Surgery Casebook flashcards III Flashcards

chest tube
Terms Definitions
abd obstruction sx with MET ACIDOSIS think?
consider ischemic or necrotic bowle, if no other obvious cause warrant suspicion
2nd m/c cause of SMALL bowel obstruction?
indirect inguinal hernia
elderly woman, recurrent cholecystitis and cholelithiasis, with obstruction and air in biliary tree?
Gallstone Ileus!!
2 other causes of Hirschsprung's besides DS ?
Chagas' and leishmaniasis =
destruction of ganglion cells
colicky px with bloody diarrhea in kids and oblong mass palpated in midepigastrium?
think intussusception...if severe bleeding followed by obstruction, volvulus / or intussusception, think Meckel's
rule of 2's?
2% (of the population) - 2 feet (from the ileocecal valve) - 2 inches (in length) - 2% are symptomatic, there are 2 types of common ectopic tissue (gastric and pancreatic), the most common age at clinical presentation is 2, and males are 2 times as likely to be affected.
NSIM for suspected SBO that doesn't respond to supportive/nonoperative management?
explorative laparoscopy to remove adhesions
what therapy is given to prevent recurrence of adhesions post SBO?
none- there is none proven to help
options for seeing a viable but edematous/injured bowel loop after removing adhesions?
1 resection and anastomosis
2 leave alone and do second look operation in 24 hours
NSIM for freee air in pt cavity?
explorative lap
type of surg incision for incarcerated ing hernia repair in stable vs very ill appearing pt?
stable pt - do incision in groin
very ill - do midline incision so entire bowel may be inspected for ischemai,necrosis, etc.
greatest risk of unplanned enterotomy (cut the bowel accidentally ie during adhesion removal)
=small bowel fistula
if unsure whether pt's sx of crampy abd px, nausea, and abd distension are truly due to SBO or just to ie paralytic ileus or constipation, what to do before surgery?
do upper GI series with small bowel followthrough - if SBO, barium will stop at obstruction
will barium find its way to rectum if severely constipated?
tx of severe constipation?
enemas and disimpaction, NOT surgery
m/c indication for surgery in Chron's?
m/c cause of pancreatitis?
m/c cause of sbo in kids?
hernia, unless <2yo = intussusception
m/c site of gi carcinoids?
m/c cause of transfusion hemolysis?
clerical error
m/c cause of large bowel obstr?
colon cancer!
m/c cause of fever <48 hrs post surg?
m/c abd organ injured in blunt trauma? in penetrating trauma?
small bowel
m/c malignancy of the liver?
metastases from other cancer elsewhere!
m/c pneumonia bug in ICU
gram - 's !!
m/c cause of lower gi bleeding?
upper gi bleeding
what side hernia is more common?
what % of cases can US detect cholelithiasis?
what % of thoracic aortogram finds torn thoracic aorta in suspected aortic trauma?
% of pts after laparotomy that eventually develop SBO due to adhesions?
what % gallstones are visualized on abd Xray? kidney stones?
total tensile strength of wounds at 6 weeks? (%)
risk of appendiceal rupture after onset of sx?
1 unit packed RBC's increases HCT by what?
adding 1 liter O2 by nasal cannula increases FIO2 by?
autonomic instability, abd px, and diarrhea post - vagotomy+gastrojujenostomy
Dumping syndrome
elderly pt with 1 day of nausea, vomitn, abd px, low fever, nontympanic distended bowel, and non-specific ileus on xray...suspect? NSIM?
ischemic bowel
NISM = either surgery if suspect necrosis
or observation with sigmoidoscopy to look for colon ischemia, +/- mesenteric angiogram to check for any vascular problem or need for surg revasc...if problem found, undergo elective revascularization of mesenteric circulation and post op aspirin therapy
mesenteric ischemia secondary to Congestive HF...tx?
due to nonocclusive but LOW FLOW state....tx = direct injection of vasodilator ie papaverine , and tx chf to increase CO
when colon necrosis is suspected (ie signs of ischemic colon and also bloody diarrhea in elderly with atherosclerosis), when to do resectin and when not to?
if only mucosal involvement = support, IV fluids, AB's, and observation.
If full-thickness necrosis = do resection
when do hartman's pouch + colostomy versus just resection and reanastomosis in necrotic colon?
do hartman + colostomy if pt is unstable
do resection and anastomosis if pt is stable and conditions favorable
elderly with full necrosis from lig of trietz to tverse colon? in younger individual?
elderly = can't treat! should "close abd and let pt succumb to illness" (!?!)
younger = reanastomose, with a resulting short bowel sydrome and need for lifelong TPN, or small bowel tplantation
medical long term tx of UC vs Chron's?
UC = 5-asa, steroids for short term
Chron's = immunosuppressives (ie TNFa inh's), metronidazole fro perianal disease, steroids for short term
stricture of Chron's disease suspected cause for SBO....NSIM? tx?
CT of abd to check for terminal ileal stenosis/inflammation, abscess, fistula.
tx should be TPN, bowel rest, and observation until flatus andbowel movements return.
