Notebook Flashcards
1
Q
Pre-Op Care:
EF < ______ is prohibitive with a 55-90% risk of MI perioperatively
A
35%
2
Q
Golfman’s index of cardiac risk includes what factors
A
1) JVD
2) Recent MI –> defer for 6 months
3) CHF –> ACEi + BB + dig + diuretics before surgery
4) PVCs or other arrhythmias
5) Age > 70
6) Emergency surgery
7) Aortic valvular stenosis
8) Poor medical condition
9) surgery within the chest or abdomen
3
Q
Hepatic risk is quantified with what factors?
A
A BEAP
Ascites Bilirubin Encephalopathy Albumin PT (INR)
4
Q
Nutritional risk assessed with what 4 factors?
A
decrease in body weight by 20% over months
Serum albumin < 3
Serum transferrin < 200
Anergy to skin antigens
Nutritional support pre-surgery! Can check nutritional status with pre-albumin
5
Q
When should you stop Warfarin?
A
3-4 days PTS (INR < 1.5 for high risk bleeding surgeries)
6
Q
When should you resume LMWH or heparin after surgery?
A
12 hours post surgery
7
Q
Main causes of post-op fever and timeframe (8)
A
1) Malignant hyperthermia (during surgery)
2) Bacteremia (right after surgery)
3) Atelectasis (POD 1)
4) Pneumonia (POD 3)
5) UTI (POD 3)
6) DVT (POD 5)
7) Wound infection (POD 7)
8) Deep abscess (POD 10-15)
8
Q
What is the goal urine output?
A
0.5 mL/kg/hr
9
Q
Paralytic ileus
A
POD 1-2
No bowel sounds, no passage of gas
mild distention, no or mild pain
SI and LI all dilated
10
Q
Ogilvie syndrome
A
paralytic ileus of the colon
- Elderly, sedentary, s/p surgery
- Abd distention (Tense, nontender)
- Massively dilated colon, small bowel NORMAL
11
Q
Treatment of Ogilvie syndrome (3)
A
Colonoscopy
Long rectal tube
Neostigmine
12
Q
Wound Dehiscence
A
salmon colored fluid (peritoneal fluid) - failure of the fascia –> hernia + fluid drainage
POD 5
TX: binders, decrease straining, reoperate
13
Q
Cholecystitis
DX and TX
A
RUQ US, HIDA scan
NPO, IVF, IV abx
cholecystectomy (urgent 72-96 hours
Cholecystostomy if a nonsurgical candidate)
14
Q
Choledocolythiasis
DX and TX
A
RUQ US, MRCP
TX: NPO, IVF, IV abx, urgent ERCP, elective cholecystectomy
15
Q
Cholangitis
DX and TX
A
RUQ US
TX: emergent ERCP to drain infected bile with sphincterotomy and stent placement + urgent/elective cholecystectomy, IVF, IV abx, NPO
16
Q
Which abx are used to treat galbladder pathology?
