Flashcards in Surgery Deck (188)
What are the most important risk factors prior to surgery that increase the risk of perioperative and postoperative complications? (3)
1. EF < 35 %
2. recent MI in last 6 months (defer surgery for 6 months & perform stress test)
3. CHF (optimize w/ ACE inhibitor, beta blocker, spirinolactone)
What test should be done prior to elective surgery in a pt less than 35 y/o without history of cardiac disease?
What tests should be done prior to elective surgery for a pt with history of cardiac disease? (3)
2. Stress test (coronary vessel disease)
3. ECHO (structural disease & EF)
What are cardiovascular risk factors used in the assessment prior to elective surgery? (4)
4. male over age of 45
What is the test of choice for pulmonary disease risk assessment prior to surgery?
pulmonary function tests
(have pt quit smoking 6-8 weeks prior to surgery)
Who should undergo testing for pulmonary disease risk assessment prior to surgery?
1. known lung disease (asthma, COPD)
2. smoking history
What should be done in a pt with known renal disease prior to surgery?
1. hydrate w/ fluids before and during surgery
2. dialzye 24 hours prior to surgery (if on dialysis)
What is the best way to maintain an airway in patients who lack facial trauma?
What is the best way to maintain an airway in patients with facial trauma?
What is the best way to maintain an airway in a patient with cervical spine injury?
orotracheal tube using a flexible bronchoscopy
What is the goal for oxygen saturation in the setting of trauma/ emergency?
oxygen sat > 90%
What should be done in the setting of a trauma to maintain circulation?
obtain 2 large bore IVs and begin aggressive fluid resuscitation
What types of surgeries are considered high risk?
1. vascular surgery
What is the most important pulmonary predictor of perioperative complications?
What are the criteria for SIRS (systemic inflammatory response syndrome)? (4)
1. temp < 36 or > 38
2. HR > 90
3. RR > 20 or PCO2 < 32 mmHg
4. WBC < 4000 or > 12000
What is the most common cause of fever occuring 1-2 days post-op?
What are the five W's of post-op fever?
What is the most common cause of fever occuring 3-5 days post-op?
Urinary tract infection
(especially if have indwelling catheters)
What is the preventative treatment for atelectasis?
What is the treatment for hospital acquired pneumonia?
Vancomycin with zosyn (pipercillin tazobactam)
What is the most common cause of fever occuring 5-7 days post-op?
DVT (deep vein thrombosis), PE or thrombophlebitis
(especially if immobilized)
What is homen's sign and what disease is it associated with?
pain in calf with foot dorsiflexion; DVT
What is the most common cause of fever occurring 7 days post-op?
Wound infections and cellulitis
(associated erythema, purulent discharge, swelling)
What is the most common cause of fever occurring 8-15 days post-op?
2. deep abscess
What is the best step in management of a patient with fever occuring 8-15 days post-op?
1. stop offending medication
2. CT scan (to assess for deep abscess)
What is the next best step in management for a post-op patient who is confused?
1. obtain ABG
2. obtain CXR
3. obtain CBC
What is the likely cause of post-op confusion in a patient with an abnormal ABG?
1. Atelectasis (abnormal CXR)
2. Pneumonia (abnormal CXR)
3. PE (normal CXR, obtain CTA)
What is the likely cause of post-op confusion in a patient with an abnormal CBC?
1. bacteremia (blooc cultures)
2. UTI (urine cultures)
A pt develops severe hypoxia, tachypnea, accessory muscle use for ventilation and hypercapnia with bilateral pulmonary infiltrates on CXR without JVD postoperatively most likely suffers from ....
Adult Respiratory Distress Syndrome (ARDS)
What is the treatment of adult respiratory distress syndrome?
mechanical ventilation with maximized PEEP (positive end expiratory pressure)
What is the treatment for a pt who develops a second pulmonary embolism while on coumadin?
IVC filter via inguinal catheterization
What are the risk factors for pulmonary embolism?
1. stasis (immobility- surgery/ travel; obesity)
2. endothelial damage (surgery, trauma)
3. hypercoagulability (OCPs, cancer, genetic disorder- factor V leiden/ protein C/S deficiency)
What is the diagnostic test of choice for a pulmonary embolism?
