Sugery Clerkship 3 Flashcards
(111 cards)
1
Q
Signs of shock
A
- Pale, diaphoretic, cool skin
- Tachycardia, Tachypnea
- Hypotension
- Decreased pulse pressure
- Mental status changes
- Poor capillary refill
- Poor urine output
2
Q
Lab values that can help assess tissue perfusion
A
- Lactic acid (increased with inadequate tissue perfusion)
- pH from ABG (acidotic)
3
Q
MC etiology of septic shock
A
Gram (-) septicemia
4
Q
Tx for septic shock
A
- IVF
- Abx (empiric, then by culures)
- Drainage ofinfection
- Pressors PRN
- Xigris (activated protein C)
5
Q
Signs/Symptoms of cardiogenic shock
A
- Dyspnea
- Rales
- Pulsus alterans
- Loud pulmonic component of S2
- Gallop rhythm
6
Q
Tx for cardiogenic shock
A
- Diuretics if CHF
- Afterload reduction
- Pressors
- Intra-aortic balloon pump
- Ventricular assist device
7
Q
Definition of neurogenic shock
A
Inadequate tissue perfusion from loss of sympathetic vasoconstrictive tone
8
Q
Signs of neurogenic shock
A
- Hypotension
- BRADYcardia
- Neurologic deficit
9
Q
Tx for neurogenic shock
A
- IV fluids
- (Vasopressors are reserved for hypotension that’s refractory to fluid resuscitation)
10
Q
acronym for tx of anaphylactic shock
A
BASE
- Benadryl
- Aminophylline (bronchodilator)
- Steroids
- Epinephrine
11
Q
Classic signs/symptoms of inflammation/infection
A
- Tumor (swelling/edema)
- Calor (heat)
- Dalor (pain)
- Rubor (redness/erythema)
12
Q
SIRS
A
Systemic Inflammatory Response Syndrome
- Fever
- Tachycardia
- Tachypnea
- Leukocytosis
13
Q
Cellulitis (definition)
A
Blanching erythema from superficial dermal/epidermal infection
14
Q
Tx for UTI
A
Antibiotics with gram (-) spectrum
- Bactrim
- Gentamicin
- Ciprofloxacin
- Aztreonam
15
Q
Patient with a central line has unexplained hyperglycemia, fever, decreased mental status, hypotension, and tachycardia. What do you suspect?
A
Central line infection
16
Q
Major finding associated with central line infection
A
Unexplained hypoglycemia
17
Q
When do wound infections typically arise (what POD)?
A
PODs #5 - 7
18
Q
MC bacteria found in postoperative wound infections
A
- Staph aureus (20%)
- E. coli (10%)
- Enterococcus (10%)
19
Q
Which bacteria cause fever and wound infection in the first 24 hours after surgery?
A
- Streptococcus
- Clostridium
20
Q
Clean wound (definition)
A
Elective, nontraumatic wound without acute inflammation
21
Q
Clean-contaminated wound (definition)
A
Operation on GI or respiratory tract without unusual contamination; without entry into biliary or urinary tract
22
Q
Contaminated wound (definition)
A
- Acute inflammation,
- Traumatic wound,
- GI tract spillage, or
- Major break in sterile technique
23
Q
Dirty wound (definition)
A
- Pus present,
- Perforated viscus, or
- Dirty traumatic wound
24
Q
When should an abdominal CT scan be obtained looking for a postoperative abscess? Why?
A
- After POD #7
- Because otherwise, the abscess will not be “organized” and will look like a normal postoperative fluid collection
25
Major CT finding indicating an abscess (as opposed to normal postoperative fluid collection)
- Gas in the fluid collection
| - Fluid collection with a fibrous rind
26
All abscesses must be drained except which type?
Amebiasis
27
Classic necrotizing fasciitis causative agent
Streptococcus pyogenes
28
MC clostridial myositis causative agent
Clostridium perfrigens
29
Post-op patient develops fever, shock, and a foul-smelling brown fluid leaking from her incision site. You note crepitus and find subcutaneous air on x-ray. What's going on?
Clostridial myositis
30
Infection/abscess formation in apocrine sweat glands
Suppurative hidradenitis
31
Suppurative hidradenitis MC causative organism
Staph aureus
32
Infection of the parotid gland
Parotitis
33
What is the most common time of occurrence of parotitis?
