surgery Flashcards
(164 cards)
1
Q
Who to refer to secondary care for consideration of varicose vein treatment
A
- Symptoms associated with varicose veins such as ‘heavy’ or ‘aching’ legs.
- Skin changes associated with chronic venous insufficiency such as venous eczema or haemosiderin deposition.
- Superficial vein thrombosis.
- A venous leg ulcer (a break in the skin below the knee that has not healed in 2 weeks), either active or healed.
2
Q
Scrotal swelling palpable as separate from body of testicle?
A
Epidydymal cyst
Fluid filled benign lump
Smooth, regular
Associated w/ PCKD, CF, vHL syndrome
3
Q
Layers of abdo wall
A
- skin
- fatty layer superficial fascia- campers fascia
- membranous layer of superficial fascia- scarpas fascia
- external oblique
- internal oblique
- transversus abdominis
- fascia transversalis
- extreperitoneal tissue
- parietal layer peritoneum
4
Q
Most commonly strangulated hernia?
A
Femoral hernia
Inferolateral to pubic tubercle
Vomiting, bloody stools, ischaemia/ necrosis
5
Q
Location of inguinal hernia
A
Superior and medial to pubic tubercle
6
Q
prehn’s sign
A
Elevation of testis eases pain in epididymitis
negative prehns- more likely torsion
7
Q
Complications of total parenteral nutrition
A
- sepsis
- re-feeding syndrome
- deranged lfts
8
Q
who to refer 2ww in aortic aneurysms
A
- symptomatic
- aortic diameter > 5.5cm
- rapidly enlarging >1cm/yr
9
Q
Commonest cause of acute pancreatitis
A
- alcohol
- gallstones
10
Q
Acute limb-threatening ischaemia features
A
Features - 1 or more of the 6 P’s
* pale
* pulseless
* painful
* paralysed
* paraesthetic
* ‘perishing with cold’
11
Q
most common organism causing infective mastitis
A
Staph aureus
12
Q
Mx for testicular torsion
A
Emergency bialteral orchidopexy- fixation of both testes to prevent torsion of the other
13
Q
What not to give a pt who’s been in a car accident
A
Nitrous oxide
As it can cause a pneumothorax to develop into a tension pneumothorax
and the car accident puts them at risk of a pneumothorax to start with
14
Q
Crepitus over chest wall….
A
Subcutaneous erythema
Boerhaave’s syndrome - repeated vomiting causing spontaneous rupture of oesophagus
15
Q
BPH mx
A
- 1st line alpha blockers- tamsulosin, alfuzosin
- 5 alpha-reductase inhibitors e.g. finasteride
- Combination therapy if the man has bothersome moderate-to-severe voiding symptoms and prostatic enlargement
- mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried
- Surgery- TURP
16
Q
Name some voiding and storage symptoms
A
voiding symptoms (obstructive):
* weak or intermittent urinary flow
* straining
* hesitancy
* terminal dribbling
* incomplete emptying
storage symptoms (irritative)
* urgency
* frequency
* urgency incontinence
* nocturia
17
Q
Airway mx for pt undergoing bowel obstruction
A
They’ve either been vomiting/ high risk of regurgitation of gastric contents on induction of anaesthesia
Require endotracheal intubation
18
Q
List a few rf for vte
A
- active cancer/chemotherapy
- aged over 60
- known blood clotting disorder (e.g. thrombophilia)
- BMI over 35
- dehydration
- one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies; respiratory disease; acute infectious disease and inflammatory conditions)
- critical care admission
- use of hormone replacement therapy (HRT)
- use of the combined oral contraceptive pill
- varicose veins
- pregnant or less than 6 weeks post-partum
19
Q
Obstructed defecation since giving birth…
A
Rectal intussusception (internal rectal prolapse)
Defecating proctogram Ix (rather than barium enema)
20
Q
Imaging for suspected renal colic
A
non contrast ct kub
21
Q
Features of colostomy
A
- Large bowel
- LIF
- Solid faeces
- Flush to skin
22
Q
Features of colostomy
A
- Large bowel
- LIF
- Solid faeces
- Flush to skin
23
Q
Features of ileostomy
A
- small bowel
- RIF
- liquid
- spouted- faeces can drain w.o touching skin
24
Q
causes of epididymo orchitis
A
It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae, typically seen in sexually active younger adults) or the bladder (E. coli, typically seen in older adults with a low-risk sexual history).
