Surgery Flashcards
Management of heparin-induced thrombocytopenia
STOP heparin, and begin direct thrombin inhibitor (e.g., argatroban) or fondaparinux
When >150,000, can safely switch to warfarin
Trousseau syndrome
Migratory superficial thrombophlebitis associated with pancreatic cancer (among others)
If blunt abdominal trauma
Need to evaluate for intra-abdominal bleed
If hemodynamically stable:
- NOT alert/AMS –> serial abdominal exams +/- CT
- alert/no AMS –> FAST
FAST - –> serial abdominal exams +/- CT
FAST + –> CT abdomen
Causes of hyperbilirubinemia
UNCONJUGATED
- overproduction (hemolysis)
- reduced uptake (drugs, portosystemic shunt)
- conjugation defect (Gilbert syndrome)
CONJUGATED
- AST/ALT
- viral hepatitis
- autoimmune hepatitis
- toxin/drug-related hepatitis
- hemochromatosis
- ischemic hepatitis
- alcoholic hepatitis
- alkaline phosphatase
- cholestasis of pregnancy
- malignancy (pancreas, ampullary)
- cholangiocarcinoma
- PBC
- PSC
- choledocholithiasis
- normal liver enzymes
- Dubin-Johnson syndrome
- Rotor syndrome
Positive pressure ventilation in a hypovolemic patient
PPMV causes an acute increase in intrathoracic pressure, which, in a severely hypovolemic patient with low central venous pressure, can collapse venous capacitance vessels (e.g., IVC) and cut off venous return. This sudden loss of RV preload can cause acute circulatory failure and cardiac arrest.
Sedatives also cause relaxation of capacitance vessels and can also contribute to decreased venous return
Rupture of bladder dome
Urine leaks into peritoneal cavity causing chemical peritonitis
Pulmonary contusion
Intraalveolar hemorrhage and edema
Presents <24h after blunt trauma
Tachypnea, tachycardia, hypoxia
Rales or decreased breath sounds
CT (>CXR) w/ patchy alveolar infiltrate not restricted by anatomical borders
Hemothorax on CXR
pleural effusion
Green drainage in chest tube
Esophageal perforation
Esophageal perforation
Severe chest pain, pneumothorax, pneumomediastinum, subcutaneous emphysema, pleural effusion w/ GI fluid (green, lo pH, hi amylase, food particles)
Water contrast esophagography
Surgery
Post-traumatic neuroma
- weeks to months after amputation
- focal tenderness, altered sensation
- decreased pain w/ anesthetic injection
- management: excision
Surgical indications for severe chronic mitral valve regurgitation
The measured LVEF in MR patients overestimates LVEF because regurgitant flow accounts for a large amount of the stroke volume
Primary MR
- surgery if LVEF 30-60%, regardless of sx
- consider surgery if successful valve repair is highly likely:
- symptomatic and LVEF <30%
- asymptomatic and LVEF >60%
Secondary MR
-medical management
Repair is preferred over replacement
Splenic abscess
Fever and tender splenomegaly
A rare, life-threatening consequence of bacteremia from a distant infection
Concerning side effect of anticholinergics in elderly
Urinary retention
Need to cath
Heterogenous echotexture in testicular torsion
testicular necrosis
Recent diagnosis of DM in older adult
Pancreatic cancer
Especially atypical DM (thin, older patient)
Angiosarcoma
Malignant tumor from lining of blood vessels and lymphatics.
