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1
Q

Management Hyperpyrexia

A

Dantrolene and cooling

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2
Q

Inidcations for emergency thoracotomy

A

> 1.5L drained on insertion

> 200ml/hr for 2-4 hours

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3
Q

Definition of flail chest

A

Fractures of 2 or more adjacent ribs

With 2 or more fractures on each rib

Mx: epidural and PCA –> need good respiratory effots
if conservative fails –> PPV

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4
Q

Kussmaul’s sign

A

Increased JVP on inspiration

=cardiac tamponade

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5
Q

Pulsus paradoxus

A

Systolic blood pressure FALLS >/10 mmHg on inspiration

=cardiac tamponade

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6
Q

Beck’s triad

A

Hypotension

Raised JVP

Muffled heart sounds

=cardiac tamponade

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7
Q

low voltage QRS ± electrical alternans

A

= cardiac tamponade

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8
Q

+ve diagnostic peritoneal lavage

A

> 100,000 RBCs/mm3,

Bile/intestinal contents

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9
Q

Anterior urethral injury

A

Spongy urethra: penile + bulbar

Saddle injuries / instrumentation

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10
Q

Posterior urethral injury

A

Membranous injuries

Pelvic fractures

High-ridingm prostate

Blood at meatus

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11
Q

Indications for intubation with head injury

A

GCS <8

PaO2 <9 on RA
PaO2 <13 on O2
PaCO2 >6

Spontaneous hyperventilation –> PaCO2 <4

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12
Q

Management of achalasia

A

Med: CCBs, nitrates

Int: botox injection, endoscopic balloon dilatation

Surg: Heller’s cardiomyotomy (open or lap)

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13
Q

Plummer Vinson

A

Severe iron deficiency anaemia

  • -> hyperkeratinisation of upper 3rd oesophagus
  • -> web formation

Pre-malignant: 20% risk of Squamous cell carcinoma

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14
Q

Management oesophageal cancer

A

Neo-adjuvant chemo: 5-FU + cisplatin

Ivor-lewis: 2 stage. abominal and R thoracotomy

McKeown: 3 stage, abdominal + R thorocotomy + L neck

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15
Q

Indications for Nissen fundoplication

A

Severe symptoms

AND

Refractory to medical therapy

AND

Confirmed reflux

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16
Q

Antrectomy with vagotomy

A

Billroth 1: directly to duodenum

Billroth 2 /Polya: to small bowel loop with duodenal
stump oversewn

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17
Q

Metabolic complications of by-pass

A

Dumping syndrome

  • Abdo distension, flushing, n/v, fainting, sweating
  • Early: osmotic hypovolaemia
  • Late: reactive hypoglycaemia

Blind loop syndrome → malabsorption, diarrhoea
-Overgrowth of bacteria in duodenal stump

Vitamin deficiency

  • ↓ parietal cells → B12 deficiency
  • Bypassing proximal SB → Fe + folate deficiency
  • Osteoporosis

Wt. loss: malabsorption of ↓ calories intake

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18
Q

Indications for surgical intervention in upper GI bleeding

A

Re-bleeding

Bleeding despite transfusing 6u

Uncontrollable bleeding at endoscopy

Initial Rockall score ≥3, or final >6.

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19
Q

Ramstedt pyloromyotomy

A

Divide down to mucosa

Mx for pyloric stenosis

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20
Q

Blood group A

A

Risk factor for GASTRIC CANCER

  • Atrophic gastritis (→ intestinal metaplasia)
  • Pernicious anaemia / AI gastritis
  • H. pylori
  • Diet: ↑ nitrates – smoked, pickled, salted (↑ Japan)
  • Nitrates → carcinogenic nitrosamines in GIT
  • Smoking
  • Blood group A
  • Low SEC
  • Familial: E. cadherin abnormality
  • Partial gastrectomy
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21
Q

Sister Mary Joseph nodule

A

Transcoelmic spread to umbilicus from gastric carcinoma

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22
Q

OGD: well-demarcated spherical mass c¯ central

punctum

A

= GIST

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23
Q

Management of GIST

A

Medical: Imatinib (tyrosine kinase inhibitor)

