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SUMGERI > GERI-ER.Surgery (QL-SS) > Flashcards

GERI-ER.Surgery (QL-SS) Flashcards

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1
Q

Should you refer a patient directly to the hospital?

A

YES! Pts INC mortality thru ED

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2
Q

how do patients survive in ED Visit?

A
  • 5% of d/c elderly patients will die.
  • 20% will require admission
  • 20% require another ED evaluation
  • 10-48% suffer decline in functional abilities.
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3
Q

What are the ABCDs of an ED visit?

A
  • A= airway compromise
  • B= breathing
  • C= circulation, shock<90mmHg
  • D= neurologic Disability
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4
Q

What is your DDX of SOB?

A
  • MI: MC elderly
  • Pneumonia
  • CHF
  • PE
  • Cardiac dysrhythmia
  • COPD
  • Asthma
  • Anaphylaxis
  • Bronchitis
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5
Q

What is plan, if you cannot exclude or you cannot stabilize an acute exacerbation of disease, a life threatening cause of dyspnea?

A

Send to the ED!!

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6
Q

What are the MCC of COPD exacerbations?

A
  • Viral or bacterial infection
  • CHF
  • Cold weather
  • Narcotic use
  • Anemia
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7
Q

What are the most life-threatening components of a COPD exacerbation?

A

Hypoxemia and hypercarbia/capnea. INC CO2

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8
Q

What is the treatment of a COPD exacerbation?

A
  1. Oxygen
  2. Bronchodilators: albuterol and ipratropium
  3. Corticosteroids:
  4. Antibiotics for sputum or fever).
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9
Q

What is your next step If a pt continues to deteriorate despite NPPV and other interventions,

A

Endotracheal intubation

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10
Q

What types of syncope have no increased risk?

A
  • Vasovagal syncope

- Orthostatic hypotension syncope

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11
Q

How should you treat a patient with orthostatic hypotension syncope in the ED?

A

Hydration and re-evaluation.

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12
Q

What types of syncope are associated with a high risk and hospitalization?

A

structural heart disease,
heart failure,
abnormal ECG,
anemia.

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13
Q

What brain abnormality is common in the elderly?

A

Cerebral atrophy.

INC risk of brain injury and hemorrhage.

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14
Q

why are intracranial hemorrhage hard to DX in elderly?

A

elderly have little or no neurologic deficits!

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15
Q

what is happening If a pt present to the ED s/p minor head trauma with associated vomiting?

A

INC intracranial pressure from hemorrhage.

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16
Q

What medication is SO important to note if a patient presents with a head trauma?

A

ANTICOAGULANTS! **Dramatically increases morbidity, mortality, and difficulty of treatment.

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17
Q

What BP is concerning In an elderly trauma patient w/ severe organ damage than the rest of the population?

A

Systolic < 110!

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18
Q

Patients with what characteristics after a trauma should prompt an ER visit?

A
  • > 55 y/o - SBP <110 in pt over 65. - Low impact mechanism in an elderly patient. - Pt on anticoagulation with a head injury.
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19
Q

what type are majority of strokes are ?

A

Ischemic NON CON CT
TX- RtPA administration W/IN 1 hour of symptom onset goal!

EARLYL TO Prevent or decrease damage to critical brain structures preserving function.

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20
Q

What are the traditional symptoms of stroke?

A
  • Unilateral paralysis of face, arm, legs.
  • Sudden confusion
  • Aphasia
  • Memory deficits
  • Severe headache
  • Dizziness
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21
Q

What are atypical symptoms of stroke?

A
  • LOC
  • Pain -
    Palpitations
  • Altered mental status
  • SOB
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22
Q

What is the most common mimic of a stroke? What test should you perform to rule this out?

A 
Hypoglycemia! Get a finger stick! MC-
- Seizures 
- Confusional states 
- Syncope -
 Toxins 
- Neoplasms 
- Subdural hematoma
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23
Q

What are your first steps after stroke diagnosis?

A
  1. Point of care glucose
  2. transfer to stroke center
  3. Oxygen
  4. Obtain IV access fluids
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24
Q

What are the 4 main categories of a surgical acute abdomen?

