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Internal Medicine > Surgery > Flashcards

Surgery Flashcards

1
Q

When is cryoprecipitate used?

A

DIC - for the fibrinogen

Cryoprecipitate has Factor 8, 13, fibrinogen, vWF

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2
Q

Malignant hyperthermia - pathophysiology

A

Exposure to halothane/succinylcholine –> Calcium ryanodine receptors remain open –> skeletal muscle contraction everywhere

This is due to an autosomal dominant mutation

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3
Q

Succinylcholine - possible adverse effect

A

Malignant hyperthermia

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4
Q

Malignant hyperthermia - signs

A

Rising end-tidal CO2
Muscle spasms
Rising heat

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5
Q

Malignant hyperthermia - treatment

A

Dantrolene
Cooling blankets
ICU monitoring

Next day: U/A for myoglobinuria

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6
Q

Necrotizing fasciitis - signs, treatment

A

Postoperative day 0/1:
High fever
Extreme pain
Gray-colored abdominal fluid

Treatment:
Wide resection
Broad-spectrum antibiotics

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7
Q

What are the prophylactic skinbiotics?

A

2nd-generation cephalosporins: cefazolin, cefoxitin, cefotetan

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8
Q

How does treatment differ between abscess with anastomotic leak vs without?

A

No leak: percutaneous drainage
Leak: surgery, washout, repair

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9
Q

Postoperative abscess - signs, diagnosis

A

POD 5-7:
Fever with abdominal pain or ileus that fails to resolve

Use CT with contrast to diagnose

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10
Q

Due to risk for aspiration, how long should patients be NPO prior to surgery?

A

Small meals: 6 hours
Clear liquids: 4 hours

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11
Q

If you suspect paralytic ileus, what initial imaging should you do?

A

KUB X-ray - should show distended small/large bowels

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12
Q

How would fascial dehiscence present?

A

Gush of salmon-colored fluid (blood + peritoneal fluid)

Use abdominal binder, wait for adequate healing of intact skin, then elective OR

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13
Q

What should you do in the case of evisceration?

A

Wet, warm dressings
Do NOT push bowel back in until washout is performed in the OR

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14
Q

When is a temporary abdominal vacuum wound enclosure indicated?

A

When abdominal contents and skin are too tight from volume overload to close effectively

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15
Q

What is the first thing to do in a postop patient with zero urinary output and a Foley in place?

A

Reposition it

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16
Q

In a perianal abscess, in whom is systemic antibiotic therapy indicated?

A
  1. Systemic symptoms (e.g. fever) or cellulitis
  2. Risk of severe infection (e.g. diabetes, immunocompromised)
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17
Q

How long is postoperative atelectasis possible?

A

Common up to 5 days after abdominal procedures
Presents with hypoxemia and dyspnea

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18
Q

When are wet-to-dry dressings used? When should they be discontinued?

A
  1. infected wounds
  2. Freshly debrided wounds
  3. Devitalized tissue

Discontinue one healthy granulation tissue (red, well-vascularized connective tissue) appears
Replace with nonadherent, moisture-retaining dressings

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19
Q

When is emergent thoracotomy indicated for hemothorax?

A

> 1500 ml or >200 ml/hr for 2+ hr

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20
Q

CO2 insufflation side effects during laparoscopy

A

Peritoneal stretch receptors –> increased vagal tone:
1. Severe bradycardia, AV block, asystole
2. Increased BP due to mechanical increase in systemic vascular resistance

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21
Q

Inhaled halogenated anesthetics (e.g. halothane) can cause what organ toxicity?

A

Hepatoxicity with significantly elevated aminotransaminase levels

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22
Q

Diagnostic peritoneal lavage is used in what cases of blunt abdominal trauma?

A

Hemodynamically unstable, equivocal FAST for intraabdominal hemorrhage

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23
Q

What is the most sensitive predictor of postoperative anastomotic leak?

A

HR >120/min

Symptoms usually develop within first week and also include:
Fever, abdominal pain, tachypnea

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24
Q

Succinylcholine indication and risks

A

Depolarizing neuromuscular blocker (binds to ACh receptors to trigger Na influx + K efflux, thereby causing temporary paralysis through delayed repolarization of skeletal muscle membrane

Risks:
Cardiac arrhythmia due to severe hyperkalemia, particularly in patients with skeletal crush injury (rhabdomyolysis –> hyperkalemia; injury also upregulates postsynaptic ACh receptors)

Should use nondepolarizing neuromuscular blocker (e.g. vecuronium, rocuronium) instead

25
Q

Which are the nondepolarizing neuromuscular blockers?

A

Vecuronium
Rocuronium

26
Q

What conditions cause upregulation of ACh receptors (and thus should not use depolarizing neuromuscular blocker succinylcholine)?

A
  1. Skeletal crush injury
  2. Burn injury
  3. Disuse muscle atrophy
  4. Denervation (e.g. stroke, Guillain-Barre, critical illness polyneuropathy)
27
Q

Propofol adverse effect

A

Severe hypotension due to myocardial depression

28
Q

Nitrous oxide affects vitamin B12 how?

A

Inactivates –> inhibition of methionine synthase –> subsequent neuropathy in patients with preexisting B12 deficiency

29
Q

Etomidate adverse effect

A

Inhibits 11b-hydroxylase –> adrenal insufficiency

30
Q

What tissue is injured most by electrical shock?

A

Bone has most resistance and generates most thermal energy from electrical energy; muscles will be damaged, leading to acute compartment syndrome, rhabdomyolysis, heme pigment release/AKI

31
Q

How does acute tissue injury affect platelets?

A

Thrombocytopenia - due to consumption and dilution from aggressive resuscitation

32
Q

What is associated with increased risk of surgical site infection?