If no resolution , do surg to relieve obstruction via resection of strictures
if term ileum is resected, what nutrients are lost from being absorbed?
bile acids - diarrhea, malabsorption, oxalate stones, gallstones
Vit B12 - macrocytic anemia,etc
superficial Chron's anal fistula tx? for perianal abscess?
open the tract if superficial...
setons, plastic tubes through fistula that slowly allow fistula to close for deeper tracts
metronidazole tx

tx for perianal abscess is surg drainage
UC yearly requirements?
yearly colonoscopy after 8-10 yrs of disease with random biopsies to check for severe dysplasia...if found = removal of colon/rectum indicated
newer and more acceptable procedure for UC with dysplasia?
total proctocolectomy (removes entire mucosa and thus the risk of cxr), with creation of ileal pouch, and anastomosis of pouch to the anus.
reoperative rate = 15%
If all the UC pt's colon and rectum are removed, how often should do surveillance for cxr?
not necessary b/c risk of cxr is eliminated. But if some of rectal mucosa is present, do proctoscopy every 6mo-1yr
blood tinged diarrhea , pain ondefecation in post - IBD pt who had surgical total proctocolectomy? tx?
pouchitis = infalmmation of ileal pouch/reservoir = develops in 1/3 of pts with ileal pouch. tx is metronidzole
pt with UC with abd px, distention, fever, and bloody diarrhea?
be concerned about toxic megacolon!!
(vs in Chron's, SBO from stricture is more common)
dx confirmation of toxic megacolon?
abd xray findings
toxic megacolon management?
High dose IV steroids,
NPO/TPN, IV fluids, and broad spectrum AB's...
MONITOR b/c IF perforation, mortality ranges from 27%=44%!!
procedure if toxic megacolon with perforation in UC pt?
ileostomy with Hartmann pouch of rectum and total colectomy
(vs total proctocolectomy (col and rectum) for DYSPLASIA tx of UC)
If rectum is left intact after colectomy for UC toxic megacolon, is risk of cancer reduced?
is reduced but still present...definitive surgery may still be required to remove all mucosa
in managing toxic megacolon, what do if no change in pts condition after 3-6 days?
surgery (hartmann's pouch and ileostomy)
give px medication to pt with mild acute abd sx?
NO...should avoid these b/c don't want to mask the progression of sx which are indicative of appendicitis
does laparoscopy for appendicitis prove any decreased post op px, hospital stay, or cost?
are there dysuria and urinary WBC increased with appendicitis?
yes, but mild, but even if severe, should still tx for UTI but continue observation for any progression of sx clearly indicating appendicitis
what if RLQ px but tenderness to cervix on exam?
consider PID...refer for gynecological exam
what if RLQ px but tenderness to adnexa on exam?
consider PID, +/- tubo ovarian abscess --> see gynecologist
RLQ px plus bloody urine?
consider kidney stone or obstruction; do IVP but continue monitoring for appx signs
if open a pt for IBD, should also remove appendix?
yes, to prevent future appendicitis
in pt with RLQ px, what does marked tenderness to right pelvis upon rectal exam signifiy? NSIM?
RETROcecal appendicitis - doesn't have anterior abd wall tenderness but tenderness deeper...go to surgery
do older pts have normal appendiceal signs?
no - often just have vague abd pxs, sepsis, and altered consc.
do children <5y/o present with normal appendiceal signs?
no - often just present after perforation!
RUQ or flank localizing px in pregannt woman
think appendicitis!! appendix is pushed upwards in pregnancy
NSIM appendicitis suspected in pregnant woman?
do surgery
if cecum is involved in inflammatory process of acute gangrenous appendicitis, what should be done?
right colectomy (this also to prevent missing a perforated colon cancer)
if normal appendix is found upon exploration for appendiceal signs, what should be done?
apendectomy to prevent future acitis,
look for other causes of px ie meckel's, term enteritis, ovarian or fallopian tube disorders, or diverticulitis, or mesenteric adenitis
1cm small, yellow firm mass at tip of the appendix, dx? NSIM
if >2cm and is at BASE of appendix?
1 carcinoid tumor...remove appendix only
2 carcinoid tumor with malignant behavior; do full right colectomy!
dx for large, pedunculated mass in term ileum? tx?
adenocarcinoma or carcinoid tumor.
must resmove involved ileum and regional l/n's, and examine rest of bowel for lesions
post -surgical tx for carcinoid tumor?
follow 5-HIAA levels
do octreotide scan which localizes to neuroendocrine tumors, to look for other tumors
recommendationf or screening for crc?
1st at 50 then every 10 years; +/- yearly FOB stool tests
unless increased risk
1st degree relative with CRC or polyp, when start colonoscopy
at age 40, not 50
fam hxof FAP management?
yearly sigmoidoscopy until polyps are discovered (will be found at some pt in 100% of pts)
Then total colectomy
fam hx of HNPCC management?
colonoscopy every 1-2 yrs starting at 25 y/o, and every year after 40
any polyps removed, when should have follow up colonoscopy? waht about CRC removed?
polyp -3 yrs after polyp was found / removed
CRC- 1 year after op, and screening at 3 yr and then 5 yr intervals
after a CRC is removed, what shoudl be taken every 2-3 months for up to 2 yrs?
CEA levels,
what % of CRC recurrences may CEA detect?
up to 80%
m/c bright red streaks of blood in stool?
iniital management of blood-streaked stool with hemorrhoids found? if continue to bleed?
First should still RULE OUT CRC if elderly pt.
Then, to tx hemorrhoids, give sitz baths, stool softeners, and fiber diet
if continued bleeding = surgical removal in op room
tx of hemorrhoids external vs internal?
ext = surg excision
int = " or banding
tx of thrombosed hemorrhoids that are refractive to conservative management?
Incision and Drainage
surveillance colonoscopy for pt with 1cm polyp removed?