A
Cipro + Metronidazole
OR
Amp-Gent + Metronidazole
DO NOT use pip-tazo (works, but is too expensive and too broad)
17
Q
Necrotizing surgical site infection
A
- pain, edema, red beyond surgical site
- fever, decreased BP, increased HR
- paresthesia at wound edges
- “dishwater drainage” - purulent, cloudy, gray
- Subcutaneous gas, crepitus
TX = parenteral abx, urgent surgical debridement
18
Q
Torus Palatinus
A
chronic growth on hard palate, benign bony growth
- non-tender
- can ulcerate due to thin epithelium over growth
- surgery if symptomatic
19
Q
Anterior mediastinal mass can be…
A
4 T’s:
Thymoma, Teratoma, thyroid neoplasm, terrible lymphoma
20
Q
What other kinds of aneurysms are associated with AAA
A
popliteal and femoral aneurysms - no relation with brain aneurysms
21
Q
Mechanism/pathophysiology of AAA
A
increased MMP activity
atherosclerosis –> decreased diffusion of nutrients
-poorly developed vaso vasorum (particularly at infrarenal aorta)
-CT disease (Marfan, Ehler’s), trauma, cystic medial degeneration, infection
-Increased diameter –> decreased velocity blood flow –> thrombus formation along wall
22
Q
Phases of wound healing (3)
A
1) Inflammatory (0-2 days)
2) Proliferative
3) Remodeling (2-3 weeks)
23
Q
Inflammatory wound healing stage
A
hemostasis, then inflammation
Neutrophils –> macrophages with PDGF, TGF-B growth factors
TGF-B can cause collagen overexpression and result in KELOID formation
24
Q
Proliferative phase of wound healing
A
fibroblasts proliferate –> COLLAGEN III replaces fibronectin-fibrin matrix
- -> angiogenesis
- -> keratinocytes epithelialize wound
25
Remodeling phase of wound healing
fibroblasts produce COLLAGEN I (replaces III)
--> increases wound strength (tensile)
-Wound contraction by myofibroblasts, pull collagen fibers together
26
If you have less than ______ drainage a day from a wound drain, you can typically remove it
30 cc/day
27
Post-op complications of Lap Gastric Bypass (8)
1) Gallstones
2) Marginal ulcers
3) Anastomotic leak
4) stenosis of pouch/anastomosis
5) malnutrition
6) incisional hernia
7) splenic injury
8) iron or B12 deficiency
28
Peterson's Hernia
internal hernia of small bowel through opening in omentum formed by the roux limb
29
Retroperitoneal structures
SAD PUCKER
```
Suprarenal (adrenal) glands
Aorta, IVC
Duodenum (2nd-4th parts)
Pancreas (except tail)
Ureters
Colon (descending and ascending)
Kidneys
Esophagus (thoracic portion)
Rectum (partially)
```
30
iron is absorbed in the ______ as _____
duodenum, Fe2+
31
B12 is absorbed in the ______ with ______
terminal ileum, with intrinsic factor
32
Falciform ligament
connects liver --> anterior abdominal wall
contains ligamentum teres hepatis (fetal umbilical vein)
33
Hepatoduodenal ligament
connects liver --> duodenum
contains portal triad (common bile duct, proper hepatic artery, portal vein)
*connects greater and lesser sacs
34
Gastrohepatic ligamen
connects liver to lesser curvature of stomach
contains gastric arteries (left and right)
separates greater and lesser sacs on the right
35
Gastrocolic ligament
connects greater curvature of the stomach to the transverse colon
contains gastroepiploic arteries
36
Gastrosplenic ligament
connects greater curvature to spleen
contains short gastrics, L gastroepiploic artery
37
Splenorenal ligament
connects spleen to the posterior abdominal wall
contains splenic artery/vein, and tail of pancreas
38
Layers of the gut wall (4 - and what they do)
1) Mucosa = epithelium, lamina propria, muscularis mucosa
2) Submucosa = Meissner's nerve plexus, secretes fluid
3) Muscularis externa = Myenteric nerve plexus (Auerback), motility
4) Serosa (intraperitoneal) or Adventitia (retroperitoneal)
39
Types of diarrhea
1) Watery (osmotic, secretory, functional)
2) Fatty
3) Inflammatory
40
How to differentiate osmotic and secretory diarrhea
Stool osmotic gap = plasma osmolarity = 2x(stool Na + stool K)
Osmotic diarrhea = increase SOG (> 125 mOsm/kg)
Secretory = decreased SOG (< 50)
41
Common causes of secretory diarrhea
bacterial or viral infections, congenital disorders, ileocolitis, post surgical changes
s/p bowel resection or cholecystectomy when unabsorbed bile acids reach the colon and directly stimulate luminal ion channels
42
Pelvic fracture can lead to what injury in men?