25
most common type of renal stone
Calcium oxalate
26
causes of raised psa
* benign prostatic hyperplasia (BPH)
* prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
* ejaculation (ideally not in the previous 48 hours)
* vigorous exercise (ideally not in the previous 48 hours)
* urinary retention
* instrumentation of the urinary tract
27
Abdominal wound dehiscence mx
coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics along with analgesia, IV fluids and arrangements for a return to the operation theatre.
28
Abdominal wound dehiscence mx
coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics along with analgesia, IV fluids and arrangements for a return to the operation theatre.
29
Causes of BO
Small- cancers, adhesions, incarceration of hernia, Crohn's disease
Large- cancers, diverticular, volvulus
30
Who to refer for prostate ca 2ww
* DRE abnormal
* High PSA
31
ASA score 2?
* Mild systemic disease
* BMI 30-40
* Smoker
32
ASA III?
* Severe systemic disease
* Alcohol dependence
* BMI> 40 morbid obesity
* Poorly controlled DM/ htn/ COPD
* Active hepatitis
* Implanted pacemaker
* End stage renal disease undergoing dialysis
* MI hx
33
Acute prostatitis in a young man
* Test for STIs
* 14 days of a quinolone (ciprofloxacin)
34
Malignant hyperthermia- features & cause & mx
* Cause- following anaesthetic agents; suxamethonium
* Features- hyperpyrexia and muscle rigidity
* Mx- dantrolene
35
How to differentiate inguinal hernias clinically?
* Press on deep inguinal ring and ask pt to cough
* This reduces an indirect hernia - if the hernia reappears when the pt coughs its more likely to be a direct hernia as you now have the indirect hernia under control
36
Susceptibility to malignant hyperthermia
inherited in an autosomal dominant fashion
37
Drugs causing ED
Beta blockers
SSRIs
38
Acute panc ix
* amylase >3x upper limit normal
* lipase- for presentations > 24 hrs
* Imaging not required for diagnosis if characteristic pain + amylase/lipase
* early USS - aetiology- gallstones/ biliary obstruction
* other options- contrast CT
39
biliary colic lfts
ALL NORMAL!
40
bladder ca 2ww
age >45 and unexplained visible haematuria/ visible haematuria that persists or recurs after UTI mx
age > 60 and unexplained non visible haematuria or dysuria or raised wcc
41
bladder ca non urgent referral
age > 60 and recurrent uti
42
Varicocele cancer cause?
renal cancer
majority are left-sided
caused by the tumour compressing veins
43
Ascending cholangitis features
* Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
* fever is the most common feature, seen in 90% of patients
* RUQ pain 70%
* jaundice 60%
* hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds' pentad)
* raised crp
44
Haematuria following catheter for chronic UR?
Decompression haematuria occurs commonly after catheterisation for chronic urinary retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment and resolves spontaneously over a few days. Patients should be monitored to ensure the bleeding does not become severe.
45
Treatment of mass in hepatic flexure causing BO
Caecal, ascending or proximal transverse colon cancer → right hemicolectomy
hepatic flexure is at the top of the ascending colon, before transverse
46
Caecal volvulus associations
* pregnancy
* all ages
* pregnancy
47
BMI > 50 mx
1st line bariatric surgery
If the patient had medical conditions that were affected by weight then a referral for surgery can be considered at a BMI greater than 35 kg/m².