3-6 mo, then every 3 yrs
50% of CRC's are found where?
in rectum
follow up of polyp vs CRC or carcinoma insitu removed?
polyp = 3-6 mo then every 3 yrs
CRC/ CIS = 3-6 mo then every 1yr
what length margins must be present if carc found in stalk of polyp after removal via colonoscopy?
>2mm = don't need resection of bowel wall. if less , need to mark with tattoo and return surgically to resect
management for sessile (flat) polyp found to be malignant?
bowel resection b/c recurrence rate even after endoscopic resection is 20%
other tests to perform when CRC confirmed?
LFT's (and CT if elevated)
Is pain more common in cancer of colon or rectum? what about bleeding?
colon has more px
rectum cxr has more bleeding
quick CRC staging?
I = T1,2 (no invasion into muscularis propria
II = T3,4 (extends through wall (3)or into local structures (4) but no L/N's
III = any T, N1,2,3, no M's = mets to regional L/N's
IV = mets to liver or distant sites
adjuvant therapy def?
Adj = After
given post op to pts with no apparent residual disease
who give adjuvant therapy for after CRC removal?
pts with stage III
give 5FU and leucovorin/levamisole
factors associated with worse prognosis in CRC resection?
poorly diff'd tumors, mucin producing tumors, signet cell tumors, and tumors with venous or perineural invation, or tumors with perforation
what should be considered if 2cm lung nodule found on CXR of an elderly pt going in for colectomy for CRC tumor?
this makes a curative operation highly unlikely; colectomy does not need to be as extensive as it might otherwise be.
vomiting of feculent material and abd distension on 3rd day post-op?
feculent vomiting =bact overgrowth in the stomach/SI due to failure to move food through;
evaluate with obstructive series for mechanicial adhesions. if none seen,
then probably due to persistent ILEUS, due to leakage from anastomosis
after colon surgery, if anastomotic leak of fecal matter seen coming through wound, NSIM?
just NPO and IV fluids - most will close spont., as long as the anastomosis is still open...if anast is obstructed and fistula is only pathway for fecal matter, it won't close
+/- CT scan of abd to determine if there's an undrained collection
post colectomy 10days, with acute temp of 104 and abd RLQ px...dx? tx?
suspect ABSCESS!
dx via CT
tx with drainage
necessary tests if ANY tumor of rectum/colon is found?
-full colonoscopy to r/o other tumors
-test for wall invasion ie transrectal US
-CT for adj structure and other organ involvement
-CXR and CEA for before any colon surgery
rectal carcinomas spread via?
to local structures and via lymphatics!!
complications of abdominoperineal (anus and rectum) resection taht aren't seenin proctocolectomy (rectum and colon)
50% get impotence due to symp plexus nerves located around rectum;
bladder fxn also may be impaired; injury to ureter;
what are colostomy complications?
retraction, prolapse, stricture, and /or obstruction
abdominoperineal resection is for tumors how close to anal verge?
less than 5 cm, b/c these lesions often also inlcude anal sphincter involvement
recommended margins for rectal carcinomas?
2 cm for well diff'd lesions
5 cm for poorly diff'd lesions, anaplastic, or signet cell carcinomas
what stage rectal carcinomas require adjuvant chemo after surg resection?
stage III or high risk stage II
preoperative radiation for what type of rectal carcinoma? why?
large and bulky, or those extending outside wall of bowel
b/c it decreases local recurrence rate after surgery
post surgical recurrent pelvic pain after rectal carc removed?
consider local recurrence of tumor; check CEA levels, do physical exam and CT
if liver mets seen in post CRC pt, when can/ cant resect?
to resect these liver mets, must NOT be:
1) invading to local vascular structures
2) in both lobes
3) in pt already having cirrhosis
4) invading local structures ie diaphragm
single resectable lesion 5 yr survival vs unresectable lesion?
cm margins needed in liver resection?
cancer of anal verge - what histological type?
squamous cell carcinoma
is anal carcinoma treated with surgery?
ONLY if small , mobile lesions; or after NIGRO protocol tx with biopsy proven residual cxr. otherwise, do NIGRO only (readiation and chemo and mitomycin C tx)
what is Nigro protocol
do external rad to tumor and ing l/n's from days 1-21
give IV 5FU on days 1-4, 28-31
give IV Mitomycin C 1 bolus on day 1
LLQ pain tenderness and fever in elderly...dx? tx?
if minimal sx, give outpt tx with BSAB's and liquid diet
if sever sx, IV hydration, AB's and bowel rest
diverticulitis suspected...what tests to perform?
do obstructive series to r/o obstruction
do CT to confirm diverticula / with thickened wall = diverticulitis (but not necessary for management)
post - diverticulitis tx
7-10 days of oral BSAB's;
advise a higher fiber diet
follow up in months ahead with colonoscopy to r/o cxr and to confirm diverticula
likelihood of diverticulitis recurrence?
only 30%
NSIM in 2nd episode of diverticulitis?
tx, then after resolved, suggest elective colectomy b/c risk of perforation or abscess is very high (anastomosis usually performed without need for colostomy)
diverticulitis refractive to tx with IV AB's, fluids, etc...dx? tx?
either abscess or perforation
do CT to demonstrate
if abscess: CT-guided drainage with placement of catheter and sample for bact
after recovery, do colectomy with anastomosis ( hartman's+colostomy only needed if pt worsened clinically)
first steps in management of tachycardic, hypotensive woman with BRBPR?
hypovolemia = 2 large bore IV needles
+ 1-2 liters of lactated ringer's
blood studies, PT/PTT, CXR, cross-match
Foley cath
NG TUBE TO R/O UPPER GI BLEED!! --> if blood = do upper GI endoscopy
ANOSCOPY - to r/o hemorrhoids, bleeding rectal varices, etc
first steps in management of tachycardic, hypotensive woman with BRBPR...m/c dx's?