CTA (spiral CT)
Sepsis is characterized by ....
2 SIRS criteria with a source of infection
Severe sepsis is characterized by ...
2 SIRS criteria, source of infection, and organ dysfunction
(Sepsis + organ dysfunction)
What is are the characteristic findings on EKG for severe right sided heart failure (that could be due to massive pulmonary embolism)?
(prominent S wave in lead 1, pathologic Q wave in lead 3, inverted T wave in lead 3)
Septic shock is characterized by ...
2 SIRS criteria, source of infection, organ dysfunction, and hypotension
(Severe sepsis + hypotension)
What are the risk factors for abdominal aortic aneurysm? (5)
1. age > 65
2. smoking history
5. Male gender
A pt presents with gradually increasing abdominal pain, pulsatile mass, auscultated abdominal bruit, and hypotension most likely suffers from ...
Ruptured Abdominal Aortic Aneurysm (AAA)
What size is considered an abdominal aortic aneurysm?
aortic diamete> 1.5x normal
(involving all layers of wall)
What is the most common location for abdominal aortic aneurysm?
distal to bifurcation of renal arteries
What is the diagnostic test used to monitor the size of a known abdominal aortic aneurysm?
What is the treatment for an abdominal aortic aneurysm measuring 3-4 cm?
ultrasound every 2-3 years
What is the treatment for an abdominal aortic aneurysm measuring 5.5 cm or greater?
What is the treatment for an abdominal aortic aneurysm measuring 4-5.4 cm?
ultrasound or CT every 6-12 months
What patients should undergo ultrasound screening for abdominal aortic aneurysm?
male pt who has a smoking history and is 65 years or older
A pt presents with sudden onset tearing chest pain that radiates to the back and asymmetric blood pressure (elevated in right compared to left) is most likely suffers from ....
Aortic Dissection (tear in intimal wall allowing blood to flow btw layers of wall)
What are the risk factors for aortic dissection?
1. HTN (most important)
3. age > 40 years old
4. collagen vascular disease (marfan's disease, ehlers danlos)
What is the best initial test for aortic dissection?
CXR (widening of mediastinum)
What is the most accurate test for aortic dissection?
transesophageal ECHO (TEE)
(especially if acute chest pain and/or clinically unstable)
When would you obtain an MRA for suspected aortic dissection?
pt has chronic chest pain and hemodynamically stable
When would you obtain a CTA for suspected aortic dissection?
if contraindications for MRA and TEE
What is the treatment for ascending aortic dissection?
Surgery (emergent b/c tear can propagate back to heart causing pericardial tamponade)
What is the treatment for descending aortic dissection?
medical therapy with beta blockers (control heart rate and lower blood pressure to halt propagation)
A pt presents with calf/ leg pain on exertion that is relieved by rest most likely suffers from ....
What is the best initial test for claudication?
Ankle brachial index (< 0.9 is claudication)
What is the medical treatment for claudication?
1. smoking cessation
2. graded exercise (promote collateral blood flow)
4. aspirin or clopidogrel
What is the treatment for a patient with claudication who failed medical therapy?
What are the 5 organ systems that be affected by shock?
1. brain (confusion, altered mental status)
2. kidney (increased BUN, creatinine)
3. liver (elevated AST/ ALT)
4. heart (chest pain, SOB)
5. blood (increased lactic acid)
What are indications for intubation in the setting of trauma/ emergency?
1. facial trauma
2. altered mental status
3. apnea (not breathing on own)
What is the treatment for hypovolemic shock?
fluids and pressors
What are the ways to maintain an oxygen saturation > 90% in the setting of trauma/ emergency?
1. nasal cannula O2
2. non-rebreather face mask
3. mechanical intubation
What is assessed to determine adequate circulation in a pt in the trauma/ emergency setting?
1. pulses (distal -> proximal)
2. manage hemorrhage sites (direct pressure)
3. blood pressure monitoring (if hypotensive, place 2 large bore IVs with normal saline)
What are the ABC's of trauma workup?