48
Scrotal swelling you can't get above
Inguinal hernia
49
Anal fissure mx
1. soften stool- bulk forming 1st line
2. lubricants eg vaseline
3. topical anaesthetics, analgesia
4. chronic- topical gtn 1st line
5. >8wks- refer for sphinectorotomy or botulinum toxin
50
Mx of warfarin pre-op
stop 5 days before
Commence lmwh - shorter acting anticoagulant- as risk of thromboembolic disease
51
Duct ectasia
non-malignant breast disease with thick green nipple discharge, occurring with breast involution
52
NICE guidelines for postop wound cleaning
* Sterile saline up to 48hrs after surgery
* Shower after 48hrs
* Use tap water for cleaning after 48hrs if the surgical wound has separated or has been surgically opened to drain pus
53
Investigations for suspected epididymo-orchitis
* sexually active younger adults: NAAT for STIs
* older adults with a low-risk sexual history: MSSU
54
What is epididymo-orchitis
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling.
55
Which anaesthetic agent has inherent anti-emetic properties?
Propofol
56
Lidocaine MoA
Blockage of sodium channels disrupting the a.p.
57
Monitoring in chronic panc pts
Diabetes- HbA1c annually
often develops >20yrs after
58
Post-op hip surgery, inability to dorsiflex foot...?
Sciatic nerve damage-esp w/ post approach to hip
59
ED Ix?
* morning testosterone - if abnormal check fsh, lh, prolactin- if abnormal refer to endo
* have qrisk calculated
60
When to surgically excise breast fibroadenoma
If >3cm
61
Screening for an abdominal aortic aneurysm
single abdominal ultrasound for males aged 65
62
Staghorn calculus
Struvite (ammonium magnesium phosphate, triple phosphate)
63
Most important rf for bladder cancer?
SMOKING
dyes too but less common
64
TURP syndrome
hen irrigation fluid enters the systemic circulation
triad features-
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity
65
Treatment for diverticular disease
Common cause of divertuclosis is constip, so advise to increase diatary fibre intake
Mild attacks- abx
66
Mx of thrombosed haemorrhoids
Anorectal pain and tender lump on anal margin
within 72hrs presentaiton of pain onset- admit for surgical mx
Following the first 72 hours of acute thrombosis, the thrombus is likely to organise and contract- lessening symptoms and typically self-resolving within a few weeks. In such scenario, it is more appropriate to offer conservative management options including analgesia, stool softeners and using ice-packs to reduce pain.
67
Rules about eating and drinking prior to GA
No food for 6 hours and no clear fluids for 2 hours before
Patients should be allowed to drink water or other clear fluids until 2 hours before the induction of general anaesthesia. This is to reduce the likelihood of pulmonary aspiration of gastric contents.
68
Diverticulitis symptoms + vaginal passage of faeces or flatus
?colovaginal fistula
69
Superficial thrombophelbitis
NSAIDs- topical for mild, oral for more severe
COmpression stockings - measure ABPI
Topical heparnoids
70
Local anesthetic toxicity
* This is a medical emergency. Initial features may be agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, and dysarthria. If not promptly recognised and treated, these signs and symptoms can progress to seizures, respiratory arrest, and/or coma.