(if black tarry, = upper GI bleed)
hemorrhoids (but rarely massive)
vascular ectasia (angiodysplasia)
meckel's div
aortoenteric fistula
isch colitis
rectal varices
CXR!! (but rarely massive bleed)
do most diverticular bleeds stop spontaneously? what about vascular ectasia?
yes (80%), yes (90%)
what percent of diverticulosis bleeding or vasc ectasia bleeding recurs?
When do you perform colonoscopy to check for diverticulosis or vasc ectasia?
ONLY after bleeding stops!
angiodysplasia usually affect what structures? what about diverticulosis
cecum and ascending colon;
descending colon and rectum; however right sided diverticula are more apt to bleed!
tx for vascular ectasia? for diverticulosis?
coagulation with monopolar current
for div = no endoscopic tx works
if BRBPR rebleeding / continual bleeding occurs (ie requiring 4+tfusions) despite observation and IV resusc, what do?
do technetium labled RBC scan or mesenteric angiography to check for site of bleed, and after found, go directly to surgery
angiography can isolate a bleeding rate of what? RBC scan?
0.5ml/min or more (faster bleeds)
.1 ml/min or more (slower, more stable bleeds)
is technetium RBC scan or mesenteric angiography better for unstable pts?
for unstable do mes angio b/c have better monitoring and resusc in angio suite. for stable to RBC scan
in general, how much blood loss indicates need for surgery to stop bleedin?
if >4-6 tfusions required, go to surgery
if pt is Jehovah's witness and doesn't want tfusions, or
if pt's blood type is hart to determine
go to surgery EARLIER
when to go to surgery to stop bleeding EARLIER than 4-6 bl tfusions given?
if pt is Jehovah's witness and doesn't want tfusions, or
if pt's blood type is hart to determine
go to surgery EARLIER
what else given in angiography suite to decrease bleeding before going into surgery?
after site of bleed found, injection of vasopression (s/e = vc of coronaries so give nitro also; bleed recurrence in 50% at site given) or embolization (s/e =increased risk for transmural necrosis in large bowel!!)
should angiography ever be bypassed on way to surgery for large GI rebleeding/continual bleeding (>4tfusions needed)?
NO, b/c very difficult to find site of bleed during surgery
m/c obstruction in nursing home pt?
sigmoid volvulus due to chronic lax use, chronic illness, or dementia
confirmationof volvulus?
barium enema
tx of volvulus?
rigid proctosigmoidoscopy detorsion, but since recurrence rate is 50%, should also undergo definitive surgery in same hospitalization, ie Hartmann's +colostomy OR primary anastomosis
cecal volvulus tx?
in most stable pts = not reducible by enema orcolonoscopy, so do right colectomy with primary anastomosis
cecum or right colon dilation >10 cm? tx?
Ogilvie's syndrome
seen in ICU and intubated pts due to laplace's law distending the cecum/colon...
tx = trial of neostigmine = PSNS stimulant to constrict bowel. If doesn't work, do surgical decompression or right colectomy
for constipation, should cathartic med be given first, or rectal de-impacting be done first?
rectal de-impacting first, then enemas...
only if this doesnt work, should cathartic (accelerates defecation) be given
where are anal fissures most always located?
posterior midline
tx for most anal fissures?
sitz baths, stool softeners, bulk agents
tx for deep and chronic anal fissures?
lateral sphincterotomy = cut internal spincter muscle ...relieves pressure...over 90% of fissures heal after this procedure...
bx of suspicious chronic fissures for anal cxr
tx of fistula in ano?
difference b/w fistula / fissure sx and abscess?
abscess sx are with fever, fluctuation
tx of anal abscess?
drainage, NO AB's necessary!
what's a pilonidal abscess, how tx?
infection in hair-containing sinus in sacrococcygeal area of lower back. tx = unroof the abscess, remove all hair, and leave wound open to heal by secondary intention
3 common causes of PERMANENT stomas?
1) abdominoperineal resection (ie due to rectal carcinoma)
2) ileostomy after total proctocolectomy(rectum and colon) after UC (this is being replace dby ileoanal pullthroughs)
3) ileal conduit draining the urinary system to the skin
weak, fever, abd / pelvic px in post - colectomy patient with malodorous stool,
pouchitis due to inflamm of ileoanal pouch
what else besides ileoanal pouch can pouchitis occur in?
acutely tender testicle ddx?
test torsion
viral orchitis
large soft mass in scrotum, separate from testicle with fullness in inguinal canal?
segment of bowel that has migrated down canal into scrotum
is strangulated hernia a surgical emergency? what's its incidence among ppl with hernias? mortality?
1-3% /year
12% mortality!!
is strangulation more common in femoral hernias or inguinal?
femoral!! 50% of femoral hernias manifest with strangulation
breakdown of hernias by percent?
60% indirect 30% direct, 10% fem
what nerves are involved in cremasteric reflex?
fem branch of g/f nerve,
and ilioinguinal nerve fibers are stimulated upon thigh stroke. then they send signal to motor nerve (genital branch of g/f) to cause test pulled upward
where is ilioinginal nerve? genital branch of genitofemoral nerve?
