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Surgery - Cardiopulmonary Flashcards

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1
Q

S/p CABG a few days

+ fever, tachy, CP, leukocytosis, purulent wound discharge

A

Acute mediastinitis
- complication of cardiac surgery

Need drainage/debridement + prolonged abx

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2
Q

What post op days is atelectasis most common?

A

day 2 and 3

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3
Q

Preventing atelectasis…

A

pain control
deep breathing exercises
early mobilization
incentive spirometry

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4
Q

Reason for atelectasis post-op

A

Pain and changes in lung compliance post op can cause impaired cough and shallow breathing

Shallow breaths:
decrease recruitment of alveoli at lung bases

Weak cough:
causes small airway mucous plugging

Results in hypoxia –> increase RR –> blow off CO2

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5
Q

How do you get hematuria with AAA?

A

hematuria in AA rupture –> aortocaval fistula w/ IVC –> venous congesion in retroperiteoneal structures (eg bladder) –> fragile and distended veins in bladder can rupture –> gross hematuria

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6
Q

Which diaphragm is more prone to injury?

A

Left

  • congenital weakness in diaphragm’s left posterolateral region
  • also liver protective effects on R side

Can have late presentation of diaphragm injury

Use CT to diagnose diaphragmatic injury

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7
Q

How much circulating blood vol can a hemithorax hold?

How much blood is a massive hemothorax?

A

50% of circulating blood vol

Massive > 1.5 L

Will have FLAT NECK VEINS

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8
Q

Characteristics of hemothorax

A

tracheal deviation
Reduced breath sounds
dullness to percussion over involved side
flat neck veins (if hypovolemic)

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9
Q

Takotsubo’s cardiomyopathy

A

is a type of non-ischaemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). Because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up, or constant anxiety, it is also known as broken heart syndrome

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10
Q

What kind of heart attack is perioperative MI?

A

NSTEMI

O2 demand > delivery

Will have increased HR w/ pain, anxiety and also increased contractility –> need more O2 demand but not enough delivery

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11
Q

How do you handle MI sx post-op?

A

EKG before, 1 day post op, 2 day post op, 7 day post op

Troponins day 1, 2, 7

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12
Q

How can you try and ppx against NSTEMI peri-op?

A

+ Beta blocker

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13
Q

How do you avoid pulm complications post-op?

A

Incentive spirometer before and after surgery

DO NOT need PFTs

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14
Q

Cardiac cath MAJOR complications

A

MDS

MI
Death
Stroke/TIA

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15
Q

Cardiac cath MINOR complications

A

CHHAAP

Contrast allergy
Hemostasis @ access site
Hematoma formation (retroperitoneal)
AV fistula
Arterial thrombosis
AKI
Pseudoaneurysm
Perforation of heart or great vessels
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16
Q

Which bronchus is more commonly injured w/ tracheobronchial perforation 2/2 to blunt thoracic trauma?

A

Right main bronchus

Confirm w/ CT scan or surgical exploration

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17
Q

Pneumomediastinum causes

A

Tracheal rupture

Esophageal rupture

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18
Q

ARDS vs. pulmonary contusion

A

Pulmonary contusion usually within first 24 hrs

ARDS usually 24-48 hrs from trauma
- also, b/l lung involvement usually

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19
Q

Tension pnsumothorax

A

Life threatening

Air w/in pleural space displacing mediastinal structures
- air can enter pleural space but cannot excape naturally

Findings:

  • SOB
  • tachycardia
  • tachypnea
  • HYPOtn
  • distension of neck veins (b/c SVC compression)

1/4 of these in hospital caused by placement of subclavian central venous catheters

Tx: needle thoracostomy + emergency tube thoracostomy

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20
Q

When ok to give heparin for aortic dissection?

A

DO NOT GIVE if it’s ruptured

Give if not ruptured

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21
Q

How high can diaphragm be?

A

4th thoracic dermatome on R

5th thoracic dermatome on L (nipples)

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22
Q

Cx negative infective endocarditis

A

HACEK

Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
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23
Q

UTI associated endocarditis

A

Enterococci (esp fecalis)

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24
Q

How much blood needed to cause sudden rise in intrapericardial pressure that compresses cardiac chambers and compromises both venous return and CO?

