosing Cholangitis: UC

o PSC leads to higher risk of cholangioCA

 Highest risk of colon cancer: UC (another reason for colectomy)  Fistulae likely: Crohn’s (give metronidazole)

o For Crohn’s, give metranidazole for ANY ulcer or abscess

 Granulomas on biopsy: Crohn’s  Transmural inflammation: UC  Smokers have lower risk: UC

o Smokers have higher risk for Crohn’s  Associated w/ p-ANCA: UC

 Treatment = ASA, sulfasalzine to maintain remission o Corticosteroids to induce remission

o Azathioprine, 6MP and methotrexate for severe dz

TRANSPLANT

Hyperacute Rejection

 Vascular thrombosis in minutes  Caused by preformed antibodies Acute Rejection

 Organ dysfunction (incr. GGT or Cr depending on organ) in 5days/3mos o Due to T-lymphocytes

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o Tx w/steroid bolus and antilymphocyte agent (Muromonab, anti-CD3)  Technical problems common in liver:

o 1st, US check for biliary obstruction o Then check for thrombosis by Doppler  Cardiac sxs come late periodic ventricular bx Chronic Rejection

 Occurs after years  Due to T-lymphocytes

 Untreatable need re-transplantation

ANESTHESIA

Local

 Lidocaine, etc.: Give with epi to prevent systemic absorption

 numb tongue, seizures, hypotension, bradycardia, arrhythmias  NO epi: Fingers, nose, penis, toes

Spinal/subarachnoid

 Bupivicaine, etc.: Pts who can’t be intubated

o Can’t give if incr ICP or hypotensive

 Epidural (local + opioid): If “high block,” blocks cardiac SNS/phrenic nerve General

 Meperidine: Norperidine metabolite can lower seizure threshold, esp. in pts w/renal failure

 Succinylcholine: Can cause malignant hyperthermia, hyperK (do not use in burn or crush victims)  Rocuronium, etc.: Sometimes allergic rxn in asthmatics

 Halothane, etc.: Can cause malignant hyperthermia (tx w/dantrolene Na), liver toxicity

UROLOGY

BPH: Anticholinergics worsen  foley for acute urinary retention  Medical tx 1st : Tamsulosin or finasteride

Surgical tx: TURP (hyponatremia, retro-ejac) Prostate Cancer

Nodules on DRE or elevated/rising PSA: Transrectal ultrasound and bx.  Bone scan looks for blastic lesions.

 Tx w/surgery, radiation, leuprolide or flutamide Kidney Stones

 CT is best test

 Stone <5mm: Hydrate and let pass  >5mm: Shockwave lithotripsy  >2cm: Surgical removal Scrotal Mass

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 U/S & excision o Don’t bx!  Know hormone markers! Testicular Torsion

 Acute pain and swelling w/ high riding testis

STAT Doppler U/SNo flow (contrast w/ epididymitis)Can surgically salvage if <6hrs: Orchiopexy to BOTH testes

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