RF: localized radiation for cancer treatment; breast cancer survivors w/ chronic lymphedema
Ecchymoses or purpuric lesions
Indications for surgery in midshaft humerus fracture
- open fractures
- significant displacement (arm shortening)
- neurovascular compromise (asymmetric radial pulses)
- polytrauma
- pathologic fractures
Necrotizing surgical site infection presentation and management
Presentation:
- pain, edema, or erythema spreading beyond surgical site
- systemic sx (fever, tachycardia, hypotension)
- paresthesia or anesthesia at wound edges
- purulent, cloudy-gray discharge (“dishwater drainage”)
- subcutaneous gas or crepitus
- more common in patients w/ DM and tend to be polymicrobial
Can develop into necrotizing fasciitis, so need emergent surgical debridement and parenteral antibiotics
Leriche syndrome
Aortoiliac occlusion
Triad:
- bilateral hip, thigh, and buttock claudication
- absent or diminished femoral pulses (often w/ symmetric atrophy of b/l LEs d/t chronic ischemia)
- impotence
Risk of laparoscopic appendectomy vs laparotomy
Lap appy:
intra-abdominal abscess: fever and abdominal sx several days after abdominal operation
Treatment of acute bacterial prostatitis
Fluoroquinolone or TMP/SMX for 6 wks
If a bruit is heard under clavicle in clavicle fracture
ANGIOGRAM to rule out injury to subclavian artery
Femoral artery aneurysm
Pulsatile groin mass below the inguinal ligament
Anterior thigh pain
Anteromedial humerus fracture risk
Injury to the brachial artery and median nerve (pass ant. to humerus)
Anterolateral humerus fracture risk
Radial nerve injury
Dangerous side effect of succinylcholine
Life-threatening arrhythmia d/t hyperkalemia
More common in certain patients where there is upregulartion of ACh-R:
- crush injury (hyperkalemia)
- burns
- diffuse muscle atrophy
- denervation (Guillain-Barré, critical illness polyneuropathy)
To avoid, use nondepolarizing neuromuscular blockers (vecuronium, rocuronium)
Components of Glasgow coma scale
Does not diagnose coma, but shows severity of coma
- eye opening (1-4)
- verbal response (1-4)
- motor response (1-6)
Tamponade findings
- hypotension (unresponsive to IVF)
- tachycardia
- elevated JVP
CMV infection in immunosuppressed
Colitis or enteritis w/ fever, malaise, vomiting, bloody diarrhea, and abdominal pain.
Cytopenias and atypical lymphocytes.
Large, shallow erosions or ulcers on colonoscopy.
Treat w/ gancyclovir and reduction of immunosuppressants
Ganglion cyst
Mobile, nontender swelling most commonly on dorsal surface of wrist
Diagnosis obvious on exam but can be confirmed with transillumination
Most resolve spontaneously
If appendicitis symptoms >5d, consider
appendiceal abscess
Maneuvers that assess deeper spaces (e.g., psoas sign) may be more revealing than anterior palpation of the abdomen
If stable, treat w/ IV hydration, antibiotics, bowel rest, and interval appendectomy (6-8 weeks later elective)
Evaluation of blunt genitourinary trauma
- UA
- contrast CT (if stable w/ hematuria)
If unstable, IV pyelography before surgery
MCL tear PE
Laxity on valgus stress test
MCL tears are caused by valgus stress or twisting
MRI most sensitive
Ruptured ovarian cyst symptoms and imaging findings
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity. Can be complicated by hemoperitoneum and hemodynamic instability, especially in patients on anticoagulation.
US: pelvic free fluid
If unstable, needs surgery
Post-CABG patient presentinh w/ copious drainage from sternal wound
Concern for mediastinitis
Needs chest imaging –> fluid collections or pneumomediastinum
Giant cell tumor of bone
Progressive pain w/ lytic bone lesion
Benign but locally destructive
Pulmonary mets and malignant transformation may occur
Soap bubbles appearance
Surgery is first line
Danosumab (Ab against RANKL) can be used to shrink tumor
Complicated vs uncomplicated diverticulitis
Uncomplicated: in stable patients can be managed outpatient w/ bowel rest, oral antibiotics, and observation
Complicated: diverticulitis associated with an abscess, perforation, obstruction, or fistula formation
Fluid collection <3 cm: antibiotics and observation unless worsening symptoms
Fluid collection >3 cm: CT-guided percutaneous drainage. If symptoms not resolved by fifth day, surgical drainage and debridement.
Most common cause of small bowel obstruction
adhesions
Charcot joint
Neurogenic arthropathy.