I.i. runs on top of spermatic cord, genital branch of g/f nerve runs in it
difference b/w adults and babies in inguinal hernia repair?
babies - don't need to repair inguinal floor; just do high ligation of the hernia sac, b/c due to patent processus vaginalis, not due to tvsalis fascia weakness
bassini's vs lichtenstein repair?
b's - sutures int oblique, tvsus abdominus, and tvsalis fascia to ing ligament; high tension
l's - sutures mesh to inguinal ligament; low tension
repair of femroal hernia?
McVay repair
indications for intubation?
laryngeal edema
trauma to larynx
inadequate resp effort
severely depressed mental status
GC score 8 or less
severe resp structure injury
tx for simple ptx?
chest tube
what must check before inserting chest tube?
insert finger to make sure in the right place
when to remove chest tube?
when lung is fully inflated (as seen on serial cxrays) and no further air leak is apparent
if chest tube is inserted for ptx, and afterwards, air continues to leak into chest tube over next 6 hrs and lung only partiall inflates?
this is sign of bronchial laceration or major airway hole ...tx with thoracotomy and partial lung resection
tx of small, simple ptx in asx pt without fluid in pleural space?
chest tube is required for simple ptx in what other trauma pt?
any trauma requiring general anasth surgery, b/c this will require positive pressure assisted vent which may cause simplt ptx to convert to larger or even tension ptx
either tamponade, or tension ptx (can diff b/c tension ptx has decreased breath sounds as well)
tension ptx immediate order of tx?
is a CLINICAL dx, therefore do
needle aspiration to relieve pressure, then
THEN do CXRAY, etc
immediate workup for pt with normal breath sounds but severe hotn and JVD?
tamponade= do immediate FAST survey to check for pericardial fluid --> if + , do pericardiocentesis
other signs of ctamponade
muffled heart sounds
kussmaul sign (decr in cvp during inspir)
pulsus paradoxus
hotn and JVD that's not due to ptx or ctamponade?
MI, myocardial contusion ( look for ECG changes)
what is M/C cause of hotn in trauma pts?
what % blood loss almost ALWAYS requires bl tfusion?
if 30-40% loss (class III shock)
SHOCK stage I - IV resp rate?
I = 14-20
II = 20-30
III 30-40
IV >35
HR stave I - IV?
I <100
II >100
III >120
common causes of HOTN not easily seen on primary or even secondary survey?
intrabd injury or pelvic fracture
what is cushing's triad and its mechanism?
HTN - due to brain edema --> symp stimulation --> V/C of peripheral arteries and increased CO of heart --> incr bl pressure stim's baroreceptors --> PNS stimulation --> Bradycardia
Abnormal Respirations
what classes of shock have decreased BP?
III and IV
indications of urethral injury? NSIM?
-blood on catheter or before catheter insertion
-highriding prostate gland on rectal ex
-penile or scrotal hematoma
NSIM: catheter is C/I'd do retrograde cystourethrogram to check for injury. If injury occurred, insert suprapubic catheter
simple way to check for cervical spine during rapid primary assessment in trauma?
palpate for tenderness, fractures, then ask pt to wiggle toes and fingers
Then always do lat cerv spine
how to clear the pt of cerv spine immobilization if the pt is in coma?
you can't
some dr's will do MRI, then clear the pt
for any cerv spine injury, what drugs you immediately give?
steroids to minimize edema to areas of sc
can headtilt be done for intubation in pt with cerv spine injury?
no - to op or nt intubation w/o tilting
priaprism in trauma pt indicates?
fresh sc injury
what inidicates immediate thoracotomy in chest wound pt? why?
if wound is affecting vital structures ie heart or great vessels
if chest tube drains over 1500ml right away, OR >200ml/hr for >3 hrs, then do thoracotomy

Thoracotomy should be done to evaluate for lung hilar or injury to heart and repair
when should explorative surgery be done in stab injury just below clavicle?
if pt is unstable. If stable, just do arteriogram and r/o major bleeds
wounds below the nipples affect what organs?
diaphragm, abd organs (liver), (and heart/lungs if wound goes upwards)
any diaphragmatic injury suspected...NSIM?
explorative surg/ lapscopic ok if pt stable
widened mediastinum DDX?
aortic dissection
only type of reliable xray to determine if pt with widened mediastinum has ao dissection/transsection? what look for?
look for widening,
indistinct ao knob or descending ao
deviation of trachea or esoph to right
pleural cap (fluid at top of lung cupola
to confirm dx for ao dissection/transsection?
Ao angio = gold standard
CT of chest
what type pts with MINOR injuries still require full trauma assessment?
chronic debilitating diseases
I/C hosts

(these all have limited reserve to tolerate injury)
gunshot to abd - NSIM?
explorative surg, with preop xray to determine current location of bullet
when is DPL most useful?
in situations where dx of abd injury is not clear and hemodynamic instability is present
waht may DPL miss?
retropt injuries such as to duo or pancr
what indicates positive DPL?
>10ml blood ; DPL removed and ab explored
CT shoudl be avoided in waht type of pts?
unstable or severely injured pts
trauma pt with hotn with no obvious blood loss on primary assessment...NSIM?
FAST or DPL to check for fluid; if + go straight to explorative surg; NOT CT b/c pt is unstable
known pelvic fracture in trauma pt. NSIM?
(FAST first to r/o other fluid in abd - if +, do explor surg FIRST)
If FAST -, do pelvic angiogram and embolization; then reductionand external fixation of fractured pelvis
splenic injury in unstable pt NSIM?
in stable pt?