A

100-200mL

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25
Respiratory quotient - what is it? - different values = what?
= Steady state CO2 produced : O2 consumed / unit time Can be used to make assessments of metabolism in particular organs or in body as whole ``` RQ = 1 = carbs major nutrient oxidized RW = 0.8 = protein metabolism only RW = 0.7 = fatty acid metabolism only ```
26
Ppx for bacterial endocarditis for these procedures: - dental/oral - GI/GU
Dental/oral/resp/esoph: - give 1 hr before procedure - amoxicillin - clindamycin / cephalosporin / clarithromycin GI/GU high risk - ampicillin + gentamicin before and after - vanco + gentamicin before ONLY GI/GU mod risk - amoxicillin / ampicillin before ONLY - Vanco before ONLY
27
Cardiac index =
CO / body surface area CO = SV x HR
28
What does PCWP via swann ganz catheter represent?
L atrial P L ventricular EDP Pulm vasc disease can increase PCWP independent of LAP or LVEDP Mitral stenosis and regug increase LAP and PCWP and falsely elevated LVEDP in swann ganz catheter reading PEEP/CAP can alter PCWP on SG catheter
29
Tx gastric aspiration into tracheal tree
Tracheal intubation and suctioning
30
Tracheostomy - tips
Trachea should be entered at 2nd or 3rd cartilaginous ring
31
Central venous pressure - increasors - decreasors
Increase - vasoconstrictor - PEEP - mediastinal compression - hypervolemia - acute PE (RV overload --> increase RAP0 Decrease - sepsis
32
1st branch of ascending aorta
Coronary A
33
1st branch off internal carotid A
Ophthalmic A
34
Internal and external carotid relationship
Internal carotid is always posterior Internal carotid is lower resistance b/c it perfuses the brain
35
A-a gradient
= PAO2 - PaO2 PAO2 = 150 - PaCO2 / 0.8
36
Tx hemothorax
Chest tube Don't need surgery to stop bleeding usually - will stop by itself if it is the lung bleeding Need thoracotomy if systemic vessel (intercostal A) is bleeding Surgery if: - >1500 mL blood when chest tube put in - > 600 mL blood / 6 hrs with CT
37
Danger of pulmonary contusion and how that plays for tx
Very sensitive to fluid overload Tx = fluid restriction + diuretics Can happen from flail chest
38
Tx myocardial contusion
Troponins are specific - get when sternal fracture Tx focuses on complications (like arrhythmias)
39
Ddx subQ emphysema
Rupture of trachea Rupture of esophagus (usually w/ endoscopy or vomiting) Tension pneumo
40
Sudden death in chest trauma pt who is intubated + on respirator Tx? Prevent?
Air embolism also happens when subclavian opened to air (eg central line placement, supraclavicular node bx) Tx: - cardiac massage w/ pt L side down Prevent: - Trendenlenburg if putting in central line
41
Vascular ring
congenital defect in which there is an abnormal formation of the aorta and/or its surrounding blood vessels. The trachea and esophagus are completely encircled and sometimes compressed by a "ring" formed by these vessels, which can lead to breathing and digestive difficulties.
42
1d old child w/ cyanosis - what do they have? What do you do next? what keeps them alive?
Transposition of great vessels Echo next ASD, VSD, or PDA keeps them alive
43
When do you do a valve replacement for aortic stenosis?
Gradient > 50 mm Hg 1st indication of CHF, angina or syncope
44
Repair for chronic vs acute aortic regurg?
Chronic - repair when see signs of LV dilatation Acute - immediate repair! Long term abx needed. Usually 2/2 endocarditis via drugs
45
What's the best surgery for mitral regurg?
Valve annuloplasty (preferred over prosthetic replacement)
46
CAD intervention indication?
If >=1 vessles have > 70% stenosis and the distal vessel is still ok --> do angioplasty + stent Triple vessel disease - best to use bypass via internal mammary
47
Post op care of cardiac pt - if the CO is low, what do you do next?
Find out the PCWP If it is low, then need more IVF If it is high, then you have ventricular failure
48
1st thing you do after pt has a coin lesion on CXR?
Find old xray and compare to see if it was there before, got bigger, etc
49
Tx central vs peripheral lung cancer. Indications?
Central = pneumectomy Peripheral = lobectomy A minimum of FEV1 = 800 mL is needed post op. Tx w/ chemo and radiation if pt is not a surgical candidate
50
Subclavian steal syndrome - pathophys - signs - dx - tx
Arteriosclerosis plaque at origin of subclavian (before vertebrals branch off) lets arm have enough blood at rest but not w/ activity Arm will try to steal enough to meet higher demands --> arm will steal blood from brain by reversing flow in vertebral Signs: - claudication of arm - posterior neuro signs (visual sx, equilibrium problems) when arm exercised Dx: Duplex scanning when it shows reversal of flow Tx: Bypass
51
When repair AAA?
> 5-6 cm --> elective repair If grow 1cm/year or faster --> elective repair Tender AAA (impending rupture) Back pain in AAA pt (aneurysm is already leaking, rupture is imminent)
52
Best way to dx thoracic aortic dissection
spiral CT scan Will have wide mediastinum on CXR Manage ascending surgically Descending --> medically w/ HTN control in ICU
53
Pulmonary contusion
Can be caused by severe blunt chest trauma Dyspnea Tachypnea Chest pain Hypoxemia WORSENED by intravascular volume explansion Patchy, irregular alveolar infiltrates in CXR
54
Square root sign
Constrictive pericarditis Equalization of pressures in RA, RV, LA, LV