* treated with IV 20% lipid emulsion
71
Complications of enteral feeding
* Diarrhoea in 1 in 6 pts
* Aspiration
* Metabolic- hyperglycaemia, refeeding syndrome
72
Strongest rf for anal cancer
HPV infection
73
Causes of acute panc
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
74
Glagow imrie criteria
for acute pancreatitis
75
Peripheral arterial disease mx
* Treat htn, dm, obesity
* Atorvastatin 80 mg
* Clopidogren 75 mg > aspirin 75mg
* Exercise
* Endovascular revascularisation- angioplasty +/- stent - for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
* Surgical revascularisation- surgical bypass w/ autologous vein or prosthetic material - for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
76
Probability of strangulation of indirect hernia
3%
Elective repair less risks- emergency repair higher mortality
77
ERCP complications
Acute panc
ERCP
Common bile duct perf is RARE - 1% procedurs
78
tracheoesophageal fistula
* Long term ventilation
* Physical communication between trachea + oeseophagus forms due to proximity of the structures & inflam around the tube in the trachea
* Presents with productive cough and choking after feeds and acutely w aspiration pneumonia
79
Acute limb ischaemia mx
* Analgesia- para, codeine, IV opioids
* IV heparin
* Vascular review- emergency embolectomy via fogarty catheter
* <50- thrombophilia screen
* Check lactate levels (ischaemia)
80
Ascending cholangitis most common causative agent
E coli
Next most common- Klebsiella
81
ABPI >1 cause
Hardening of vessels
Secondary to calcification of arteries
Secondary to T2DM, advanced age, PAD
82
Early causes of post-op pyrexia (0-5 days)
* Blood transfusion
* Cellulitis
* Urinary tract infection
* Physiological systemic inflammatory reaction (usually within a day following the operation)
* Pulmonary atelectasis
83
Late causes (>5 days) of post-op pyrexia
* Venous thromboembolism
* Pneumonia
* Wound infection
* Anastomotic leak
84
Grey-Turner's sign
Grey-Turners sign occurs in patients with severe haemorrhagic pancreatitis. In this situation the major vessels surrounding the pancreas bleed. The pancreatitis process also results in local fat destruction, this results in blood tracking in the tissue planes of the retroperitoneum and appearing as flank bruising.
85
Why is hartmanns preferred where large fluids are administered?
Excessive infusions of any intravenous fluid carry the risk of development of tissue oedema and potentially cardiac failure. Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.
86
Thyroid cancer follow up- bloods for recurrence
Thyroglobulin antibodies
87
Why is fluids needed in BO?
because when the bowel segment becomes occluded, the proximal segment of the bowel will enlarge and undergo more peristalsis. This will lead to the secretion of electrolytes in the bowel, most importantly, potassium, causing hypokalemia.
(add K)
88
Why avoid cannulating diabetic foot?
Neuropathy- risk of diabetic ulcer
89
Cullens sign
Severe acute peri-umbilical bruising in the setting of acute pancreatitis
Cullens sign occurs when there has been intraabdominal haemorrage. It is seen in cases of severe haemorrhagic pancreatitis and is associated with a poor prognosis. It is also seen in other cases of intraabdominal haemorrhage (such as ruptured ectopic pregnancy).
90
Long term mechanical ventilation in trauma patients.... complication
Tracheo-oesophageal fistula
91
Most common cause LBO
Bowel cancer
92
Where to give TPN, complications?
central vein as it is strongly phlebitic (hypertonic to blood, with a high osmolality)
usually done by ultrasound insertion of a long catheter into a peripheral arm vein that sits in the superior vena cava
Long term use is associated with fatty liver and deranged LFT's
93
Boerhaave's syndrome ix
The investigation of choice is a CT contrast swallow, which classically shows pneumomediastinum (hence the crepitus on palpation due to subcutaneous emphysema), pneumothorax, pleural effusion, and oral contrast leaking into the mediastinum.
94
What is the use of amylase in pancreatitis
Diagnosis
no prognostic value
(nb- lipase more sensitive and specific)
95
Local anesthetic toxicity
IV 20% lipid emulsion
96
When does BP fall in haemorrhagic shock
30% blood loss
97
Angiodysplasia
Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms. The right side of the colon is more commonly affected.
The colonoscopic stigmata are easily missed by poor bowel preparation.
98
Purpose of FAST scan
FAST scans can be used to assess the presence of fluid in the abdomen and thorax
=(focused assessment with sonography for trauma
This non-invasive test can be used within emergency care in the primary or secondary survey to quickly investigate the extent of free fluid or pneumothorax.
99
Isolated fever in well patient in first 24 hours following surgery?