posterior urethral injury
43
posterior uretheral injury presentation and DX
abrupt upward shift of bladder and prostate --> urethral tearing of MEMBRANOUS urethra at bulbomembranous junction (between anterior and posterior urehtra)
**blood in meatus, inability to void, perineal or scrotal hematoma, high riding prostate
DX: retrograde urethrogram (look for extravasation of contrast from urethra or no contrast in bladder)
44
Tracheobronchial perforation
secondary to blunt thoracic trauma
R main bronchus (most commonly injured)
SX = persistent pneumothorax despite chest tume, pneumomediastinum, subcutaneous emphysema
DX = CT, bronch, surgical exploration
TX = surgical repais
45
Duodenal hematoma
secondary to blunt abdominal trauma of duodenum against vertebral column
More common in children
-Blood collects between submucosal and muscular layers of duodenum --> partial/complete obstruction
TX = NG tube, parenteral nutrition, +/- surgery or percutaneous drainage
46
3 components of an inhalation injury
1. Upper airway edema
2. Acute respiratory failure
3. CO poisoning (nml PaO2, decreased SaO2)
Suspect with carbonaceous sputum, change in voice quality, facial burns, or singed nasal hairs
47
Curling's ulcer
ulcer of duodenum in severe burns
due to decreased intravascular volume and decreased perfusion of GI tract
*give PPO or H2 blocker as ppx
48
Most common organisms in burn wound infections?
1) Pseudomonas
2) Staph aureus
3) Strep pyogenes
4) Fungal later on in recovery (Candida)
49
How do you diagnose an inhalational injury?
fiberoptic bronchoscopy
50
appropriate fluid resuscitation in burns:
total fluid volume = 4cc/kg x weight (kg) x TBSA%
*use LR
51
Alkalai bruns
full thickness
skin appears pale
feels slippery
52
Acid burns
partial thickness
| develop erythema and erosion
53
Acute epidural hematoma
```
modest trauma
lucid interval
LENS shaped
coma, ipsilateral fixed/dilated pupil, contralateral hemiparesis
meningeal arteries
```
54
Acute subdural
big trauma
crescent shape
monitor ICP, elevate head, hyperventilate (PCO2 35), avoid fluid overload, mannitol/furosemide or emergency surgery
-venous injury
55
How do you define a massive hemothorax that requires surgery?
> 1.5 L with chest tube OR > 600 mL over 6 hours from chest tube
56
traumatic rupture of the aorta should be suspected when? what happens?
occurs at junction of arch and ascending aorta
suspect with: 1st rib, scapula, sternum fractures or widened mediastinum
57
Bladder injury:
| -Extraperitoneal leak
at base of bladder, tx with foley catheter
58
Bladder injury:
| -Intraperitoneal leak
surgical repair with suprapubic cystostomy
59
Reducible hernia
contents pushed back through defect
60
incarcerated hernia
contents stuck in hernia sac
61
strangulated hernia
incarcerated hernia with compromised blood flow to herniated organ
*requires prompt surgical intervention
- irreversible ischemia/necrosis -->SIRS
- redness of overlying hernia, pain
62
Direct inguinal hernia - how does it form?
protrude through abdominal wall due to acquired weakness in the TRANSVERSALIS fascia
-bulges through parietal peritoneum MEDIAL to inf. epigastric vessels, but LATERAL to the rectus abdominus muscle in HESSELBACH's TRIANGLE
- occur in old men who chronically strain
- least likely to incarcerate
63
What covers a direct vs. indirect inguinal hernia vs. femoral hernia?
direct - peritoneum
indirect - all 3 layers of spermatic fascia (external spermatic fascia, cremasteric fascia, internal spermatic fascia)
femoral - peritoneum
64
Indirect inguinal hernia
protrude through internal inguinal ring (LATERAL to inf. epigastric vessels) through superficial (external) inguinal ring, then into scrotum
-due to failure of processus vaginalis to close (can also cause a hydrocele)
= CONGENITAL - follows spermatic cord/round ligament
-most common hernia in men/women/children
65
Femoral hernia
occur in femoral canal, INFERIOR to inguinal ligament and MEDIAL to femoral vein (NAVEL = lat to medial)
- 10% of hernias, more common in Women
- highest rate of strangulation/incarceration
Risks = multiple pregnancies, dilate femoral veins --> widen femoral canal
66
Umbilical hernia
pediatric population, congenital hypothyroidism
-Most asymptomatic and close spontaneously with no intervention
in adults, associated with increased intra abdominal pressure (pregnancy, ascites, weight gain)
-surgery if symptomatic
67
repair of indirect inguinal hernia
open sac anteriorly, assess intestine viability, reduce contents
- high ligation of internal ring of hernia sac (eliminates processus vaginalis)
- excise distal sac or leave in situ if large
- Reinforce floor of inguinal canal with tension free mesh
68
repair of direct inguinal hernia
reduce sac, reinforce floor with tension free mesh = LICHTENSTEIN repair
- DO NOT open sac
- if in kids, don't need mesh, and need to look bilateral
69
Most commonly injured nerve in 20% of hernia repairs?