2. oxygen exchange
4. disability (altered mental status using glasglow coma scale)
5. exposure (secondary survey to assess for hidden injuries)
What elements go into determining the glasgow coma score in a pt in the trauma/ emergency setting?
1. eye response
2. verbal response
3. motor response
(if less than 8, requires intubation)
What type of shock is associated with pale & cool extremities, trauma, elevated systemic vascular resistance (SVR), decreased central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) and decreased cardiac output?
(intravascular volume depleted leading to vasoconstriction of skin and extremities)
What type of shock is associated with pale & cool extremities, chest pain, SOB, JVD, increased CVP, SVR, and PCWP with decreased cardiac output?
(heart can't pump forward)
What type of shock is associated with warm extremities, trauma, and decreased CVP, SVR, CO, and PCWP?
(intravascular volume being improperly distributed)
What type of shock is associated with warm extremities, faint pulses, infection (UTI, wound, pneumonia), decreased CVP and SVR, increased CO, and no change in PCWP?
(due to endotoxins in blood leading to global vasodilation)
What are common causes of hypovolemic shock? (3)
What are common causes of cardiogenic shock? (3)
What should you avoid in a patient with cardiogenic shock?
IV fluids (worsens problem)
What is common cause of neurogenic shock?
CNS damage (cervical/ throracic spinal cord injury)
What are the most common causes of septic shock?
1. E. Coli
2. S. aureus
What type of shock is associated with warm & flush extremities, wheezing, hives, decreased CVP, SVR, and PCWP, and increased CO?
(release of histamine causing vasodilation)
What is treatment for anaphylactic shock?
What are the types of shock associated with pale & cold extremities?
1. Cardiogenic shock (elevated PCWP)
2. Hypovolemic shock (decreased PCWP)
(differentiated by PCWP)
What are the types of shock associated with warm & flushed extremities?
1. Neurogenic shock (decreased CO)
2. Anaphylactic shock (increased CO, decreased PCWP)
3. Septic shock (increased CO, no change in PCWP)
What is Cullen sign and what diseases does it suggest?
bruising around the umbilicus; hemorrhagic pancreatitis/ ruptured AAA
What is Grey Turner sign and what does it suggest?
bruising in the flank; retropertioneal hemorrhage (pancreatitic hemorrhage)
What is the treatment for gunshot wounds?
What is the treatment for stab wound of abdomen?
1. stable -> FAST ultrasound
2. unstable -> exploratory laparotomy
A pt presents with penetrating or blunt trauma, respiratory distress, Kehr's sign, and loops of bowel in thoracic cavity on CXR most likely suffers from ...
Diaphragmatic Rupture (mainly left side)
What is Kehr's sign and what does it suggest?
left shoulder pain; diaphragmatic rupture/ splenic rupture
What is balance sign and what does it suggest?
dull percussion on left and shifting dullness on the right; splenic rupture
A pt presents with blunt abdominal trauma, lower rib fractures, Kehr's sign, hypotension most likely suffers from ...
A pt presents with blunt abdominal trauma, lower rib fractures, right shoulder pain and hypotension most likely suffers from ...
A pt presents with blunt trauma to epigastric area (bike handlebars, car dashboard), abominal pain radiating to back, Cullen's signs and/or Grey-Turner's sign, and hypotension most likely suffers from ...
What is the best initial test for blunt abdominal trauma?
FAST ultrasound scan
(evaluate for intraabdominal bleeding)
What four areas of the abdomen does the FAST ultrasound scan evaluate for intra-abdominal bleeding (dark hypoechoic region)?
1. pericardial sac
3. peri-splenic recess on left
4. hepato-renal recess on right
When should a CT scan be obtained if a FAST scan is negative in setting of blunt abdominal trauma?
1. suspected splenic rupture
2. retroperitoneal bleed (ruptured AAA or hemorrhagic pancreatitis)
What is the treatment for blunt abdominal trauma patients who are hemodynamically unstable?
A pt presents with one sided chest pain with ipsilateral decreased breath sounds, ipsilateral hyperresonance to percussion and contralateral tracheal deviation after thoracic trauma most likely suffers from ...
What is the best initial test for suspected pneumothorax?