Think physiological reaction to operation
Post-operatively, there is massive production of pro-inflammatory cytokines that can induce a systemic inflammatory immune response, leading to the patient's presentation, as seen in this vignette. Additionally, fevers presenting within less than 48 hours of surgery are unlikely to be of a new infectious aetiology.
100
Grading of internal haemorrhoids
Grade I Do not prolapse out of the anal canal
Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced
101
Most common causes oesophagus rupture
iatrogenic (such as endoscopy) or after severe forceful vomiting.
102
Gold standard achalasia ix
Oeseophageal manometry - absence of oeseophageal peristalsis, failure of LOS to relax, high resting LOS tone
103
Hiatal hernia mx
Wt loss & PPI
Conservative measures - alter diet, low fat, smaller portions, sleep with head of bed raised
104
RF for PUD
The two main risk factors for peptic ulcers are H. pylori infection and prolonged NSAIDs
Others- corticosteroids, prev. gastric bypass surgery, physiological stress, zollinger ellison syndrome
105
Eradication therapy for H Pylori
eradication may be achieved with a 7-day course of
a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)
if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin
106
Important imaging for acute upper abdo pain
Erect CXR to rule out perforated peptic ulcer (air under diaphragm seen)
107
1st line ix for acute limb ischaemia
Bedside doppler examination of pulses to confirm they are absent
108
Mx of diverticulitis flares
Oral abx at home
No improvement within 72hrs- IV ceftriaxone + metronidazole
109
Nocturanl diarrhoea + faecal incontinence...
IBD- proctitis
110
Solitary rectal ulcer syndrome...
Fibromuscular obliteration
Bright red rectal bleeding
Require diagnostic work up to elicit the undertlying cause of the altered bowel habit
Extensive collagenous deposits often seen
111
Ruptured AAA- what to do in terms of blood products?
Crossmatch 6 units of blood
activate major haemorrhage protocol
112
Takayasu's arteritis
Young asian females
Peripheral pulses absent
113
Takayasu's arteritis
Young asian females
Peripheral pulses absent
## Footnote
Subclavian steal syndrome
114
Takayasu's arteritis
Young asian females
Peripheral pulses absent
## Footnote
Subclavian steal syndrome
115
Takayasu's arteritis
Young asian females
Peripheral pulses absent
## Footnote
Subclavian steal syndrome
116
Unilateral middle ear effusion- glue ear- in adults
2ww ent- could be nasopharyngeal ca
esp if east asian
117
Ix for pancreatitis > 24 hrs
Lipase- longer half life than amylase may be useful in late presentations
118
Non healing perforated tympanic membrane
Myringoplasty
119
What types of shock cause warm peripheries?
Neurogenic
Septic
Anaphylactic
120
Surgery / metformin on day of surgery:
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
121
Causes of gingival hyperplasia
phenytoin, ciclosporin, calcium channel blockers and AML
(Acute myeloid leukaemia)
(CCBs esp nifedpine)
122
AAA screening programme
Sngle abdominal usss age 65 for males
123
ESRD ASA score (undergoing regular dialysis)
ASA III
124
Absolutely c/i to laparoscopic surgery
* haemodynamic instability/shock
* raised intracranial pressure
* acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
* uncorrected coagulopathy
*
125
venous ulcers location
Medial malleolus
126
Incarcerated vs strangulated hernias
Hernias can be incarcerated (where they are irreducible, but no pain or any other symptoms are present), which predisposes them to become strangulated (where the blood supply to the herniated tissue becomes compromised risking ischaemia and necrosis)
127
Mx of unilateral vs bilateral hernias?
Unilateral- open repair with mesh- recurrence rates are higher in pts who have had laparoscopic repair
do laparoscopic repair in bilateral hernia as an open approach would lead to more openings beingmade &risk of larger scars, infection, bleeding
128
presentation & mx of prostatitis?
