GEN SURG part 3

Question 1

What are the 2 main causes of hypovolaemic shock?

Answer 1

Haemorrhage

Dehydration

Question 2

E.g.s of distributive shock (3)

Answer 2

Sepsis
Anaphylaxis
Neurogenic shock

Question 3

Causes of cardiogenic shock (4)

Answer 3

MI
Arryhthmias
Valve dysfunction
Metabolic disturbance

Question 4

Causes of obstructive shock (3)

Answer 4

Massive PE
Cardiac tamponade
Tension pneumothorax

Question 5

CO =

Answer 5

SV x HR

Question 6

BP =

Answer 6

CO x SVR

Question 7

MAP =

Answer 7

Diastolic BP + (systolic-diastolic) /3

Question 8

What are the 3 essential features of any kind of shock?

Answer 8

Fall in BP by at least 40mmHg
TachyC
Tachypnoea

Question 9

Other features of hypovolaemic/cardiogenic shock

Answer 9

Cold pale clammy pt
Rapid thready pulse
Pulse P = narrow b/c vasoconstriction

Question 10

Other features of septic shock

Answer 10

Patient = flushed
Hot + sweaty w/ rapid ‘bounding’ pulse
Pulse P = wide b/c vasodilation

Question 11

Effect of shock - cerebral

Answer 11

Autoregulation over MAP 50-100

Below this pt becomes agitated, confused, drowsy, then unresponsive

Question 12

Effect of shock - respiratory

Answer 12

Incr RR due to metabolic acidosis

Question 13

Effect of shock - renal

Answer 13

Autoreg 70-170 MAP

Below this - oliguria –> toxic build up

Question 14

Effect of shock - GI

Answer 14

Decr gut motility + nutrient absorption

Decreased ability to sustain norm flora –> infections

Question 15

MEWS score >3 =

Answer 15

Urgent med review

Question 16

MEWS score >5 =

Answer 16

Critical care teams involved

Question 17

What is SIRS?

Answer 17

Systemic inflammation response syndrome

Question 18

SIRS criteria

Answer 18

2+ new from: 
T >38.3 or <36 
RR >20
HR >90
WCC <4 or >12

Question 19

What is septic shock a result of?

Answer 19

Over activation of the immune system b/c infective causes

Question 20

Acute Mx of sepsis

Answer 20

Sepsis 6 within 1 hr 
O2
IV fl (500ml crystalloid stat) 
IV Abx 
Serum lactate - urgent Sr review if >4
Cultures 
Catheterise

Question 21

When to Tx - ‘suspected sepsis)

Answer 21

New alteration in mental state 
RR >25
HR >130
SBP <90 or >40 
Not passed urine for 18 prevhrs 
Mottled, ashen, cyanosed skin, or non-blanching rash

Question 22

Acute Mx of anaphylactic shock

Answer 22

A-E 
Remove cause 
Adrenaline 0.5mg IM + repeat ev 5 mins 
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
Raise feet off bed to help restore circulation 
Serum trypase to confirm ddiag

Question 23

mx class 1 hypovolaemic shock

Answer 23

Crystalloids

Question 24

mx class 2 hypovolaemic shock

Answer 24

Consider giving blood

Question 25

Mx class 3 hypovolaemic shock

Answer 25

give blood, consider surgical mx

Question 26

Mx class 4 hypovolaemic shock

Answer 26

Will need sugrical mx

Question 27

initial Mx cardiogenic shock

Answer 27

``` A-E IV diamorphine 2.5-5mg Assess for pulm oedema Consider Swan-Ganz catheter + art line If pulm cap wedge pressue = low - give 100mg plasma ev 15mins If ok - give inotropic support ```

Question 28

Mx neurogenic shock

Answer 28

Fluid resus + vasopressors

Question 29

What is the difference between neurogenic shock and spinal shock

Answer 29

Neurogenic = inhibition of sympathic outflow from spinal cord --> VD Spinal shock = concussion of spinal cord --> flaccid arreflexia which resolves as soft tissue swelling decreases

Question 30

Reflexes in spinal shock

Answer 30

None below level of injury | May be priaprism

Question 31

What is the triad of death?

Answer 31

Coagulopathy Hypothermia Metaolic acidosis

Question 32

What is a superficial incisional SSI

Answer 32

INfection of skin and sct tissue of incision

Question 33

What is a deep incisional SSI

Answer 33

Infection involving deep tissues such as mm/fascial layers

Question 34

What is an organ/space SSI

Answer 34

Infection involving any site involved in the operation other than the incision

Question 35

What is impetigo

Answer 35

Superficial purulent infection caused by staph/strep w/ a characteristic golden crust on an erythematous base

Question 36

What is ecythma

Answer 36

Purulent ski infection caused by staph/strep, ulceration under a crust

Question 37

What i s ecythma assoc w/

Answer 37

Poor hygiene + malnutrition

Question 38

What is erythrasma

Answer 38

Mild itchy eruption betw toes or in flexures, caused for corynebacterium Tx = TO miconazole or PO erythromycin

Question 39

What is folliculitis

Answer 39

Caused by staph, pustules heal in 7-10 days in superficial folliculitis w/ PO fluclox

Question 40

Staph Scalded skin syndrome

Answer 40

Fever Irritable + skin tenderness before erythema Skin blistering develops after 24-48 hr b/c toxins from S aureus

Question 41

Mx scalded skin syndrome

Answer 41

Take swab | + immediate IV fluclox + supportive measures

Question 42

What is anaerobic gangrene caused by

Answer 42

Clostridium perfringens found in soil/faeces

Question 43

Pathohpysiology of anaerobic gangrene

Answer 43

Arise from trivial injury | Intiially gas in tissues w/ oedema + spreading gangrene + systemic upset

Question 44

Tx anaerobic gangrene

Answer 44

REsus | Aggressive debridement + IV penicillin + metronidazole

Question 45

Pathophys synergistic gangrene

Answer 45

Aerobes + synergistic anaerobes infect initial wound/surgical site, --> severe wound pain + (g) in tissues May be extensive subdermal gangrene

Question 46

Tx synergistic gangrene

Answer 46

Debridement, ABx + systemic support

Question 47

Steps in reviewing someone with a fever post op

Answer 47

Review obs + UO Inspect wound for superficial infection/haematoma Inspect cannula sites for thrombophlebitis/infection Examine chest to excl infection, infarction, acute HF Examine legs for DVT Consider sources of infection - GI/urine

Question 48

Common locations intra-abodominal abscess

Answer 48

Alongsidee the organ Pelvic Subphrenic

Question 49

Features - intra-abominal abscess (5)

Answer 49

``` Malaise Anorexia Swinging pyrexia TachyC Possible mass ```

Question 50

Ix intra-abdominal abscess

Answer 50

CT abdo/pelvis

Question 51

Mx intra-abdo abscess

Answer 51

iv abx | radiological guided draining

Question 52

HOw to drain an abscess

Answer 52

Under GA + strong analgesia Point of max fluctuance = incised Small - dry dressing Deep -antiseptic ribbon gauze + packing to keep open until they have filled w/ granulation tissue