Surgical: resection

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24
Q

Rigler’s triad

A

= gallstone ileus

Pneumobiliia
Small bowel obstruction
Gallstone in RLQ

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25
Tc pertechnecate scan +ve in 70%
Meckel's diverticulum Detects gastric mucosa
26
Carcinoid syndrome
=by-pass of first pass metabolims = Live rmetastasis Usually appendix primary Increased serotonin: - Flushing: paroxysmal, upper body ± wheals - Intestinal: diarrhoea - Valve fibrosis: tricuspid regurg and pulmonary stenosis - whEEze: bronchoconstriction - Hepatic involvement: bypassed 1st pass metabolism - Tryptophan deficiency → pellagra (3Ds)
27
Tx carcinoic crisis
High dose octreotide
28
Cope sign
Flexion + internal rotation of R hip → pain | = Appendix lying close to obturator internus
29
Psoas sign
Extension of hip --> pain = Retrocaecal appendicitis
30
Appendix mass
=complication of appeniditis Omentum and small bowel stuck to appendix Mx: - NBM and ABx - Interval appendectomy - 6 week colonoscopy to r/o malignancy If doesn't resolve --> appendix abscess - -> percutaneous driange - -> ultimate management in failed cases --> R hemicolectomy
31
Components of Truelove and Witts
Grading UC ``` Motions PR bleed Temp HR Hb ESR (<30, >30) ```
32
Day 3 Acute UC
On day 3: stool freq >8 or CRP >45 Predicts 85% chance of needing a colectomy during the admission Emergency medical Mx: -ciclosporin, infliximab or visilizumab (anti-T cell)
33
UC 1st lien management
Induction: sulfasalazine or mesalazine AND prednisolone Mainteance: sulfasalazine or mesalazine 2nd line: azathioprine or mercaptopurine
34
Emergency surgery for UC
Total / Sub-total colectomy + End-ileosotmy +/- mucous fistula 3 months later: a) Completion proctectomy + Ileal-pouch anal anastomosis (IPAA) or end ileostomy b) Ileorectal anastomosis (IRA)
35
Maintaining remission Crohns
1st line: azathioprine or mercaptopurine 2nd: methotrexate (Note difference, no 5-ASAs)
36
Induction Crohn's
1st line - - Ileocaecal: budesonide - - Colitis: sulfasalazine 2nd line: prednisolone (tapering) 3rd line: methotrexate 4th line: infliximab or adalimumab
37
Hinchey Grading
Diverticulitis perforation I- IV III and IV --> surgeyr -indicated by peritonitis (III: purlent, IV: faecal)
38
Gardeners
TODE Thyroid tumours Osteomas of the mandible, skull and long bones Dental abnormalities: supernumerary teeth Epidermal cysts
39
5q21`
= APC gene --> FAP Autosomal dominant
40
Lynch 1
HNPCC AD Lynch 1 = right sided CRC
41
Lynch 2
HNPCC AD Lynch 2 = colorectal cancer +endometrial +prostate +breast
42
Diagnosis of HNPCC
3, 2, 1 rule ≥3 family members over 2 generations c¯ one <50yrs
43
STK11 gene
Peutz-Jeghers syndrome AD Mucosal hyperpigmentation CRC, pancreatic, breast, lung, ovaries, uterus
44
Peutz-Jeghers
AD - STK11 gene Mucocutaneous hyper-pigmentation Multiple GI hamartomatou spolyps --> intussusception --> haemorrhage Cancer: - CRC - Pancreatic - Breast - Ovarian - Uterine - Lung
45
Cowden syndrome
AD Macrocephaly + skin stigmata Intetsinal hamartomas Increased risk of extra-intestinal cancers
46
Goodalll's Rule
Posterior fistula drian --> 6 Anterior fisture drain radially
47
Anal lymph drainage
Above dentate line → internal iliac nodes Below dentate line → inguinal nodes
48
HPV oncogenic strains
16, 18, | 31, 33
49
McEvedy Approach
High approach Inguinal EMERGENCY in obstruction --> allows inspection for ischaemic bowel
50
Lockwood Approach
= LOW Elective Low incision over hernia c¯ herniotomy and herniorrhaphy (suture ing. ligt. to pectineal ligt.)
51
Classification of malignant melanoma
Superficial Spreading: 80% - Irregular boarders, colour variation - Commonest in Caucasians - Grow slowly, metastasise late = better prognosis Lentigo Maligna Melanoma - Often elderly pts. - Face or scalp Acral Lentiginous - Asians/blacks - Palms, soles, subungual (c¯ Hutchinson’s sign) Nodular Melanoma - All sites - Younger age, new lesion - Invade deeply and metastasis early = poor prog Amelanotic -Atypical appearance → delayed Dx
52
Malignant parotid tumours
Malignant (CN7 palsy + fast growing) 1st: Mucoepidermoid 2nd: Adenoid cystic
53
Transverse rectus abdominis myocutaneous flap
Gold-standard Pedicled (inf. epigastric A.) Or free: attached to internal thoracic A CI if poor circulation: smokers, obese, PVD, DM Risk of abdominal hernia
54
Latissimus dorsi myocutaneou sflap
Pedicled flap: skin, fat, muscle and blood supply Supplied by thoracodorsal A. via subscapular A. Usually used c¯ an implant
55
Definiton of chronic limb ischaemia
Ankle artery pressure <50mmHg Toe <30mmHg (diabetics) And either: - Persistent rest pain requiring analgesia for ≥2wks - Ulceration or gangrene
56
Critical limb ischaemia
Rest pain - Especially @ night - Usually felt in the foot - Pt. hangs foot out of bed - Due to ↓ CO and loss of gravity help Ulceration Gangrene
57
Buttock claudication and wasting Erectile dysfunction Absent femoral pulses
Leriche's syndrome
58
Buerger's angle
≥90: normal 20-30: ischaemia <20: severe ischaemia
59
Fontaine classification
A: asymptomatic B: intermittenet claudication A = >200m B = <200M C: rest pain D: ulceration or gangrene
60
Doppler waveforms
Normal: triphasic Mild stenosis: biphasic Severe stenosis: monophasic
61
ABPI values
Asymptomatic / Fontaine 1 = 0.8-0.9 Claudication / Fontaine 2 = 0.6-0.8 Rest pain / Fontaine 3 = 0.3-0.6 Ulceration and gangrene / Fontaine 4 = <0.3 Exercise test important: ABPI measured before and after: 20% ↓ is sig
62
Indicationds for end-arterectomy
Symptomatic + >70% occlusion = major indication >50% occlusion if low operative risk <75 years age Asymptomatic ≥60% benefit if low risk
63
Aneurysm monitoring
UK Small Aneurysm Trial suggested that AAA <5.5cm in maximum diameter can be monitored by US (/CT) <4cm: yearly monitoring 4-5.5cm: 6 monthly monitoring
64
Indications for aortic aneurysm intervention
Symptomatic (back pain = imminent rupture) Diameter >5.5cm Rapidly expanding: >1cm/yr Causing complications: e.g. emboli

MRCS (24 decks)

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