lateral femoral cutaneous nerve (lateral thigh to knee sensation)
70
inguinal ligament is formed by what?
aponeurosis of external oblique
71
layers of the abdominal wall ABOVE the arcuate line
1) Skin
2) subcutaneous fat (camper's fascia)
3) scarpa's fascia (first identifiable named, subcutaneous layer)
4) anterior layer of rectus sheath
5) External oblique/aponeurosis
* *Rectus abdominus muscle**
6) Internal oblique/aponeurosis
7) posterior layer of rectus sheath
8) transversus abdominus/aponeurosis
9) transveraslis fascia
10) parietal peritoneum
72
Layers of the abdominal wall BELOW the arcuate line
1) Skin
2) subcutaneous fat
3) superficial abdominal fascia
4) Rectus sheath
5) External oblique/aponeurosis
6) Internal oblique/aponeurosis
7) transversus abdominus/aponeurosis
* *Rectus abdominus muscle**
9) transveraslis fascia
10) parietal peritoneum
73
what is the arcuate line?
the inferior edge of the posterior layer of the rectus sheath
74
Indications for laparoscopic repair of hernia
1) bilateral inguinal hernias
2) recurring hernia
3) need to resume full activity ASAP
75
first subcutaneous vein ligated in open inguinal hernia repair?
superficial epigastric vein
76
Inguinal ligament attaches from the ________ to the _________
ASIS to the pubic tubercle
77
Nerves involved in the inguinal hernia repair (3)
1) ilioinguinal
2) iliohypogastric
3) genital branch of genitofemoral nerve
78
Ilioinguinal nerve
found ON TOP of spermatic cord
damage causes numbness of inner thigh or lateral scrotum (resolves in 6 months usually)
-can be purposely cut in order to avoid risk of entrapmentand post op pain
79
Genitofemoral nerve
travels IN spermatic cord
80
Boundaries of the FEMORAL canal
1. Coopers ligament (posterior)
2. Inguinal ligament (anterior)
3. Femoral vein (lateral)
4. Lacunal ligament (medial)
81
boundaries of the inguinal canal
1. external oblique aponeurosis (anterior wall
2. internal oblique muscle and transversus abdominis (roof)
3. Transversalis fascia and parietal peritoneum (posterior wall)
4. Inguinal ligament (aka aponeurosis of external oblique) = floor
82
deep inguinal ring
outpouching of the transveralis fascia, lateral to the lateral umbilical fold (containing inferior epigastric vessels
83
derivation of internal spermatic fascia, cremaster muscle, and external spermatic fascia?
internal spermatic fascia = transversalis fascia
cremaster muscle/fascia = internal oblique
external spermatic fascia = external oblique
84
The rectus sheath is created by the....
fusion of the aponeurosis of the transversus abdominis and abdominal oblique muscles
85
The rectus sheath is created by the....
fusion of the aponeurosis of the transversus abdominis and abdominal oblique muscles
86
Most common causes of SBO (7)
- Crohn's
- Gallstone ileus
- Hernia
- intra-abdominal adhesions (60% of SBO in USA)
- intussusception
- neoplasm
- volvulus
87
small bowel has _______ while large bowel has ________
small bowel - plicae circularis (lines on imaging all the way around the bowel)
large bowel - haustra (lines halfway through the bowel on imaging)
88
Portal venous gas
air in periphery of liver due to centrifugal portal flow
LATE presentation of pneumatosis with air in portal venous system
89
management of partial and complete SBO
fluids, electrolytes, NG tube for gastric decompression, indwelling catheter to monitor Uop
- partial SBO --> initial non-op management (unlikely to strangulate)
- complete SBO --> can delay and observe for 12-24 hours
90
Charcot's triad
RUQ pain, jaundice, fever = cholangitis
91
Acidemia and alkalemia at pH of what?