Impaired sensation and proprioception in the foot lead to altered weight bearing, mechanical stresses, and recurrent trauma
Most commonly seen in diabetic peripheral neuropathy, other neuropathies (B12), syringomyelia, spinal cord injury, and tabes dorsalis
Peritonsilar abscess
Fever, pharyngeal pain, earache
Trismus, muffled voice, swelling of peritonsillar tissues w/ deviation of the uvula
Tx: needle aspiration or I&D w/ antibiotics
If stable gallstone pancreatitis
cholecystectomy
Indications for ERCP in gallstone pancreatitis
- cholangitis
- visible CBD dilation/obstruction
- increasing liver enzymes
Most common cause of esophageal perforation
Endoscopy (especially w/ adjunctive procedures like biopsy or dilation)
Confirm esophageal perforation
Water-soluble contrast esophagography
Aortic injury risk factor
Rapid deceleration blunt chest trauma
Compartment syndrome
Common features:
- pain out of proportion to injury
- pain increased by passive stretch
- rapidly increasing and tense swelling
- paresthesia (early)
Uncommon:
- decreased sensation
- motor weakness (w/in hrs)
- paralysis (late)
- decreased distal pulses (uncommon)
Diagnosed by needle manometry (delta P [diastolic - compartment] <30 is suggestive)
Treat w/ urgent fasciotomy
Treatment of anal fissures
- high-fiber diet and adequate fluid intake
- stool softeners
- Sitzs baths
- topical anesthetics and vasodilators (nifedipine, nitroglycerine)
Surgical intervention (e.g., lateral sphincterotomy, fissure excision) is reserved for fissures that are refractory to medical therapy
Tramatic diaphragmatic injury
Migration of abdominal organs into the chest with resulting symptoms d/t lung compression (respiratory distress) or bowel obstruction (nausea, vomiting, abdominal pain)
Femoral vs inguinal hernia
Femoral is at higher risk for strangulation, so elective surgery is warranted, whereas inguinal hernias can be managed w/ reassurance and watchful waiting
Evaluation of suspected urethral injury
retrograde urethrogram
Indications for urethrogram
- blood at meatus
- hematuria
- dysuria
- urinary retention
Primary vs secondary polycythemia
Primary: decreased EPO
- Polycythemia vera (JAK2 mutation)
- EPO receptor mutations
Secondary: normal/increased EPO
- hypoxemia (cardiopulmonary disease, OSA, high altitude)
- EPO-producing tumors (renal, hepatic)
- Congenital (high-affinity Hgb)
- following renal transplantation
- androgen supplementation
Anterior cord syndrome
Loss of movement, pain, and temperature
Intact position, vibration, and touch [dorsal columns spared]
Emphysemetous cholecystitis
Fever, RUQ pain, gas in GB wall, surrounding tissue, or hepatobiliary system; unconjugated hyperbilirubinemia, mildly elevated LFTs
d/t gas forming organisms like Clostridium or E. coli infecting damaged or ischemic tissue
SURGICAL EMERGENCY: immediate cholecystectomy
Delirium tremens
48-96h after last drink
Confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations
5% mortality
Treat w/ benzos
Preferred fluid for burn victims
Lactated Ringer’s (LR)
Why is LR preferred over NS for burns?
LR is balanced (physiologic) and contains buffer to maintain pH while NS is not–
NS has supraphysiologic [Cl-] which can cause hyperchloremic metabolic acidosis. It has also been associated w/ hypocoagulability.
Cat bite
Amoxicillin-clavulanate
Atraumatic splenic rupture
Associated w/ hematologic malignancies, infection (EBV, malaria), inflammatory diseases (SLE)
Diffuse or LUQ pain w/ L shoulder pain (Kehr sign) and hemodynamis instability
Acute anemia
Intraperitoneal free fluid on imaging
Stable: catheter-based angioembolization
Unstable: emergency splenectomy
Cholangiocarcinoma markers
Elevated CEA and CA19-9
Normal AFP
Hypoparathyroidism
Hypocalcemia and hyperphosphatemia in the presence of normal renal function
Causes:
- post-surgical (most common)
- autoimmune
- congenital absence or maldevelopment of paratyroid glands (DiGeorge syndrome)
- defective calcium-sensing receptor on parathyroids
- infiltrative destruction (hemochromatosis, Wilson disease, neck irradiation)
Complication of circumferential, full-thickness burns
compartment syndrome
d/t eschar formation that restricts venous and lymphatic drainage
Symptoms of diverticulutis
- LLQ abdominal pain
- N/V
- bladder symptoms (urgency, frequency, dysuria) or sterile pyuria (+LE, – nitrites)
- alterations in bowel habits (constipation, diarrhea)
Next step after central venous catheter placement
CXR (to confirm proper placement)
Anterior dislocation risk
