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Flashcards in MTB - Surgery Deck (144):
1

How do you secure the airway in trauma pt with cervical spine injury

1. Orotracheal intubation with manual cervical immobilization
2. Best answer - flexible sigmoidoscopy

2

Best way to secure airway in pt with extensive facial trauma and bleeding into airway

Cricothyroidotomy

3

In a patient with hemorrhagic shock - what next steps should you take in management?

Prep for surgery
- 2 large bore IVs
- fluids, blood, type and screen
- insert Foley catheter
- administer IV abs

4

Initial bolus of fluids for children

20 ml/kg of Ringers lactate

5

Signs to make you think of vasomotor shock

Hypotension
Tachycardia
Warm and flushed skin
History of medication, spinal anesthesia or allergen exposure

6

First step in management of vasomotor shock

Vasoconstrictors and fluids

7

Asymptomatic head injury with closed skull fracture - management

No surgery is needed
Next step - clean any lacerations

8

Tx. Depressed or comminuted skull fractures

Surgery - repair or craniotomy

9

First step - head trauma and LOC

CT of the head and neck without contrast

10

What should be given to all patients with open skull fractures

Tetanus toxoid
Prophylactic antibiotics

11

Management of a CSF leak due to skull fracture

CT scan of head and neck
No treatment of CSF leak - it will stop on its own
Prophylactic antibiotics are not necessary

12

Management of all patients with epidural hematoma

Emergency craniotomy

13

Management of subdural hematoma

Emergency craniotomy only if there are lateralizing signs or midline displacement

14

Management of diffuse axonal injury

No surgery
Therapy aimed at preventing more damage from raised ICP

15

How does hyperventilation help with lowering ICP

Causes vasoconstriction and thus, decreased blood volume in the brain and therefore, lowers ICP

16

First line measures in elevated ICP

1. Head elevation
2. Hyperventilation
3. Avoid fluid overload

17

Second line measures for lowering ICP

1. mannitol - use very cautiously
2. Sedation and /or hypothermia (lower oxygen demand)

18

What causes of acute abdomen are treated with surgery? (4)

1. Peritonitis
2. Abdo pain plus signs of sepsis
3. Acute intestinal ischemia
4. Pneumoperitoneum

19

Primary peritonitis

Spontaneous inflammation in children with nephrosis
Adult with ascites and mild abdominal pain

20

Three things that can mimic acute abdomen

Lower lobe pneumonia
Myocardial ischemia
Pulmonary embolism

21

CF: GI perforation

Acute abdo pain that is sudden, severe, constant and generalized. It is excruciating with any form of movement

22

MCC of GI perforation

Diverticulitis
Perforated peptic ulcer
Crohn's disease

23

Best dx test - GI perforation

Supine and erect CXR
- will show free air under the diaphragm or falciform ligament

24

Management - GI perforation

NPO and IVF
IV antibiotics
Emergency surgery

25

Preferred method of securing airway in trauma patient

Orotracheal intubation

26

Study of choice for suspected esophageal perforation

Gastrograffin contrast esophagogram

27

Baby is born and it is excessively salivating and has had multiple choking spells with feeding - dx?

esophageal atresia

28

first step - esophageal atresia?

NG tube - coils in upper chest on XR

29

Tx. esophageal atresia

primary surgical repair
- if delayed, do gastrostomy to prevent acid reflux into lungs

30

Tx. Anal Atresia

if a fistula is present - repair can be delayed until further growth; if no fistula - colostomy

31

VACTERL

Vertebral Anomalies
Anal atresia
Cardiovascular anomalies
TE fistula
Renal and/or radial anomalies
Limb defects

32

Management - Congenital Diaphragmatic Hernia

1. Endotracheal intubation
2. Low pressure ventilation
3. Sedation
4. NG Suction
5. Repair in 3-5 days

33

Management - Gastroschisis or Omphalocele

if large --> Silastic Silo and manual replacement of bowel daily
1. supplement with TPN

34

Tx. Exstrophy of the Bladder

Transfer to specialized center with repair in 1-2 days!