```
Acidemia = pH < 7.36
Alkalemia = pH > 7.44
```
92
non-anion gap metabolic acidosis causes
HARD UPS
```
Hyperalimentation
Acetazolamide
Renal tubular acidosis
Diarrhea
Uretro pelvic shunt
Post-hypocapnea
Spironolactone
```
93
causes of metabolic alkalosis
CLEVER PD
```
Contraction
Licorice
Endocrine (cushing's, Conn's, Bartter's)
Vomiting
Excess alkalai
Re-feeding alkalosis
Post diuresis
```
94
Cancer that can cause obstructive jaundice?
1) cholangiocarcinoma
2) Duodenal
3) Head of pancreas
4) Ampullary
95
what must you do before endoscopy with biopsy when you suspect esophageal cancer?
barium swallow
96
anal fissures are usually located where?
posterior midline
97
Fibroadenoma
YOUNG women, firm, rubbery, moves with palpation
```
DX = FNA or US
TX = removal optional
```
98
Cystosarcoma phyllodes
late 20's, can become very large
benign, but have potential for malignant transformation to sarcoma
TX: must remove
DX: core or incisional bx (FNA not sufficient)
99
Fibrocystic disease (aka mammary dysplasia)
related to menstrual cycle - come and go, multiple lumps, worse in last 2 weeks of cycle
DX: aspiration (NOT FNA)
only bx or do cytology if mass persists or bloody fluid
100
Intraductal papilloma
young women, bloody nipple discharge
DX: not shown by mammography
101
Breast abscess
only in lactating women, otherwise considered CA until proven otherwise
TX: I&D with biopsy of abscess wall
102
what is the daily fluid requirement?
30 mL/kg/day (approx 125 cc/hr)
103
Volvulus
sigmoid or cecal, TWISTING of the bowel
can see "whirl sign"
TX = "DETORSION" - attempt untwisting of volvulus via endoscopy or contrast enema (high recurrence rate)
104
Cecal volvulus
thought due to congenital problem when R colon/cecum not fixed
105
Sigmoid volvulus
acquired with progressive stretching
"coffee bean sign"
increased risk with anticholinergic drugs, neuro/psych diseases, CF, chagas, high fiber diet, constipation
106
Malrotation
congenital condition, bowel not in normal positions
can predispose to volvulus
bowel/mesentery not properly fixed/attached --> twisting, obstruction
107
Possible complications of diverticulitis
abscess, perforation, fistula (colovesical or colovaginal), stricture, LBO
108
Drainage of esophageal veins that leads to varices?
esophageal veins --> SVC
| esophageal veins also --> L gastric vein --> portal veins
109
Acute gastritis
EROSIVE superficial inflammation of the lining of the stomach
secondary to dysfunction of mucosal defenses = Prostaglandins, bicarb, somatostatin. HCl is NOT a major mechanism
110
Chronic gastritis
NON EROSIVE inflammation of gastric mucosa
type A vs. type B
111
Chronic gastritis: type A vs. type B
Type A: FUNDUS dominant --> pernicious anemia auto-ab to parietal cells
Type B: ANTRAL dominant --> H. pylori--> PUD, MALT lymphoma
112
Bleeding in PUD can be due to what 3 vessels?
1) Splenic artery --> gastric ulcer, posterior wall of the stomach
2) L gastric artery --> gastric ulcer, lesser curvature
3) Gastroduodenal artery --> duodenal ulcer, posterior wall of 1st part of duodenum
113
Triple therapy
PPI + clarithromycin + amoxicillin
114
How do you typically repair a duodenal perforation? gastric perforation?
Duodenal perf --> primary closure with omental patch
Gastric perf --> primary closure, biopsy, omental patch vs. wedge resection
-----must rule out malignancy
115
Endoderm is responsible for the formation of what in the GI tract....