Injury to the axillary nerve [innervates teres minor and deltoid]
Weakened shoulder abduction and decreased sensation over lateral shoulder
Management of massive hemoptysis
- ensure adequate patent airway
- maintain adequate ventilation and gas exchange
- ensure hemodynamic stability
- place patient so that bleeding lung is in dependent position (lateral)
- bronchoscopy
Indications for ex lap in blunt abdominal trauma
- hemodynamic instability
- peritonitis (rebound tenderness, guarding)
- evisceration
- blood from NG tube or on rectal exam
Protocol for patients on warfarin who need urgent surgery
-prothrombin complex concentrate and IV vitamin K
Effect of hyperventilation on ICP
Decreases via vasoconstriction
Chronic bacterial prostatitis
Epi:
- young and middle aged men
- diabetes, smoking, UT procedure
Pathogenesis:
- coliforms enter from urethra via intraprostatic reflux
- E. coli causes >75%
Presentation:
- recurrent UTI w/ same organism
- +/- prostatic tenderness and swelling (often absent)
- pain w/ ejaculation
- h/o antibiotic treatment –> transient improvement
Dx:
- pyuria and bacteriuria on UA
- bacteria in prostatic fluid > bacteria in urine
Tx:
-fluoroquinolones for 6 wks
Urology consult indications for kidney stones
- urosepsis (fever, tachycardia)
- anuria
- AKI
- refractory pain
- > 10mm stone
- stones that don’t pass in 4-5 wks
Indications for surgery in extremity trauma
Hemodynamic instability or:
- observed pulsatile bleeding
- presence of bruit/thrill over injury
- expanding hematoma
- signs of distal ischemia (absent pulses, cool extremities)
Flail chest
Pathophys:
-/>3 contiguous ribs fractured in />2 locations –> flail chest segment
Findings:
- paraxodical chest wall motion w/ respiration
- chest pain, tachypnea, rapid shallow breaths
- CXR: rib fractures +/- contusion/hemothorax
Management:
- pain control, supplemental O2
- PPV (+/- chest tube) if resp failure
Wound botulism
C. botulinum spores contaminate puncture injury and generate neurotoxin in vivo
Symmetric, descending neurological deficits, resp compromise, and autonomic dysfunction
Fever and leukocytosis may be present
Urgent treatment w/ equine botulinum antitoxin
Achalasia vs EoE
Achalasia: progressive, solids and liquids
EoE: intermittent, solids
Pharmacotherapy for DVT
unfractionated heparin followed by warfarin
Management of superficial wound dehiscence
If no induration, erythema, or purulent discharge, can be managed w/ regular dressing changes
Management of deep wound dehiscence
Involvement of fascia
Surgical emergency
Acute epididymitis
<35: STD (chlamydia, gonorrhea)
>35: bladder outlet obstruction (coliform bacteria)
- unilateral, posterior testicular pain
- epididymal edema
- pain improved w/ testicular elevation
- dysuria, frequency (w/ coliform bacteria)
Tx: ceftriaxone + doxycycline OR levofloxacin
NSAIDs and testicular elevation help
Which disease increases risk of osteosarcoma?
Paget disease of bone
Persistent pneumothorax and significant air leak following chest tube placement in a patient who sustained blunt chest trauma
tracheobronchial rupture
Other findings:
- pneumomediastinum
- subcutaneous emphysema
Mediastinitis
Post-operative fever (w/in 14d), fever, tachycardia, chest pain, leukocytosis, sternal wound drainage or purulent discharge
CXR: widened medisatinum (more common in non-surgical mediastinitis)
Requires drainage, surgical debridement w/ immediate closure, and prolonged antibiotic therapy
Management of small pneumothorax
observation and supplemental O2
von Hippel-Lindau disease
autosomal dominant germline mutation of VHL tumor suppressor gene on chromosome 3
- cerebellar and retinal hemangioblastomas
- pheochromocytoma
- renal cell carcinoma (clear cell subtype)
Valve replacement in aortic stenosis
Severe AS + at least 1 of:
- onset of symptoms (syncope, angina)
- LVEF <50%
- undergoing other cardiac surgery
[Severe AS:
- aortic jet velocity />4 m/s OR
- mean transvalvular pressure gradient />40
- valve area usually /< 1 cm^2 but not required]
Bug causing osetomyelitis from puncture wound
Pseudomonas aureuginosa (Staph aureus too)
ABG in atalectasis
- hypoxemia
- hypocapnia
- respiratory alkalosis
Brown recluse spider bite
Small ulcer developing at site of recent bite w/ an erythematous halo and necrotic center which can progress to an eschar
Which nerve may be damaged in parotid surgery?
Facial nerve (causing facial droop)
Management of congenital umbilical hernia
Observation (most close spontaneously by 5 y.o.)