Usually 2 weeks postoperative
34
Parotitis MC causative organism
Staphylococcus
35
Classic antibiotics for "triple" antibiotics
- Ampicillin
- Gentamycin
- Metronidazole
36
Temperature defining postoperative fever
> 38.5 C
| > 101.5 F
37
When would a UTI cause a postoperative fever?
After POD #3
38
When would a wound infection cause a postoperative fever?
Usually after POD #5, but can be anytime
39
What causes fever before 24 postoperative hours?
- Atelectasis
- Beta hemolytic strep or clostridial wound infections
- Anastomotic leak
40
Tx for malignant hyperthermia due to intraoperative anesthesia?
Dantrolene
41
What are contraindications of the depolarizing agent succinylcholine? Why?
```
Patients with:
-Burns
-Neuromuscular diseases/Paraplegia
-Eye trauma
-Increased IOP
Because it can cause life-threatening hyperkalemia
```
42
Contraindications to nitrous oxide. Why?
NO is poorly soluble in serum, so it expands any air-filled body pockets. So avoid in:
- Pneumothorax
- Small bowel obstruction
- Middle ear occlusion, etc.
43
What medication is a contraindication to Demerol?
MAO-I's
44
Why should you give Demerol (meperidine) with pancreatitis or biliary surgery over Morphine?
Morphine causes spasm of the sphincter of Oddi
45
Tx for respiratory depression caused by narcotics?
Narcan (naloxone)
46
Major side effect of epidural analgesia
Orthostatic hypotension
47
Major side effect of spinal anesthesia
Urinary retention
48
Benefit of epidural analgesia
You get the analgesia without the decreased cough reflex
49
Major side effect of inhalation anesthesia
Hypotension
50
Examples of nondepolarizing muscle blockers
Vecuronium, Pancuronium
51
Depolarizing muscle blocker
Succinylcholine
52
Labs used to evaluate acute abdomen
- CBC with differential
- Chem-10
- Amylase
- Type and screen
- Urinalysis
- LFTs
- Beta hCG
53
What does a "left shift" indicate?
Inflammatory response
54
How can you rule out free air on x-ray if the patient cannot stand
Left lateral decubitus position
| Make sure it's left so the air will collect over the liver - that way, it won't get confused with the gastric bubble
55
Classic diagnosis for "abdominal pain out of proportion to exam"
Mesenteric ischemia
56
Classic diagnosis for hypotension and a pulsatile abdominal mass
Ruptured AAA
57
Classic diagnosis for Fever, LLQ pain, and a Change in bowel habits
Diverticulitis
58
Imaging of choice for cholelithiasis
U/S
59
Imaging of choice for bile duct obstruction
U/S
60
Imaging of choice for mesenteric ischemia
Mesenteric angiogram
61
Imaging of choice for an AAA
Abdominal CT or U/S
62
Imaging of choice for an abdominal abscess
Abdominal CT
63
Imaging of choice for severe diverticulitis
Abdominal CT
64
Classically, what endocrine problems can cause abdominal pain?
- Addisonian crisis
| - DKA
65
Boundaries of Hesselbach's triangle
- Inferior epigastric vssels
- Inguinal ligament
- Lateral border of the rectus sheath
66
What attaches the testicle to the scrotum?
The gubernaculum
67
Does a femoral hernia travel down the femoral can medial or lateral to the femoral vessels?
Medial
68
During ATLS, how and when should the patient history be obtained?
While completing the primary survey
69
In addition to the airway, what must be considered during the airway step of ATLS?
Spinal immobilization
70
What's the quickest way to test for an adequate airway in an alert patient?
If the patient can speak, the airway is intact
71
Flail chest (define)
Two separate rib fractures in 3 or more consecutive ribs
72
What's the major cause of respiratory compromise with flail chest?