1) Epithelial lining
| 2) specific cells --> glands, hepatocytes, exocrine/endocrine cells of the pancreas
116
Visceral mesoderm is responsible for the formation of what in the GI tract...
stroma (connective tissue for glands), muscle, connective tissue, peritoneal components of the wall of the gut
117
Dorsal mesentery:
extends from lower esophagus to cloacal region of hind gut
= GREATER OMENTUM (Mesogastrium= mesoduodenum, mesocolon, mesentary proper)
--> grows down from greater curvature to transverse colon where it fuses with the mesentery of transverse colon
118
Ventral mesentery:
LESSER OMENTUM = extend from lower esophagus, stomach, upper duodenum to liver
FALCIFORM LIGAMENT = extend from liver the ventral body wall
119
Development of stomach
- rotates 90 degrees around longitudinal axis --> LEFT side faces ANTERIOR, right side faces posterior --> left vagus = anterior branch, right vagus = posterior
- Posterior stomach grows faster = greater curvature
120
How is the lesser sac formed?
Rotation of the stomach pulls the dorsal mesogastrium (greater omentum) to left and creates a space behind the stomach
121
Development of the pancres
formed by the DORSAL and VENTRAL buds originating from endodermal lining of duodenum
-when the duodenum rotates to the right and becomes C shaped, the ventral pancreatic bud moves dorsally until it is behind the dorsal bud --> fusion of buds
122
Dorsal pancreatic bud
close to the dorsal mesentary
forms remaining head, body, and tail, as well as main pancreatic duct --> major papillae
123
Ventral pancreatic bud
close to bile duct
forms uncinate process, inferior head of pancreas, can also form the accessory pancreatic duct --> minor papillae (santorini)
124
Hindgut embryology
ENDODERM of hind gut also forms the internal lining of the bladder and urethra
125
_______ forms the caudal anal canal, while ________ forms the cranial anal canal
ECTODERM forms the caudal anal canal (inferior rectal artery --> internal pundendal arteries), while ENDODERM forms the cranial anal canal (superior rectal artery, IMA)
pectinate line delineates endoderm/ectoderm
126
Aortic Arches:
1st -
maxillary artery
127
Aortic Arches:
2nd
stapedial artery
128
Aortic Arches:
3rd
common carotid artery, proximal internal carotid
129
Aortic Arches:
4th
Left --> aortic arch
Right --> R subclavian artery
--> L recurrent laryngeal nerve loops around aortic arch, R. recurrent laryngeal loops around R subclavian
130
Aortic Arches:
6th
proximal pulmonary arteries, ductus arteriosus
131
Dumping syndrome
caused by rapid distribution of food into SI due to abscence of pyloric sphincter regulation
--> hyperosmolar in intestines --> increased H2O secretion, diarrhea, hypotension
132
Management of anastamotic leaks
NO peritonitis --> upper GI with gastrograffin --> contrast extravasation confirms leak
-GET SOURCE CONTROL - can re-operate and salvage initial operation most of the time instead of resecting and revising the anastomosis
133
Margins required for colon cancer resection?
| How many lymph nodes do you need?
margins at least 5 cm
For R hemisection, length of ileum resected does NOT effect local recurrence
Regional lymphadenectomy: gives prognostic info, guides chemos, need at least 12 nodes assessed for adequate staging
90% of recurrences occur within 3 years of surgery for colorectal cancer
134
Liver capsule
Glisson's capsule
135
What divides the R and L lobes of the liver
Cantle's line
136
Blood supply to the liver
75% from portal vein (splenic vein + SMV)
| 25% from proper hepatic artery (celiac trunk --> common hepatic)
137
Falciform ligament
connects liver to anterior abdominal wall
contains obliterated umbilical vein, ligamentum teres
138
Coronary ligament
attaches liver to diaphragm, "crown" on top of liver
139
How many liver segments are there?
8
140
Venous drainage of liver
drained by R, middle, L hepatic veins --> IVC
141
Blood supply to the thyroid
superior thyroid artery (1st branch of external carotid)
inferior thyroid artery (branch off thyrocervical trunk)
drained by superior, middle, inferior thyroid veins
142
where should you look for the recurrent laryngeal nerve during a thyroidectomy?
what happens if you damage this?
tracheoesophageal groove, behind cricothyroid muscle
damage = hoarseness if unilateral - obstruction if bilateral
--> paralysis of laryngeal abductors
143
what nerves at at risk for damage during thyroid surgery?