CXR (medially dispalced lung border, loss of lung markings, tracheal deviation)
What is the treatment for normal pneumothorax?
chest tube placement
A smoking pt presents with one sided chest pain with ipsilateral decreased breath sounds, ipsilateral hyperresonance to percussion and ipsilateral tracheal deviation most likely suffers from ...
Normal Pneumothorax (not tension)
What is the treatment for tension pneumothorax?
needle thoracotomy followed by chest tube placement with CXR
A pt presents with chest pain, absent breath sounds, dullness to percussion, blunting of costophrenic angles on CXR after thoracic trauma most likely suffers from ....
Hemothorax (blood in pleural space)
What is the treatment for hemothorax?
1. chest tube drainage
2. thoractomy (if continues)
A pt presents with JVD, hypotension, muffled heart sounds, and electrical alternans on EKG after thoracic trauma resulting in broken rib or direct penetrating trauma most likely suffers from ...
What is the most accurate test for pericardial tamponade?
What is the treatment for pericardial tamponade?
What is the best initial test for bowel ischemia (chronic mesenteric ischemia)?
What is the next best step in management of a pt presenting with blood at the urethral meatus (urethral trauma)?
KUB xray followed by retrograde urethrogram
(to assess for patency of urethra)
What should you avoid doing in a pt with suspected urethral trauma?
Foley catheter placement
What is the most accurate test for bowel ischemia (chronic mesenteric ischemia)?
CT angiography (CTA)
A pt presents with diffuse crampy abdominal pain that occurs after eating, bloody diarrhea, and has hx of HTN/ HLD/ PVD/ CAD most likely suffers from ...
(atherosclerotic plaque of bowel; chronic mesenteric ischemia)
What are the common causes of RUQ abdominal pain?
1. Cholecystitis (radiates to right shoulder)
2. cholangitis (fever, jaundice)
3. perforated ulcer
What are the common causes of LUQ abdominal pain?
1. splenic rupture (radiates to left shoulder, trauma)
2. ischemic bowel disease
What are the common causes of mid-epigastric abdominal pain?
1. pancreatitis (radiate to back)
2. peptic ulcer disease
3. aortic dissection (radiates to back)
What are the common causes of RLQ abdominal pain?
2. ovarian torsion
3. ectopic pregnancy
4. diverticulitis (cecum, elderly pt)
What are the common causes of LLQ abdominal pain?
1. diverticulitis (sigmoid, elderly)
2. sigmoid volvulus
3. ovarian torsion
4. ectopic pregnancy
What is the treatment for bowel ischemia (chronic mesenteric ischemia)?
1. NPO, bowel prep, IV normal saline followed by surgical revasculariztion (arterial bypass)
What is the most commonly affected vessel in acute mesenteric ischemia?
Superior mesenteric artery
A pt presents with sudden onset, severe abdominal pain, 10/10 pain with soft abdomen, no guarding/ tenderness/ rebound tenderness, leukocytosis, lactic acidosis and has hx of a-fib most likely suffers from ...
Acute Mesenteric Ischemia
Where can inflammation of the prostate cause referred pain?
tip of penis or perineum
Where can inflammation of the gallbladder cause referred pain?
right shoulder/ scapula
What is the diagnostic finding on abdominal X-ray or CT associated with acute mesenteric ischemia?
Penumatosis Intestinalis (air in bowel wall)
Where can inflammation of the esophagus cause referred pain?
What is treatment for acute mesenteric ischemia?
emergent laparotomy with resection of necrotic bowel
What is the most accurate diagnostic test for Boerhaave syndrome?
Gastrografin Esophagogram (leaks out of esophagus)
An alcoholic pt (or pt who just underwent endoscopy) presents with substernal chest pain after episodes of persistent vomiting, Hamman sign and left shoulder pain most likely suffers from ...
Boerhaave syndrome (esophageal perforation)
What is the most common site of perforation in Boerhaave syndrome?
left posterolateral aspect
What is Hamman sign and what disease does it suggest?
crunching head upon palpation of thorax due to subcutaneous emphysema; Boerhaave syndrome
What is the most common site of injury in Mallory Weiss syndrome?