1 explorative surg
2 for stable pt, preserve spleen if possible, but if grade IV or V splenic injury, may need to remove.
all post splenectomy pts should receive?
vaccines for diplococcus (strep), Meningococcus, and Hemophilus
NSIM for liver laceration?
in stable pt - observation!
in unstable - exploration
NSIM for kidney rupture? what always do first?
in stable pt - observe
in unstable pt - exploration

should ALWAYS do IVP (ie during resuscitation) to confirm that pt has 2 kidneys before any surgery, in case removal is indicated.
what is only zone in abdomen that should be explored in stable pts with hematoma there?
central zone ie where aorta, major vessels, pancreas, or duo run. Otherwise, only do exploration for hematoma found elsewhere in UNSTABLE pt
any transection of the pancreas NISM?
kid hits abd on bicycle handlebars - m/c injury? tx?
duod hematoma -
tx observation, NPO unless unstable or hematoma persist > 7 days then explore
pelvic hematoma NSIM?
NOT exploration;
do angiography and embolization
ruptured diaphragm NSIM?
surgical repair necessary
initial step in explor surgery if can't find source of bleeding?
PACK all 4 quadrants of abd
don't pack and peek - wait until pt returns to better hemodynamic state before returning
when do colostomy vs anastomosis in trauma pts?
colostomy for high risk pts:multiple injuries, hotn, major bleeding, or significant tx delay with peritoneal contamination
retropt hematoma. explore or not?
if central zone (same as for other non-retropt abd hematomas) = explore; if zone 2 (retro flanks) or 3 (retro pelvic) = don't explore unless pt unstable
mastoid, ear, or orbital bruising indicates?
basilar skull fracture (battle's/ racoon's sign)
after normal CT scan for head trauma pt, is it safe tosend pt home?
yes - normal CT scan virtually eliminates the possibility of a serious head injury
duration of unconsciousness in trauma pt that necessitates hosptialization for observation?
>5 mins
maneuvers to lessen brain edema in severe head injury pt?
elevation to 30 deg
Mannitol (dehydrates brain w/in 15 mins = decr brain pressure)
phenytoin for 1 week to prevent seizures
AVOID meds that depress cns fxn!
AVOID hypervetilation to PCO2 26-28 UNLESS pt has clear signs of herniation ie blown pupil or lateralizing signs
s/e of fast mannitol infusion?
GCS of what = comatose?
ddx for head trauma pt with unequal pupils or lateralizing motor deficit?
1) hematoma/lesion - should be explored and removed
2) diffuse axonal injury - assoc with high mortality
for any epiduralhematoma, what is NSIM?
and emergent evacuation of hematoma
head trauma and Na level of 125mEq/L...dx? tx?
SIADH - tx is hypertonic (3%) saline (300ml over 3 hrs) and h20 restriction
what if correct hyponatremia too rapidly?
leads to CPM. should correct half the sodium deficit over 24 hrs (ie if def =10mEq/L, correct 5 in 24 hrs)
head trauma and Na level of 160mEq/L? (other sx =polyuria, polydipsia, thirst, dehydration, weakness, fever, psycic dist's, etc)
diabetes insipidus!! =dx by urine osmolality being very low after dehydration , then measured after vasopressin given (to test if central or nephrogenic).
Tx = vasopressin or dsmopressin (ddAVP) and H20
what specifically does hypothermia cause?
coagulopathy from Pl dysfunction
prolonged PT / PTT
both hypothermia and hypovolemia and subsequent tissue hypoperfusion causes what?
met acidosis
combination of abd distension and progressive oliguria?
probably due to continual abd hemorrhage causing "abd compartment syndrome" = > decreasing renal perfusion. this may also make it more difficult for inspiration as diaphragms have harder time moving down on insp
although HOTN occurs in hypovolemic shock, what is SVR? (norm = 800-1400)
in hov shock, SVR (systemic vascual resistance) is increased as a response. it's alos increased with vasoconstrictors or in hypertensive states. It's reduced in septic shock, neurogenic shock, or admin of vasodilators
common progression of sepsis?
(early blood loss = just diffuse VC (high SVR) and hypovolemia) vs.
early sepsis => diffuse VD (low SVR)and hypovolemia, decr cardiac preload-> decr CO. Then fluids given, and becomes HIGH cardiac output, VD (low SVR)
what type of shock is m/c seen in S/C trauma? (but is least common form of shock overall)
neurogenic shock = hotn due to impaired sympathetic nerv system leading to systemic VD and decreased contractile force of heart
trauma pt is hotn, slow pulse, and evidence of SC injury?
neurogenic shock!!
neurogenic shock parameters?
low SVR (b/c impaired SNS stim)
low PCWP and low CO due to decr preload and contractility
tx = give iv fluids
long term result of AV fistula ie caused by stab wound 5 yrs ago? dx?
eventually a high output c h f
look for bruit/ thrill over av fistula
what is Branham's sign?
for av fistula, if put occluding pressure over it, hr should decrease by >10mmHg due to increased periph resistance.
excessive splinting (pt doesn't move ribs b/c of px) of rib fractures may lead to?
atelectasis, hypoxia, and risk for pneumonia
o2 sat of what is acceptable in resuscitation
95%...if less, give O2
common cause of continued resp distress in ptx pt with chest tube placed?
inadequate chest tube placement or incorrect attachment to wall vacuum, etc
overwhelming px of flail chest, possible tx?
bupivacaine via thoracic epidural catheter
pt controlled narcotic
if severe resp distress = needs intubation
tx of PCO2 = 55 in ventilated pt?
this means underventilation ; increase vent rate
if increased FIO2 on intubation fails to increase pt's O2 sat, what could be occurring?
pt could be having worsening ARDS, a mucous plug, or malposition of E/T tube...
do CXR to check for atelectasis cused by 2 and 3. if so, suction tube and reposition it
FIO2 should be increased until PO2 is what?
greater than 60mmHg (and O2 sat is > 95%)
PEEP given to intubated pt with declining resp fxn has what side effect?
impairs VR to heart, so causes decreased CO and decreased BP, decreased UO, etc. must balance by giving ie more fluids, etc
where to place chest tube?