Whistling noise when breathing after rhinoplasty
Perforated septum likely resulting from a septal hematoma
Perforated viscus
Severe abdominal pain, fever, tachycardia, peritonitis (rigidity, reduced bowel sounds, bound tenderness)
Can occur in the setting of peptic ulcer disease, which is often associated w/ NSAID and alcohol use
Dx: xray of chest and abdomen – free intraperitoneal air under the diaphragm
Perianal abscess
d/t occlusion of an anal crypt gland –> bacterial infection
Tender, fluctuant, erythematous mass w/ fever and worsening pain
RF:
- anal sex
- chronic constipation
Ottawa ankle rules
Xray of ankle if:
Pain at malleolar zone AND
-tender at posterior margin/tip of medial malleolus OR
-tender at posterior margin/tip of lateral malleolus OR
-unable to bear weight 4 steps (2 on each foot)
Xray of foot if:
Pain at the midfoot zone AND
-tender at the navicular OR
-tender at the base of the 5th metatarsal OR
-unable to bear weight 4 steps (2 on each foot)
Well-circumscribed liver lesion w/ central scar
Focal nodular hyperplasia
Benign regenerative liver nodule common in women 20-50
Central stellate scar surrounding a large congenital arterial anomaly
Hyperdense on helical CT
No treatment needed
Acute mesenteric ischemia
Presentation:
- rapid onset of periumbilical pain (often severe)
- pain out of proportion to exam findings
- hematochezia (late)
RFs:
- atherosclerosis (acute on chronic)
- embolic source (thrombi, vegetations)
- hypercoagulable disorders
Labs:
- leukocytosis
- elevated amylase and phosphate levels
- metabolic acisosis (elevated lactate)
Dx:
- CT
- mesenteric angiography if diagnosis unclear
Tx:
-open embolectomy w/ vascular bypass or endovascular thrombolysis
Blunt abdominal trauma patients who are stable but with high risk features
CT
Fat embolism
Triad: respiratory distress, eurologic dysfunction, petechial rash
In the setting of fracture of marrow-containing bone, orthopaedic surgery, or pancreatitis
Consequence of mucus plugging
Large-volume atelectasis
CXR: opacification of the affected lung area and mediastinal shift toward area of atelectasis
Rising thyroglobulin in patient w/ post-thyroidectomy for thyroid cancer
recurrence
Patients need to take levothyroxine for 2 reasons:
- replaces thyroid gland function
- suppresses pituitary TSH release. Since TSH stimulates thyroid tissue growth, levothyroxine supplementation to suppress TSH (by causing a mild hyperthyroid state) may prevent thyroid cancer recurrence
TB vs. aspiration pneumonia
Aspiration pneumonia: usually affects the LOWER lobes. Acute symptoms of foul-smelling sputum production, dyspnea, and fever
TB: UPPER lobes. Subacute/chronic cough and cavitary upper lobe lesion. Low grade fever, fatigue, mild cough (worst in morning); weight loss, chest pain, dyspnea later
First line treatment of osteoarthritis
Exercise and strength exercises
If penetrating abdominal trauma w/ peritonitis
ex lap (instead of imaging)
Local vascular complication of cardiac catheterization
Retroperitoneal hematoma
- sudden hemodynamic instability
- ipsilateral back or flank pain
Dx: non-con CT of abdomen and pelvis (or abd US)
Cardiac cath complications:
hematoma vs pseudoaneurism vs AV fistula
Hematoma:
+/- mass
-no bruit
Pseudoaneurysm:
- bulging, pulsatile mass
- systolic bruit
AV fistula:
- no mass
- continuous bruit
Sliding inguinal hernia
Posterior wall of sac is a retroperitoneal viscous (colon or bladder)
More common on the L (sigmoid colon less fixed and more likely to slide down)
Clue: thickened posterior wall of hernia sac at surgery
More associated with INDIRECT inguinal hernia that has descended into scrotum
Higher risk of colonic injury during repair
Do not completely excise hernia sac
Femoral hernias
Femoral hernias occur in the femoral canal, inferior to the inguinal ligament traversing the empty space medial to the femoral vein
Higher risk of strangulation, so surgical repair is indicated
F>M
Multigravida is risk factor
Most common type of hernia in both men and women
INDIRECT inguinal hernia
Richter hernia
Only one wall of bowel protrudes into the hernia sac
Can incarcerate w/o signs or sx or radiological evidence, of SBO so can easily think is not incarcerated
Initial management of SBO
- NPO
- aggressive fluid resuscitation
- NG decompression
- CT w/ oral contrast
Ischemic orchitis
Acute testicular pain; decreased or absent flow on Doppler
Secondary to thrombosis or damage to the pampiniform plexus
Likely to occur in pts w/ large or densely adhesed scrotal hernia sacs
Sensation to the scrotum and cremaster reflex
Genital branch of the genitofemoral nerve