What is a common complication of Boerhaave syndrome?
mediastinitis (infection of mediastinum)
A pt with a history of peptic ulcer disease presents hemodynamically unstable, with hematochezia and hematemesis most likely suffers from...
(gastrodudodenal artery erosion)
A pt with history of peptic ulcer disease (heartburn, PPI use) presents with acute, progressive worsening abdominal pain that radiates to right shoulder and peritoneal signs (rigid abdomen with guarding and rebound tenderness) and presence of air under diaphragm on CXR most likely suffers from ...
What is the best initial test for gastric perforation?
upright CXR (free under diaphragm)
What is the most accurate test for gastric perforation?
What is the treatment for gastric perforation? (4 step treatment)
1. NPO (decrease leakage into peritoneum)
2. NG tube suction of gastric juices
3. IV fluids and antibiotics
A pt presents with abdominal pain that originates in the umbilical region and later begins to localize to RUQ with sharper pain, pertioneal signs, anorexia, leukocytosis, fever, Psoas/ Obturator sign most likely suffers from ..
What is Rovsing's sign and what disease is it suggestive of?
RLQ pain with palpation of the LLQ; appendicitis
What is the most accurate test for apependicitis?
What is the treatment for appendicitis?
What is psoas sign and what disease does it suggest?
pain with extension of hip; appendicitis
What is obturator sign and what disease does it suggest?
pain with internal rotation of the right thigh; appendicitis
An eldery with history of constipation pt presents with LLQ pain, fever, and peritonitis most likely suffers from ....
(can be RLQ pain as well)
What should be avoided in a patient with diverticulitis?
colonscopy and barium enema
An obese pt presenting with RUQ pain that occurs after eating and radiates to right shoulder, Murphy's signs, sonographic Murphy sign, and fever most likely suffers from ...
What is the most accurate test for abdominal abscess?
What is the most accurate test for cholecystitis?
HIDA scan (failure of gallbladder visualization)
A pt presents with epigastric abdominal pain radiating to pack with fever, nausea and vomiting in setting of history of alcoholism or gallstones most likely suffers from ...
What is the most accurate test for pancreatitis?
(amylase is sensitive; lipase is specific)
What is the treatment for pancreatitis?
NPO and IV fluids
What is a complication of pancreatitis that occurs 6-8 weeks after the acute pancreatic attack?
What are the classic ultrasound findings suggestive of cholecystitis?
1. pericholecystic fluid
2. gallbladder wall thickening
3. stones in gallbladder
What is treatment for diverticulitis?
1. bowel rest with antibiotics (first attack)
2. surgical resection (if recurrent)
What is the treatment for bowel obstruction? (4 step management)
2. NG tube to decompress
3. IV fluid hydration (replace third spacing)
4. emergent surgical resection
A pt presents with intermittent, diffuse crampy abdominal pain with associated nausea, vomiting, fever, hyperactive bowel sounds, high-pitched tinkling sound, lactic acidosis, and hypovolemia in the setting of prior abdominal surgery most likely suffers from ...
(commonly due to prior abdominal surgery adhesions or hernia)
What are common causes of bowel obstruction in children? (3)
1. intussusception (telescoping of bowel)
2. Foreign body
3. intestinal atresia (blind pouch)
What is the best initial test for bowel obstruction?
abdominal X-ray (multiple air fluid levels with dilated loops of bowel)
What is the most accurate test for bowel obstruction?
abdominal CT scan with contrast (transition zone from dilated loops of bowel with contrast to an area of bowel with no contrast)
When do you use closed reduction as a treatment for fracture?
mild fracture without displacement
When do you use open reduction and internal fixation as treatment for fracture?
severe fractures with displacement/ misalignment of bone pieces
A pt presents with pain, swelling, bony deformity in the setting of crush injury most likely suffers from ...
comminuted fractures (bone gets broken into multiple pieces)
An athlete presents with persistent pain of metatarsals or tibia with no evidence on X-ray most likely suffers from ...
What is the diagnostic test of choice for stress fractures?
CT or MRI
What is the treatment for stress fractures?
rest and PT rehabilitation
An elderly pt presents with back pain and point tenderness in the setting of history of osteoporesis most likely suffers from ...