* Pain- perineum, penis, rectum, back
* Obstructive voising sx
* Fever, rigors
* Tender boggy prostate
* Mx- 14 days quinolone
* STI screen possibly
129
Schisotosoma haematobium increases which cancer risk?
SCC of bladder
130
How to diagnose bladder cancer
Direct visualisation with cystoscopy
131
Side effects of GnRH agonists
* Paradoxical increase in LH = tumour flare- bone pain, bladder obstruction
* To prevent this, can use anti androgen cyproterone acetate which will block the androgen receptors and prevent testosterone from binding to their receptors and suppressing LH, which in turn reduces testosterone levels
* Start this 3 days prior to gnrh analogue
132
upper limits of normal residual urine volume
Post-void volumes <50 ml are normal in patients aged < 65 years old
<100 >65yo
133
what is hartmanns procedure
This procedure is used in emergency bowel surgery, such as bowel obstruction or perforation. This involves a complete resection of the recto-sigmoid colon with the formation of an end colostomy and the closure of the rectal stump
134
oeseophagus arterial supply
thoracic portion- branches of thoracic aorta and inferior thyroid artery
abdominal portion- left gastric artery
135
possible nerves that can be damaged during oeseophageal surgery
* recurrent laryngeal nerve
* phrenic nerve
*
136
possible anaesthetic risks to counsel pts on prior to surgery
Includes damage to the teeth, throat and larynx, reaction to medications, nausea and vomiting, cardiovascular and respiratory complications.
137
mx of haematemesis caused by peptic ulcer disease
* ABCDE
* Endoscopy within 24 hrs
* adrenaline injection during endoscopy
* cauterisation of the bleeding during endoscopy
* high dose PPI to reduce bleeding
138
what is the rockall score
used after endoscopy in upper gib
provides a eprcentage risk of rebleed and mortality
abcde- age, features of shock, co morbidities, cause of bleeding, endoscopic stigmata of recent haemorrhage
139
target inr prior to surgery
< 1.5
140
causes of raised amylase besides pancreatitis
* only raised in 75% acute panc
* specificity is 90% for panc
* other causes include pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis
141
modified glasgow criteria for what?
severity of acute pancreatitis within the first 48hrs of admission
any pt with more than 3 positive factors in first 48hrs should be considered to have severe panc, and HDU considered
PANCREAS
* po2 <8
* age > 55
* neutrophils > 15
* calcium < 2
* renal function (urea)> 16
* enzymes ldh > 600 or AST > 200
* albumin < 32
* sugar blood glucose > 10
142
CES vs cord compression
both present with lmn signs and bladder bowel disturbances
CES
* lower motor neurones only
Cord compression
* Umn - hypertonia, hyperreflexia (reflexes absent at the level of the lesion as the lmn is compressed), babinskis sign, clonus below the level of the lesion
143
suspected #nof, xrays dont show anything. what next?
MRI hip
144
tenderness over greater trochanter...
trochanteric bursitis
pain exacerbated with external rotation of the hip
insidious onset lateral thigh pain, radiating down thigh, but not down leg
145
Mx of displaced intracapcular hip fractures
Total hip replacement for independendently mobile, doesn't use more than a stick
Hemiarthroplasty for those not independently mobile, cognitive impairment, general frailty - goal to return back to normal function
A hemiarthroplasty typically provides poorer functional outcomes but carries a lower risk of subsequent hip dislocation. It is therefore preferred in patients with other serious comorbidities, dementia or those who are immobile
146
rules for weight bearing post#nof surgery
full weight bearing immediately post-operatively
reduces the length of stay and problems associated with prolonged immobility such as chest infection, VTE, pressure sores
147
most effective analgesia for #nof pts
iliofascial nerve block
The Fascia iliaca compartment is an area of potential space that lies between the posterior surface of the fascia iliaca and the anterior surface of the iliacus and posts major muscles. Local anaesthetic injected into this potential space affects the femoral, obturator and lateral femoral cutaneous nerves. The aim of this is to reduce the use of opioids analgesics e.g. morphine, which is particularly helpful in elderly patients who are often more susceptible to their side effects. As the vast majority of patients with neck of femur fractures are elderly, an iliofascial nerve block (5) is now the recommended first line method of analgesia in most UK hospitals.