5th intercostal space in midaxillary line
where to place needle thoracostomy for ptx?
2nd ic space in midclavic line
what is only zone of neck that requires explorative surg if injured?
zone II = from angle of mandible to cricoid cartilage
NSIM in injury to neck just above clavicle, pt is stable?
NOT explorative surg unless in zone II (above cricoid cart, below angle of mandible)
so do angiography first to define location of injury/ bleeding
subcut emphysema of neck...dx? NSIM?
airway injury! do explorative surgery
hoarsenss after trauma NSIM?
either exploration or laryngoscopy
hemiparesis after neck trauma, NSIM?
think about carotid thrombus, dislodging, etc. angiogram should be performed and consult with neurosurgeon
tx of neck trauma with suspected carotid thrombosis?
EITHER anticoag therapy OR
thrombectomy surgery
factors that suggest airway burn?
carbonaceous sputum, facial burn, facial or nasal hair burns, hoarseness, low o2 sat, dyspnea, or hx of being trapped inside with smoke for a long period
sign of 2nd degree burns?
(partial thickness burn)
blisters, or layer of white, nonviable dermis seen
sign of 3rd degree burns?
(full thickness down to subq tissue)
white, waxy appearance, NO px or sensation, leathery texture
3rd deg burns require what kind of tx?
skin grafting
indications for transfer to burn center?
3rd deg burns >5% BSA
2nd deg burns > 20% BSA
age <5 or >50 yrs
any burn on hands, face ,feet, genitals, or major joints
inhalation burn
chem or electrical burn
burn with associated trauma
parkland formula for burn fluid resusc?
% body burnt X kg X 4 ml/kg
70kg with 10% burn =2800ml
HALF give in first 8hrs, other half in next 16 hrs
mortality calc for 3rd deg burns?
age + % burn = mortality
90 y/o + 10% 3rd deg burns = 100% mortality!!
burn, what give first, colloid or crystalloid?
give crystalloid, then after 24 hrs give colloid
tx for superficial 1deg burn?
no antibact necessary
tx for deeper burns?
silver sulfadiazine, mafenide, povidone-iodine etc
+ occlusive dressings changed 2x/day
+ regular debridement until skin graft given
are AB's given for burns?
no - prophylactic systemic AB's select for resistant organism...shoudl only be used if documented infection ensues
what also checkfor in pt with inhalation injury?
1) check for CO poisoning = >5% carboxyhemoglobin (or >10% in smokers)...if found, give 100% O2 or hyperbaric O2 chamber tx for severe
2) check urine color for myoglobinuria that may cause ATN
3) check for methemoglobin...tx = IV methylene blue or hyperbaric O2 tx
ANY circumferential 3rd deg burn requires immediate what?
escharotomy to avoid contraction and impaired blood flow, ventilation, etc
any electrical burn, check for what?
ECG and cardiac enzymes for heart injury
urine for myoglobinuria due to interior muscle/tissue damage --> may cause ATN
non-depleted vs hypermetabolic pts? tx?
nondepleted = good nutritional status before surgery = give 1g/kg/day TPN
hypermetabolic pts are severely stressed catabolic state ie trauma, burn, sepsis, cxr. give >2.0 g/kg/day TPN
any temp spike >101F in pt on TPN?
think catheter infection
obtain cultures from cath and from peripheral blood.
if cultures - , replace cath over a wire, recheck later. if +, remove cath and select new cath site, and initiate IV AB's
LFT changes upon TPN tx?
expect to see mild elevation that plateaus or returns to normal in 7-14 days...if continual increase, suspect fatty liver damage from TPN or other etiology. cirrhoissi from TPN usually only occurs over years of tx
vascular profile of cardiogenic shock?
increased CVP (not hemorrhagic),
decreased CO,
Increased SVR (due to sympathetic outflow; not septic)
cardiogenic NOT give what?
fluids ! may further increase pulm edema, etc.
vascular profile of anaphylactic shock?
decreased CVP (blood lost through VD)
increased CO
Decreased SVR (VD)

tx = Vconstrictors +/- fluids
can stable pt with hemothorax or simple ptx be given cxray?
yes - only tension ptx give needle/thoracostomy right away
hemothorax with excessive (>1500ml or >300/hr for few hrs) bleeding is most commonly caused by which artery bleed?
intercostal artery
what to avoid if flail chest? what to DO?
avoid mechanically stabilizing broken ribs;
Give analgesics, cxray for PULM CONTUSION ao dissection, etc.
tx for pulm contusion?
fluid restriction, diuretics, use of colloid rather than crystalloid fluids when needed, and respiratory support (INTUBATION WITH PEEP, etc).
fatal complication of pulm contusion?
trauma to chest, with entire left chest no breath sounds...dx?
consider diaphragm rupture...always occurs on left
NSIM for widened mediastinum?
do arteriogram - ao dissection/rupture
then to surgery
trauma and sub-q emphysema...NSIM?