Underlying pulmonary contusion
73
Kussmaul's sign
- Present with cardiac tamponade
| - JVD with inspiration
74
Imaging study used to diagnose cardiac tamponade
U/S (ECHO)
75
Indications for emergent thoractomy for hemothorax
Massive hemothorax:
- >1500 cc of blood on initial placement of chest tube
- Persistent >200 cc of bleeding via chest tube per hour x4 hours
76
Initial test for adequate circulation
Palpation of pulses
- If radial pulse, systolic BP at least 80
- If femoral or carotid pulse, systolic BP at least 60
77
What comprises a complete assessment of circulation?
- HR
- BP
- Peripheral perfusion
- Urinary output
- Mental status
- Cap refill
- Exam of skin (make sure it's not cold or clammy)
78
Which patients may not mount a tachycardic response to hypovolemic shock?
- Those with concomitant spinal injury
- Those on beta blockers
- Conditioned athletes
79
What is the trauma resuscitation fluid of choice? Why?
- Lactated ringer's
| - Isotonic and the lactate helps buffer the hypovolemia-induced metabolic acidosis
80
How is gastric decompression achieved with maxillofacial fracture?
- NOT with an NG tube because it may perforate cribiform plate
- Must use an oral-gastric tube (OGT)
81
Normal glasgow coma scale score
15
82
Glasgow coma scale score for a dead person
3
83
Glasgow coma scale score for a patient in a coma
=< 8
84
Why look in the ears of a trauma patient?
Hemotypanum and otorrhea are signs of basilar skull frature
85
What does subcutaneous air indicate until proven otherwise?
Pneumothorax
86
Common trauma labs
- CBC
- Chemistry
- Amylase
- LFTs
- Lactic acid
- Coagulation studies
- Type and crossmatch
- UA
87
How will the Hct change after an acute massive hemorrhage?
It won't! No time to equilibrate
88
MC radiographic finding with thoracic aortic injury
Widened mediastinum
89
Gold standard imaging study done to rule out/rule in a thoracic aortic injury
Thoracic arch aortogram
90
MC site of thoracic aortic traumatic tear
Just distal to the take-off of the left subclavian artery
91
What diagnostic test is the test of choice for evaluation of the unstable patient with blunt abdominal trauma?
FAST (Focused Assessment with Sonography for Trauma)
92
What is the indication for DPL (Diagnostic peritoneal lavage) or FAST (Focused Assessment with Sonography for Trauma)?
Unstable vital signs (hypotension)
93
What is the indication for abdominal CT scan in blunt trauma?
Normal vital signs with abdominal pain/tenderness
94
Where should the DPL catheter be placed in a patient with a pelvic fracture?
Above the umbilicus
95
What must be placed before a DPL is performed?
NG tube and Foley to remove the stomach and bladder from the "line of fire"
96
What injuries does CT scan miss?
Small bowel injuries and diaphragm injuries
97
What injuries does DPL miss?
Retroperitoneal injuries
98
3-for-1 rule for treating traumatic hypovolemic shock
3 L of crystalloid (LR) is required for every 1 L of blood loss
99
What is the brief history taken during ATLS?
"AMPLE"
- Allergies
- Medications
- PMH
- Last meal
- Events leads up to the injury
100
Most important "test" to order for a trauma patient
Type and cross
101
What is the "lethal triad" in a trauma patient?
-Acidosis
-Coagulopathy
-Hypothermia
Think "ACHe"
102
What findings on abdominal/pelvic CT scan require exploratory lap in the blunt trauma patient with normal vital signs?
- Free air
| - No solid organ injury but lots of free fluid
103
Why are alkali burns more serious?
The body can't buffer the alkali, thus allowing it to burn for longer
104
Tx for myoglobinuria
- Hydration with IVF
- Alkalinization of the urine with IV bicarb
- Mannitol diuresis
105
Tissue involved in a 2nd degree burn
Epidermis and varying levels of the dermis
106
Tissue involved in a 3rd degree burn
Epidermis and the entire dermis
107
Tissue involved in a 4th degree burn
Epidermis and entire dermis, with injury down into the bone or muscle
108
Major clinical difference between 2nd and 3rd degree burns
2nd degree are painful, 3rd degree are painless
109
Difference between autograft and allograft
Autograft - from patient's own skin
| Allograft - from a cadaver
110
Diagnostic imaging used for smoke inhalation
Bronchoscopy
111
What lab value assess smoke inhalation
Carboxyhemoglobin