Study These Flashcards
A
  1. Peritonitis (i.e. appendicitis, cholecystitis, diverticulitis)
  2. Perforated viscus (diverticulitis, duodenal or gastric ulcer, LBO with perforation)
  3. Bowel obstruction (large bowel- incarcerated hernia, malignancy, volvulus, small bowel- adhesions, incarcerated hernia).
  4. Vascular (aortic dissection, GI hemorrhage, mesenteric infarction, ruptured or symptomatic AAA)
25
what causes must you consider first If a patient comes in complaining of abdominal pain, ?
4 causes of a surgical acute abdomen! Perforation, obstruction, peritonitis, vascular.
26
What are the symptoms of a AAA?
asymptomatic, and discovered during routine abdominal exam. symptoms range from vague epigastric discomfort back and abdominal pain. HEMATURIA.
27
What are common symptoms of a ruptured AAA?
Hypotension, ill appearance.
28
what are they at a higher risk foR If a patient has a symptomatic AAA, r?
Rupture of the AAA. | ASAP-Bedside US. ** stable, obtain a CT.
29
How should you manage a AAA in th eED?
LOWER BP SAFELY | Hemodynamic support that provides adequate perfusion -90/60mmHg in stable patients
30
What medications must you look out for in patients with an acute abdomen?
- NSAIDs - Warfarin or Dabigatran - bleeding - Steroids immunosuppression - Beta-blockers -blunt tachycardia.
31
What parts of the abdominal exam must you perform if you are concerned for a patient to have an acute abdomen?
- Inspect abdomen for scars - Auscultate for absence (i.e. ileus) or presence of bowel sounds (high pitched -> obstruction). - Percuss for presence of tympany (bowel obstruction), pain (peritonitis), or dullness from fluid (ascites) - Palpate for mass - Evaluate for hernia
32
If a patient has vomiting before abdominal pain, what causes should you think of? For pain before vomiting?
Medical/ Clininal | ! Surgical causes.
33
What 2 factors are associated with mortality in abdominal complaints?
Old age and hypotension.
34
What is the best test to perform on an elderly patient with abdominal pain?
CT!
35
When should you treat an influenza patient with Tamiflu?
``` When patient is <2 y/o, >65 y/o, morbidly obese, pregnant, nursing facility. ```
36
When can an influenza patient return to work?
afebrile for 48 hours without an antipyretic.
37
Patients living in a long-term care facility have a higher risk of what types of pneumonia?
Pneumonia necessitating broader antibiotic coverage: - Gram negative bacilli (Klebsiella) - Anaerobic organisms - Staphylococcus species
38
What is the CURB-65 and how does it relate to your pneumonia patient?
- C: confusion - U: blood Urea nitrogen >19 mg/dL or >7 mmol/L - R: high respiratory rate - B: low BP - >65 y/o Used to determine suitability for outpatient management for pneumonia.
39
When should you consider steroid use in CAP patients?
In SEVERE pneumonia only in seriously ill patients!
40
What are the biggest comorbidities to think about prior to surgery?
- CAD - Prior MI - CHF - Arrhythmias - Pacemaker - Orthostatic intolerance
41
What medications increase a patient's risk during surgery?
- Antibiotics - Theophylline - Sedative hypnotics - Analgesics - Digoxin - Anticholinergics - Antiarrhythmics - Anti-seizure Rx - Antihypertensives - Anticoagulants - Antihistamines
42
What medications should be stopped prior to surgery?
- ASA —> 7 days - NSAIDS —> 7 days - Benzos —> slow taper - Diuretics —> 48 hours - Hypoglycemics —> night before
43
What should you recommend in a COPD patient prior to surgery?
- Stop smoking - Deep breathing techniques - Incentive spirometry
44
What should you recommend in a CHF patient prior to surgery?
- Stabilize the pts medications - stay hydrated. - electrolyte imbalance
45
What should you do in a patient needing surgery who has mild-moderate HTN?
should not delay surgery.
46
If a patient with severe HTN needs emergent surgery, how should you control their BP?
IV HTN medications.
47
What procedures are higher risk for developing a DVT?
Orthopedic
48
How should you control a risk for DVT post surgery?
- Elastic stockings - Low dose unfractionated heparin - Low-molecular weight Heparin - Intermittent pneumatic compression - Warfarin - Eliquis/xarelto
49
If a low risk patient on Warfarin is going in to surgery?
Discontinue 5 days prior to surgery, INR to fall below 1.5 and resume 12-24 hours post-op.
50
If a MEDIUM risk patient on Warfarin is going in to surgery?
Discontinue warfarin 4 days prior to surgery INR to fall below 1.5. Use IV heparin if warfarin cannot be resumed within 48 hours.
51
If a HIGH risk patient on Warfarin is going in to surgery?
Discontinue warfarin 4 days prior to surgery when INR drops to less than 2.0 —> begin Heparin. Resume Heparin 12-24 hours post-op.
52
What is the goal blood glucose level for a diabetic patient going into surgery?
Glucose 100-200 through the perioperative period. | AVOID surgery RPG- >300
53
Should you use a diabetic patient's normal insulin dosage post-op?
NO! Use 1/2 dose, | restart oral hypoglycemics when full diet is resumed.
54
What surgeries have an associated high delirium risk?
- Cardiac - Hip - Thoracic - AAA repair - Opthamological - Emergent surgery
55
What intraoperative factors increase a patient's risk for delirium?
- Pre-existing dementia - Parkinson's - Low cardiac output - Hypotension - Anticholinergic medications
56
What post-op changes can increase a patient's risk for delirium?
- Hypoxia - Visual/auditory impairments - Polypharmacy - EtOH
57
What is the mortality rate in patients who develop delirium s/p surgery?
26% mortality at 6 months
58
What medical issues can occur post-operatively and we therefore must monitor patients for?
- Silent Ischemia - HTN - Arrhythmias - Hypoxemia - Venous thromboembolism - Urinary tract infections
59
What surgery has 6x greater mortaillty for >65yo?
Emergent diverticulitis

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