CXRAY to confirm air,
**Fiberoptic bronchoscopy** to confirm diagnosis and level of injury and to secure an airway.
then surgery
3 preop steps before any abd penetrating wound goes to surgery?
an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics.
(and I add: abd xray for location of bullet, any perforation/obstr, etc)
tx for penetrating injury 1 inch below nipple?
all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap.
In the absence of other clues, clinically significant hidden intra-abdominal bleeding comes from what?
ruptured spleen
surgical tx for ruptured spleen - effort made to remove or repair it?
first to repair. If can't save, remove it
tx of posterior urethral injury presenting as high riding prostate, inability to urinate, and blood in urethral meatus?
get a suprapubic catheter, and the repair is delayed 6 months.
anterior urethral injury tx?
get a suprapubic catheter, and repair is RIGHT AWAY
traumatic hematuria NSIM?
does NOT NEED SURGERY even if the kidney is smashed.
They operate only if the renal pedicle is avulsed or the patient is exsanguinating/ unstable
microhematuria after trauma in adult? in kids?
adult - observe...only tx for gross hematuria
Microhematuria in kids needs to be investigated, as it often signifies congenital anomalies - start with sonogram
scrotal hematoma NSIM?
US to check if testicle is ruptured; if so - surgery. if not, observation
large penile shaft hematoma with normal appearing glans NSIM?
surgery to repair torn tunica albuginea
tx for any chemical burns (especially alkali ie drano)
immediate, copious
tap water, for at least 30 minutes BEFORE rushing to the E.R
tx of any electrical burn victim?
MUST prevent myoglobinuria causing ARF: give fluids, diuretics (osmotic if given that choice i.e. Mannitol), perhaps alkalinization of the urine.
dx of respiratory tract burns?
3rd degree burns in kids are waht color?
deep, bright red (vs adults = white, leathery)
after burn , fluids given ...what to monitor?
CVP and hourly urinary output. Keep the former CVP below 15 or 20, aim for 1 cc per Kg body weight per hour for the URINARY OUTPUT.
where additional fluid is needed (aiming for urinary output of two cc per Kg per hour, instead of one): electrical burns, patients who get escharotomy.
when should rehabilitation begin for burn victim?
one DAY ONE!!!
very small and clearly third degree burn..NSIM?
immediate (same day) surgery for removal of dead tissue and skin graft! no need to hospitalize and waste money unnecessarily
any human bite deserves what?
rabies shot
explorative surg and debridement
what's the only imaging suitable for younger woman's breast?
mammogram will miss important chagnes due to increased breast density of youth
12 x 10 x 7 cm. mass in breast, mobile, slow growing? dx? tx?
cystosarcoma phylloides
dx = incisional or core bx
tx = margin free excision
tx for 2 cm mass in young female with hx of fibrocystic disease and monthly masses?
aspiration of cyst
if bloody = do cytology. if mass does not go away - do bx
bloody d/c on breast with no masses felt...dx? tx?
intraductal papilloma - do mammogram.
if no cxr found, still may do galactogram and resection of papilloma seen
fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis....dx? tx?
dx is breast abscess!! if lactating breast, ok to just I and D. If non lactating breast, think CANCER and do BX!!
if core bx for breast mass is -, does it rule out cxr?
no, only excisional bx will completely rule out brcxr
eczematous lesion on areola of breast?
Paget's disease (cancer) of the breast
trauma to breast causing lump that does not subside.. NSIM?
cancer until proven otherwise!!!!
preferable test for microcalcifications?
stereotactic guided core needle biopsy or localization and open surgical biopsy
is huge breast tumor attached to chest wall operable?
no - should give chemo first to hpefully reduce tumor to operable size
post surgical tx for woman with brc lump removed but l/n's + for cancer?
the rule is that premenopausal women get chemotherapy and postmenopausal women get hormonal therapy
most sensitive test if suspect bone metastases from any cancer?
bone scan
HUGE , shiny eyes in baby?
congenital glaucoma
elderly with acute frontal headache, halos seen around objects, mid-dilated pupils without reactivity to light, greenish hue to cornea? tx?
acute glaucoma;
referreal to ophthalmologist and tx with
Diamox, pilocarpin drops or Mannitol
swollen, red, hot, tender eyelids on the eye with fever and leukocytosis NSIM?
orbital cellulitis!
do CT for extent of inflammation, and
refere to opth..
as well as surgeon for drainage
A 59 year old, myopic gentleman reports “seeing flashes of light” at night, when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number ten or twenty, and that he also sees a cloud at the top
retinal detachment
tx = referral to ophth.
sudden loss of one eye vision in 56 y/o man? NSIM?
embolic occlusion of retinal artery
ER - > refer to ophth. immediately
tx for any barrett's esophagus not responsive to h2 blockers, bed elevation, etc?
Nissen fundoplication
A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. he locates the place where food “sticks” at the lower end of the sternum.
carcinoma of esophagus
do barium swallow, then endoscopies/ BX / CT
dx of boerrhave's syndrome in pt who comes in post-drinking and wretching, with diaphoresis and hotn, unstable, etc
Gastrographin swallow, then if + directly to surgery
A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation. NSIM?
NOT just reassurance for hemmorrhoids; CRC MUST STILL BE RULED OUT!!
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