A
  1. Smoking - affects inflammation, perfusion, collagen synthesis; try to cease 4-6 weeks before surgery
  2. Obesity
  3. Diabetes
  4. PAD
33
Q

Nissen fundoplication - possible complications

A
  1. Dysphagia - usually self-resolves within 12 weeks (if >12 weeks, use barium swallow or esophageal manometry to identify narrowing of distal esophagus, then dilate with EGD)
  2. Gas-bloat syndrome (bloating and inability to belch) - conservative management (simethicone, avoid carbonated beverages)
  3. Gastroparesis - diagnose with scintigraphic gastric emptying scan (+ EGD to rule out obstruction)
34
Q

Who requires massive transfusion protocol?

A

> =2 of the following:
1. SBP <=90
2. Pulse >=120
3. Positive FAST
4. Penetrating mechanism of injury

1:1:1 FFP/pRBCs/platelets (to minimize risk of coagulopathy)

Limit to ~1L crystalloids if patient is hypotensive

35
Q

What is the purpose of incisional exploration and packing?

A

Manage superficial wound dehiscence or subcutaneous fluid collection (e.g. seroma, hematoma)

36
Q

Penetrating abdominal trauma - indications for laparotomy

A
  1. Hemodynamic instability (SBP <90)
  2. Peritonitis
  3. Evisceration

Peritoneal penetration and significant organ injury (imaging, local wound exploration)

37
Q

What is delayed emergence?

A

Longer than 15 min after anesthesia or without intact protective (e.g. gag) reflexes after 30-60 minutes of last anesthetic or adjuvant agent

38
Q

What can cause delayed emergence from anesthesia?

A
  1. Drug effect - preoperative or increased anesthetic dose/duration
  2. Metabolic - hyper/hypoglycemia, hyper/hypothermia, hyponatremia, liver disease
  3. Neurologic - intraoperative stroke, seizure, or elevated ICP
39
Q

What should any patient with sternal wound discharge have?

A

Chest and sternal imaging via CT - look for pneumomediastinum or mediastinal fluid collections

40
Q

Primary survey for trauma patient + adjunct imaging

A

Primary survey:
Intact airway, normal breathing, hemodynamic stability

Adjunct imaging:
Portable chest and pelvic x-rays
FAST
Cervical spine imaging (CT) - high-energy mechanism of injury, or 1 of NEXUS criteria

41
Q

NEXUS low-risk criteria for cervical spine imaging

A

Any 1 of the following:
1. Neurologic deficit
2. Spinal tenderness
3. Altered mental status
4. Intoxication
5. Distracting injury

42
Q

What “-itises” can happen after surgery or trauma?

A

Acalculous cholecystitis
Acute pancreatitis

43
Q

Volume of blood loss at which emergent surgical thoracotomy is indicated following trauma

A

> 20 mL/kg

44
Q

How do SIRS and burn wound sepsis criteria differ?

A

Burn wound temp >39, instead of 38
Burn wound tachypnea >30, instead of 20

45
Q

What is prothrombin complex concentrate?

A

Cryoprecipitate minus antithrombin and factor XI

46
Q

How long does postoperative fever from tissue trauma last?

A

Fever and leukocytosis generally <3 days; manage with acetaminophen and observe

47
Q

Cloudy-gray discharge at surgical site

A

Necrotizing surgical site infection (dishwater drainage)

Accompanied by paresthesia/anesthesia at wound edges, subcutaneous gas/crepitus

Occurs more commonly with diabetes
Usually polymicrobial

48
Q

Valvular heart disease - when is valve repair needed prior to noncardiac surgery?

A

If asymptomatic and moderate/severe VHD:
Intermediate/high risk surgery and transthoracic echo showing decreased EF or pulmonary artery hypertension

49
Q

Order of noncardiac surgery risk assessments

A

RCRI –> METS –> cardiac evaluation impact management? –> pharmacologic stress test

50
Q

Risk of positive pressure mechanical ventilation in hypovolemic patient

A

Acute increase in intrathoracic pressure –> collapse venous capacitance vessels –> cut off venous return –> acute circulatory failure and cardiac arrest

51
Q

List processes of wound healing

A

Hemostasis –> inflammation –> proliferation of superficial epithelial layer, fibroblast production of type III collagen and ground substance that forms amorphous gel layer for capillaries to grow into –> maturation replaces type III with type I collagen, reorganizes fibers along tension lines, and cross-links

Takes at least 6 weeks for surgical wounds to regain most (~80%) of their original tensile strength

52
Q

When is urgent surgical repair indicated in penetrating injury of extremity?

A

Signs of vascular injury:
1. Pulsatile bleeding
2. Bruit or thrill over injury
3. Expanding hematoma
4. Signs of distal ischemia

If hard signs are absent, look for soft signs –> need for additional testing (e.g. injured extremity index –> CT or conventional arteriography + surgery

53
Q

Which is more effective for warfarin reversal: FFP or PCC?

A

PCC better, takes <=10 min for effect
FFP requires multiple units and increases risk of volume overload

54
Q

Colloid vs FFP

A

FFP contains albumin

55
Q

Albumin transfusion indications

A
  1. Hepatorenal syndrome
  2. Spontaneous bacterial peritonitis
56
Q

When is desmopressin given preoperatively?

A

Mild hemophilia A to prevent excessive bleeding; indirectly increases factor VIII by causing vWF release from endothelial cells

57
Q

Postop management of pituitary surgery

A

Serum electrolytes:
Arginine vasopressin deficiency in first few days lasting a week
SIADH arises several days later and lasts several weeks

58
Q

When is cholestasis seen with parenteral nutrition?

A

After 2 weeks

59
Q

What is the greatest risk with parenteral nutrition?

A

Central line-associated bloodstream infection

Internal Medicine (23 decks)

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