- recurrent laryngeal nerves
| - superior laryngeal nerves (damage results in change in voice pitch, lower voice)
144
suspensory ligaments of breast
cooper's ligament
invasion of CA into this causes retraction of skin around nipples
145
boundaries of the axilla?
```
axillary vein (superior)
floor of axilla (posterior)
latissimus dorsi (lateral)
pec minor (medial)
```
146
nerves at risk during axillary dissection?
1) long thoracic (mid axillary line) --> serratus anterior --> winged scapula
2) Thoracodorsal (lateral to long thoracic) --> latissimus dorsi --> decreased internal rotation, extension, and abduction of shoulder
3) Medial pectoral (goes through pec minor, lateral to the lateral pectoral nerve) --> pec minor and major
4) Lateral pectoral nerve --> medial to medial pectoral nerve --> pec major only
147
borders of the breast
```
clavicle (superior)
inframammary fold (6th rib-ish) (inferior)
Pec major fascia (posterior)
Latissiumus dorsi (lateral)
Sternum (medial)
```
148
Conn Syndrome
hyperaldosteronism
```
SX = HYPERTENSION, HYPOKALEMIA
TX = spironolactone (aldo antagonist) - before resection, must pre-treat with spiro and K+
```
(aldo = Na+ in, K+ out in DCT)
149
Anterior Spinal Artery Syndrome (ASA)
loss of pain, temp, motor - retain dorsal columns
can be due to "burst" fx of vertebral bodies
150
Most common vertebrae fractured in the neck?
C2 > C6 > C7
most common subluxation = C5-C6
151
Above what level do you get diaphragmatic paralysis?
above C3 with complete spinal cord injury
152
Why are thoracic spinal injuries less common?
injuries less common due to high facets and ribs --> decreased motion
-also have more canal space because no anterior enlargements
153
Central cord syndrome
severe extension injury
weakness, decreased sensation in UE + proximal leg muscles, with sparing of distal LE
Why? spinal cord organized w/UE motor MEDIAL aspect of cord and LE motor lateral
154
What drugs used by anesthesia/for intubation are contraindicated in head injuries?
ketamine and succinylcholine
use rocuronium and etomidate instead
155
Central retinal artery occlusion appearance on fundoscopy and what sx?
cherry red spot on fundoscopy
sudden loss of vision in one eye, painless
Hollenborst plaques = cholesterol microembolis within retinal arterioles --> highly suggestive of embolization from plaque at carotid bifurcation
156
Central retinal artery occlusion - caused by what?
embolization from internal carotid artery
157
internal carotid vs. external carotid artery
ICA - has no branches in the neck --> opthalmic artery, ACA, MCA
ECA - branches into superior thyroid, ascending pharyngeal, lingual, fascial, occipital, posterior auricular, maxillary, superficial temporal
158
Carotid endarterectomy for carotid stenosis - indications
symptomatic + > 70% stenosis
asymptomatic + > 80% stenosis
CEA NOT recommended for symptomatic patients with 100% stenosis of ICA
+ ASA, statin, +/- clopidogrel
159
Spinal stenosis
generalized weakness of both legs that worsens with walking
-relieved by leaning forward
aka neurogenic claudication (nerve root compression)
160
Claudication
pain with walking, relieved with rest, reproducible at same distance
- ischemic rest pain associated with ABI < 0.4
- calf muscle atrophy, hair loss, dry/scaly skin, shiny skin, ulcers
- ABI < 0.9 (DM can falsely elevate ABI**)
-atherosclerotic plaque obstructing blood flow, typically at SUPERFICIAL FEMORAL ARTERY --> popliteal
161
How is claudication classified?
Rutherford classification of chronic limb ischemia
162
Buerger's sign
sign of advanced chronic limb ishcemia
-foot turns pale when elevated ==> ruborous once down