35

Conditions presenting with "double bubble" sign

Annular pancreas
Duodenal atresia
Intestinal Malrotation

36

XR - multiple air-fluid levels throughout the abdomen (dx?)

Intestinal Atresia

37

CF: Necrotizing Enterocolitis

Feeding intolerance in preemie
Abdominal distention
Dropping platelet count

38

Tx. Necrotizing Enterocolitis

1. Stop feeds
2. Broad spec. abx
3. IVF and TPN

39

When do you do surgery for NEc?

Signs of necrosis or perforation
- abdominal wall erythema
- portal vein gas
- gas in bowel wall

40

Dx. Meconium Ileus

XR --> multiple dilated loops of bowel and ground glass appearance in lower abdomen

41

Management of Meconium Ileus

Gastrograffin enema
- both diagnostic and therapeutic

42

Management of Hypertrophic Pyloric Stenosis

1. correct dehydration and electrolyte abnormalities
2. Ramstedt pyloromyotomy

43

CF: biliary atresia

progressive rise in bilirubin (CB) in a 6-8 week old baby

44

Dx. biliary atresia

Give baby 1 week of phenobarbital then do a HIDA scan; if no bile reaches duodenum --> will need surgical exploration

45

A patient presents with chronic constipation; A rectal exam causes explosive expulsion of stool and flatus w/ relief of distention - dx?

Hirschsprung dz
Dx. with full thickness biopsy of rectal mucosa

46

Management - Intussusception

Barium or Air enema

47

Dx. of Meckel Diverticulum

Radioisotope scan

48

Tx. Meckel Diverticulum

Surgical Resection

49

diagnostic testing for intestinal obstruction

CBC and lactate level (elevated)
supine/erect AXR

50

initial management of intestinal obstruction

NPO
IVF
NG suction

51

Tx. volvulus

proctosigmoidoscopy with rigid tube - leave rectal tube in place

52

What two hernia types do NOT require surgical repair?

umbilical hernias in children < 2 yo
esophageal sliding hiatal hernia

53

Diagnostic test for acute diverticulitis

CT w/ contrast
- fat stranding of inflamed bowel

54

Management of acute diverticulitis

No peritoneal signs? outpt abx
Peritoneal signs and abscess -> admission, IVF, NPO, IV abx

55

warning signs for acute hemorrhagic pancreatitis

dropping Hct
very high WBC, glucose and BUN
very low Ca

56

tx. pancreatic pseudocyst

if painless - do not drain
if painful and > 6 cm and > 6 weeks - percutaneous or endoscopic drainage

57

Dx of appendicitis

clinical picture and physical exam
- only do CT scan if those are not clear

58

What IV abx can be given in acute appendicitis

Cipro + Metro
Ampicillin/sulbactam
Levofloxacin + Clindamycin
Cefoxitin or Cefotetan

59

Abdominal pain that is out of proportion to exam - next step?

Surgery consult
Order angiography

60

Tx. of mesenteric ischemia if diagnosis is made in (1) surgery and (2) angiography

1. Embolectomy and revascularization
2. Vasodilators and thrombolysis

61

Diagnostic testing for suspected intra abdominal abscess

CBC
Contrast CT of abdomen and pelvis

62

Tx. Intra abdominal abscess

drainage
Antibiotics

63

Diagnostic testing for obstructive jaundice

USG
Confirm with EUS or MRCO

64

Treatment of obstructive jaundice due to stones

ERCP with sphincterectomy
Cholecystectomy should follow

65

Dx. Obstructive jaundice due to tumor

USG
Ct scan

66

Treatment of acute Cholecystitis

NG suction, NPO, IVF, antibiotics

67

When do you do an emergency cholecystectomy for acute Cholecystitis

1. Generalized peritonitis
2. Emphysematous Cholecystitis (perforation or gangrene)

68

Reynolds Pentad

Jaundice
Fever
Abdominal pain
Altered mental status
Shock

69

Clinical findings in acute ascending cholangitis

High fever
Very high WBC count
High ALP
High total bilirubin and direct bilirubin
Mild elevation of LFTS

70

Management of acute ascending cholangitis

1. Blood cultures
2. Antibiotics
3. Emergency decompression with ERCP

71

Antibiotics used in acute ascending cholangitis

Amp + gent
Monotherapy with either imipinem or levofloxacin

72

Hepatic risk factors with increased morbidity and mortality for surgery

1. Bilirubin > 2
2. Albumin below 3
3. Prothrombin time > 16
4. Encephalopathy (altered mental status)

73

Can you operate on someone with EF < 35%?