55
The deep sulcus sign
is when one costophrenic angle appears much 'deeper' and more lucent than the other. Additionally, that hemidiaphragm or the adjacent cardiac border may appear much crisper (clearly defined) than the other. It can be confirmed by performing a decubitus film on which air should ascend to the abnormal side. When a patient is supine, the air rises to the highest part of the thorax, namely the anterior costophrenic sulcus. Instead of seeing the typical lucency around the lung apex, as with an upright CXR, you see it at the base.
56
Pt has a fall and suspected rib fx. What imaging do you get?
You can just get CXR to r/o any hemithorax, pneumothorax. You will most likely know it is rib fx so no need for imaging ONly get rib fractures in: - children w/ suspected hcild abuse + possible posterior rib fx - patients w/ cancer
57
Pneumomediastinum causes
Spontaneous - usually young, fit, skinny men Related to high inspiratory or expiratory pressures - asthma, intubated patients (often with high PEEP settings such as acute respiratory distress syndrome) Secondary to a pneumothorax or pneumoperitoneum (e.g. laparoscopy) Secondary to esophageal perforation (vomiting, instrumentation, tumor) Traumatic from a tracheal or bronchial rupture Complication of free basing cocaine
58
Coin lesions on CXR in lung common in...
areas where fungal disease is prevalent Coccidio, histo
59
CXR has coin lesion - what is next step?
CT - defines lesion - examines if lymph nodes present Needle aspiration w/ CT
60
If CT guided needle aspiration of coin lesion is malignant or indeterminate on needle bx, what do you do? What is complicatino of needle bx
Resection complication - PTX
61
Use of the following in examining lung lesions: - bronchoscopy - mediastinoscopy
Bronch = obtain tissue diagnosis and determine location of lesion Mediastinoscopy = determines state of mediastinal lymph nodes
62
Tx small cell carcinoma of lung
Chemo b/c usually systemic spread
63
Most common non-small cell carcinomas Tx
adenocarcionma SCC ``` Stage 1 + 2: Should resect + radiation + chemo - exploratory thoracotomy - lobectomy OR - pneumonectomy (removal of all of lung) ``` Stage 3 - chemo + radiation
64
How can you assess percentage of functioning lung tissue pre-pneumectomy? How about mechanics of respiration?
Percentage - V/Q perfusion scan Mechanics - spirometry
65
Suspect pancoast tumor - workup?
CT Bronchoscopy Mediastinoscopy Needle bx of mass
66
Pancoast tumor
lung cancer in extreme apex of lung in the groove produced by subclavian artery Invades: - chest wall - lower cords of brachial plexus - subclavian A - sympathetic ganglia Results: - brachial plexopathy - horner's syndrome
67
Tx pancoast tumor
Irradiation for 6 weeks Surgical resection of invlved chest wall and lung Pts usually do pretty well
68
Bronchial adenomas
Types: - carcionid tumor - adenocystic carcionmas Can be malignant! Often cause atelectasis b/c blcok bronchus Bronch for definitive diagnosis Tx: lobectomy
69
Pleural effusion in older person - work up?
Thoracentesis + pleural bx Suspicious for malignancy/mesothelioma!
70
Tx mesothelioma
Very bad prognosis Extrapleural pneumonectomy
71
What does it mean when you see air bubbles in the water or PleurVac fo PTX?
There is still an air leak in the patient / the patient still has air in his pleura.
72
Tx spontaneous ptx
Thorascopic excision of blebs adn pleural abrasion (pleurodesis)
73
Tx empyema
Abx Evacuate pus via cehst tube drainage - otherwise risk empyema to become loculated and thoracotomy and decortication is needed to reexpand lung Reexpand lung
74
Iatrogenic causes of afib
hypokalemia | fluid overload
75
esophageal cancer tx - cervical +upper 1/3 - middle 1/3 - distal 1/3
Cervical - chemo + radiation, resection Middle - chemo + radiation, resection Distal - esophagectomy + proximal gastrectomy
76
Why would someone with suspected esophageal cancer cough constantly?
Could be 2/2 to chronic aspiration from tracheoesophageal fistula b/c tumor erodes into trachea
77
Anterior mediastinum masses
Teratoma Thymoma Thyroid cancer Hodgkin's lymphoma
78
Middle mediastinum masses
``` Lymphatic tumors Various cysts (Bronchiogenic) ```
79
Posterior mediastinum masses
``` Neurogenic tumos (from nerves and nerve sheaths in the area) - ex: neurilemoma ```
80
Who benefits the most from CABG?
3 vessel disease + reduced EF
81
Best gract patency rate for CABG
Internal mammary A graf
82
1st step in management for massive hemoptysis
Worry about asphyxiation, not exsanguination Patent airway asap! Bronchoscopy is initial procedure b/c can localize bleeding site
83
Pt w/ recent MI --> EKG later on shows persisten ST elevation and deep Q waves in same leads SOB -- what happened?
LV aneurysm
84
Systolic diastolic abdominal bruit + HTN + atherosclerosis - what is it?
Renal artery stenosis NOT ab aorta aneurysm (would maybe have systolic bruit, but not systolic, diastolic)
85
Tx symptomatic sinus bradycardia
IV atropine + transcutaneous pacing
86
Pneumonitis (patchy diffuse infiltrates) + colitis in post-bone marrow transplant pt - what is organism?
CMV Diarrhea suggests CMV! Can be P jiroveci but does not cause diarrhea
87
Dx pericardial tamponade
US
88
Tx torsades de pointes
Stop offending agents + Mg SO4

Surgery (12 decks)

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