An elderly pt presents with bone fracture (usually ribs) from coughing and has a hx of cancer/ multiple myeloma/ paget disease most likely suffers from ...
Pathologic fracture (fracture w/ minimal trauma)
What is the treatment for open fractures (broken bone pierces the skin)?
A pt presents with pain and swelling over anterior shoulder following a fall or blunt shoulder trauma with associated misalignment of the proximal and distal clavicle that is palpable most likely suffers from ...
What is treatment for clavicular fracture?
simple arm sling
A pt presents with persistent pain in the anatomical snuffbox (wrist pain and swelling at base of dorsal aspect of thumb) after falling on an outstretched hand most likely suffers from ...
(does not show up on X-ray for 3 weeks)
What is the the treatment for scaphoid fracture?
thumb spica cast
A pt presents with arm held to side and externally rotated forearm with severe pain and swelling in shoulder after falling on outstretched hand or blunt trauma most likely suffers from ...
Anterior shoulder dislocation
(anteriorly displaced humeral head)
What is the most accurate test for anterior and posterior shoulder dislocation?
MRI (elevate structural shoulder damage)
A pt presents with arm medially/ internally rotated and held to the side with pain and swelling in shoulder after seizure or electrical burn most likely suffers from ...
Posterior shoulder dislocation
What is the treatment for shoulder dislocations?
reduction of dislocation followed by dismobilization with sling
A pt presents with severe pain in a finger that is flexed while all other fingers are extended, associated popping sound when pulling finger free most likely suffers from ....
(stenosis of tendon sheath leading to finger)
What is the treatment for trigger finger?
(surgery to cut sheath if steroids not helpful)
.... is palmar fascia thickening resulting in the hand not being able to properly extended open (constant flexion of fingers) in a Northern european man over age 40 years or older and treatment is ....
Dupuytren contracture; surgery
A pt presents with neck/back pain, bilateral leg pain that worsens with exertion and better with rest, leaning forward alleviates pain and associated numbness most likely suffers from ....
(narrowing of spinal canal)
What is the most accurate test for spinal stenosis?
A pt presents with altered mental status, petechial rash and acute onset of SOB, tachypnea and dyspnea, PO2
What is the treatment for fat embolism?
maintain PO2 > 90% (supplemental oxygen or mechanical ventilation)
An elderly pt presents with electric pain that shoots down posterior leg unilaterally usually after lifting heavy object, pain reproduced with straight leg raise most likely suffers from ...
Herniated Disk (sciatica symptoms)
What is the treatment for herniated disk disease?
pain control (NSAIDs) and activity modification (while remaining mobile)
What are red flags for back pain that raises possibility for cancer or abscess? (6)
1. pain not relieved by rest
2. night pain
3. constant, dull pain for longer than 6 weeks
5. neuro deficits (bowel/ bladder control, abnormal reflexes)
6. hx of cancer
What are the 6 signs of compartment syndrome? (6 P's of an extremity)
2. pallor (decrease blood flow)
3. paresthesia (pins and needles)
6. poikilothermia (cold to touch)
What is the treatment for compartment syndrome?
A pt presents with knee pain and immediate swelling, positive anterior drawer sign (increased laxity w/ anterior pull of tibia), and positive Lachman test after direct injury to front of knee or twisted knee most likely suffers from ...
Anterior Cruciate Ligament (ACL) tear
A pt presents with knee pain, positive posterior drawer sign (increased laxity w/ posteriorly pushing tibia) after injury involving forced hyperextension (falling into hole or divet) most likely suffers from ...
Posterior Cruciate Ligament (PCL) tear
A pt presents with knee pain, immediate swelling and instability with side to side motion after trauma to contralateral aspect of knee most likely suffers from ...
Medial/ Lateral collateral Ligamet injury
What is the treatment for ACL, PCL and meniscal injury?
A pt presents with knee pain, delayed swelling, joint line tenderness, positive McMurray's sign (pain when tibia is externally rotated with medially directed force on outside of knee), clicking and locking of knee after twisting injury most likely suffers from ...