No

74

When can you do surgery on a patient with recent myocardial infarction?

Defer surgery for 6 months

75

Preop assessment: patient with severe progressive angina

Perform cardiac cath to eval for possible revascularization

76

Pre op assessment of pt who smokes

Order PFTs to evaluate fev1: if high pco2 or fev1 < 1.5 (at increased risk of pneumonia) other smoker pts should stop smoking 8 weeks prior to surgery

77

Post op fever day 1

Atelectasis
- incentive spirometry

78

Post op fever day 3

Pneumonia
- CXR infiltrate
- sputum culture and antibiotics

79

Post op fever day 3

UTI
- urinalysis and urinary culture
- antibiotics

80

Post op fever day 5

DVT
- get Doppler of LE and pelvis
- give anti coagulation

81

Post op disorientation

Always consider hypoxia first and get an ABG

82

when is open reduction and internal fixation appropriate for fracture?

severely displaced or angulated fractures that cannot be aligned

83

tx. open fractures

cleaning in the OR and reduction w/in 6 hours

84

what test should you always order in anyone with facial fracture?

spinal XR

85

Tx. gas gangrene

IV penicillin and hyperbaric oxygen

86

what do you suspect in pt with shoulder pain and inability to move arm who recently had a seizure (or got an electrical burn)?

posterior shoulder dislocation
- arm held close to body, forearm internally rotated

87

Dx. posterior shoulder dislocation

axillary or scapular views of the spine

88

patient comes in with arm held close to the body, externally rotated forearm and numbness over the deltoid muscle

anterior shoulder dislocation

89

Tx. clavicular fracture

figure 8 sling

90

Monteggia vs. Galeazzi fracture

direct blow to either ulna (monteggia) or radius (galeazzi) --> diaphyseal fracture and displaced dislocation of nearby joint

91

Tx. monteggia/galeazzi fracture

ORIF - diaphyseal fracture
closed reduction - dislocation

92

tx. femoral neck fractures

femoral head replacement - high risk of avascular necrosis

93

tx. intertrochanteric femoral fractures

Open reduction and pinning

94

Tx. femoral shaft fractures

intramedullary rod fixation

95

best initial therapy: trigger finger

steroid injection

96

best initial therapy: deQuervain's tenosynovitis

steroid injection

97

Dupuytren's contracture - tx

surgery

98

how do you differentiate between a hip fracture and posterior dislocation of the hip?

posterior dislocation - internally rotated leg
hip fracture - externally rotated leg

99

tx. rupture of achilles tendon

casting in equinis position or surgical repair

100

first step in management of compartment syndrome

emergency fasciotomy

101

neurovascular complication of oblique distal humerus fracture

radial nerve damage --> unable to extend the wrist; function is usually regained after reduction, if not - surgery

102

neurovascular complication of posterior dislocation of the knee

popliteal artery injury --> decreased distal pulses; order doppler studies or arteriogram; prophylactic fasciotomy if reduction is delayed

103

characteristic feature of lumbar spinal stenosis

increased pain with extension of the spine that improves with sitting or bending forward`

104

dx. lumbar spinal stenosis

MRI of the spine

105

Tx. lumbar disc herniation (acute)

ibuprofen and bed rest
do not need to get an MRI at first

106

when do you need immediate surgical decompression in lumbar disc herniation?

cauda equina --> bowel bladder incontinence, flaccid anal sphincter and saddle anesthesia