148
Pain on the radial side of the wrist/tenderness over the radial styloid process ?
De Quervain's tenosynovitis
149
complication of having plaster cast fo 6/52
o Compartment syndrome
o Foot drop (nerve compression/ impinge nerves)
o Pressure point sores (ulceration of underlying skin)
o Skin problems/irritation
o Muscle wasting - Loss of muscle bulk
o
o Immobility – increased DVT risk
o May hold limb in incorrect position and so heal in incorrect position
150
risk associated with hip replacement surgery - how to prevent this complication?
prosthetic hip dislocation
i. Do not cross legs 6 weeks post-op
ii. Sleep on back for 6 weeks
iii. Do not flex hip above 90 degress
iv. Use walking stick or crotched for upto 6 weeks
151
colle's fracture?
Dorsally Displaced Distal radius
Dinner fork Deformity
152
what is entonox & who cannot have it
gas and air - nitrous oxide and oxygen
controls pain and anxiety
C/I- suspected pneumothorax, head injuries, severe facial injury, small bowel obstruction, middle ear surgery, retinal surgery involvign the creation of an intraocular gas bubble
153
what fractures are at risk of compartment syndrome
supracondylar fractures and tibial shaft injuries
154
how to ix and mx compartment syndrome?
* wont show any pathology on xray
* clinical suspicion- excessive use of analgesia, pain, pallow, paraesthesia, red, may or may not feel pulse
* measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
* fasciotomy
* extensive iv fluids as myoglobinuria can occur following fasciotomy and cause RF
* death of muscle 4-6hrs
155
complications of plaster cast
* vte
* compartment syndrome
* i. Decrease blood supply
ii. Impinge nerves
iii. Hold limb in incorrect position and so heal in incorrect position
iv. Soft tissue trauma, such as to muscles, or skin
156
meaning of healing by secondary intention
i. Wound left open allowing – clot formation
ii. Neutrophil infiltration to phagocytose the debris
iii. Neo vascularisation due to cytokines
iv. Fibroblasts lay down collagen
v. Granulation tissue = collagen plus new vessels
vi. Fibroblasts convert to myofibroblasts to contract and close the wound
157
meaning of healing by secondary intention
i. Wound left open allowing – clot formation
ii. Neutrophil infiltration to phagocytose the debris
iii. Neo vascularisation due to cytokines
iv. Fibroblasts lay down collagen
v. Granulation tissue = collagen plus new vessels
vi. Fibroblasts convert to myofibroblasts to contract and close the wound
158
which section of bowel commonly affected in diverticulitis
. Sigmoid colon, as in this part of the bowel the majority of water
has been reabsorbed from the faeces, leading to high intraluminal
pressures.
159
acute and chronic complications of pancreatitis
acute- shock, ards, sepsis, dic, renal failure
chronic- pancreatic pseudocyst, pancreatic necrosis, abscess, thrombosis of splenic or duodenal arteries, chronic pancreatitis
160
how to clinically differentiate ileus and mechanical bowel obstruction
ileus- absent bowel sounds
mechanical- tinkling bowel sounds
161
contents of bile
Bile salts, bile pigments, cholesterol, phospholipid, electrolytes,
water
162
fever + muscle rigidity following anaesthetic administeration
= malignant hyperthermia
raised ck
caused by suxamethonium
treat w dantrolene
(fhx / prev reactions)
163
local anaesthetic toxicity
Local anesthetic toxicity can be treated with IV 20% lipid emulsion
164
describe the origin of appendicitis pain
initially periumbilical as appendiz is a midgut structure
then when parietal peritoneum is affected the pain becomes more localised in the rif