107

Tx. ankylosing spondylitis

anti-inflammatory agents
physical therapy

108

which ca. cause blastic bone mets?

prostate ca and breast ca

109

first test to order in suspected metastatic bone malignancy

XR

110

heel pain that is worse in the morning, resolves with walking and is accompanied by tenderness to palpation of the heel

plantar fasciitis
- bony spur on heel

111

tx. plantar fasciitis

symptomatic - resolves w/in 12-18 months on its own

112

inflammation of common digital nerve at 3rd interspace between 3rd and 4th toes; very tender to palpation in that area

Morton's neuroma

113

Tx. mortons neuroma

analgesics, appropriate footwear

114

male pt presents with severe, sudden onset testicular pain. on exam, cremasteric reflex is absent and testis is high riding. - dx? next step?

R/O testicular torsion
- order testicular USG

115

Tx. testicular torsion

immediate surgery with bilateral orchiopexy
- do not delay surgery for diagnostic tests

116

male pt comes in with acute scrotal pain, urinary symptoms and fever - dx? next step?

dx - acute epididymitis
next step - urinalysis and culture

117

Tx. epididymitis

1. males < 35 yo: ceftriaxone and doxycycline
2. older males: tx. as UTI - levofloxacin

118

management of urologic obstruction + infection

1. decompression of urinary tract above obstruction (ureteral stent or percutaneous nephrostomy)
2. IV Abx

119

MCC for newborn boy not to urinate in first DOL

posterior urethral valves

120

management: posterior urethral valves

1. catheterize bladder
2. voiding cystourethrogram

121

child with hematuria from trivial trauma

congenital anomaly until proven otherwise

122

child with UTI

undiagnosed congenital anomaly ex. vesicoureteral reflux

123

dx. vesicoureteral reflux

voiding cystogram
- give long term abx

124

young girl who voids appropriately but her underwear are constantly wet with urine

low implantation of ureter (into vagina)

125

ureteropelvic junction obstruction

only sx if diuresis occurs - ex. teenager who drinks large volumes of beer and develops colicky flank pain

126

48 year old man comes in c/o coldness and tingling in L hand as well as pain when he does strenuous work. These episodes are accompanied by dizziness and blurred vision. Dx?

Subclavian steal syndrome

127

Dx. subclavian steal syndrome

angiography

128

Tx. subclavian steal syndrome

bypass surgery

129

Tx. symptomatic AAA (abdominal pain, hypotension)

urgent surgery w/in the next day

130

Tx. asymptomatic AAA

ASA + Statins
4-5.4 cm: USG q6-12 mo
< 4cm: USG q2-3 years

131

most impt modifiable RF for AAA

smoking

132

Elective repair for AAA

1. if > 5.5 cm
2. rapidly enlarging (>0.5 cm in 6 mo)
3. AAA assoc. with PAD or aneurysm

133

MC location of AAA

infrarenal aorta

134

most important intervention to prevent progression of thoracic aortic aneurysm

BP control

135

MC complication post AAA repair

spinal cord infarction - ASA occlusion
- get immediate neuro consult

136

management of intermittent claudication (if not interfering significantly with lifestyle)

cessation of smoking
cilastazol and ASA

137

dx. intermittent claudication

doppler studies - ABI <0.9

138

When do you consider surgery stenting or angioplasty for intermittent claudication?

disabling symptoms or impending ischemia to extremity

139

preferred intubation method in pt with multiple facial fractures

oral laryngoscopy
- blind nasal intubation is C/I

140

CF: patellar tendon rupture

excrucitating pain
joint swelling of anterior knee
difficulty bearing weight
unable to perform active extension of leg
unable to maintain passively extended knee against gravity

141

CF: ACL tear

lots of pain
inability to ambulate
popping sensation/sound at time time of injury
positive anterior drawer test

142

mechanism of meniscal injury

twisting force with the foot fixed on the ground

143

what test do you use to test meniscal injury

McMurray's maneuver
- audible or palpable click or popping sensation during extension of involved knee

144

Tx. ruptured patellar tendon

early surgical repair