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Key Points > Surgery > Flashcards

Surgery Flashcards

1
Q

Pre-op Assessment

A

Cardioresp function: CXR, ECG/echo, PFT, exercise
bloods: FBC, UE, BM, XM/GS
MRSA/infection screen, current illness
DH and allergies, esp. steroids
PMH and comorbidities, pregnancy!
previous anaesthesia, intubation (neck, teeth)
special tests (e.g. bowel prep)

cannula, VTE PPx, drug chart, consent, marked, NBM

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2
Q

Vascular Imaging/Ix

A

Doppler: venous reflux, pulses (triple), ABPI
Duplex: doppler + flow direction
CT/MR angiography: non-fempop

ABPI: lying; highest arm + highest foor (each leg); 0.8/0.6/0.3
Beurger’s: reactive hyperaemia; 25 = CLI, 45 = severe
Allens: pre-ABG
Tourniquet/Trendelenburg: venous incompetence (from above)

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3
Q

SSI risk

A

Clean (hernia): not entering viscus/cavity; no ABx needed

Clean-contaminated (lap chole/appe): elective viscus/cavity; ?ABx

Contaminated (intestinal spillage/inflamm): contaminated but not infected; ?ABx

Dirty (abscess, peritonitis): active infection; ABx

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4
Q

Post-op review

A

End of the bed: well = read notes first
R/V notes: test results, fluids/tubes/drains, NEWS, meds

Hx: operation, symptoms, E+D, BO/wind, mobilise, ICE/Qs
Ex: AtoE, vitals, fluid status (incl. IV, catheter, drains), chest2, abdo, wound, legs
*wound: dressing (?leak), pain, ?infection, d/c
*drains: location, working, fluid type, volume

document: ID, summary (op, days), latest results, SOAP, sign
* plan: Ix, Tx, other (TTO, chase, d/w etc.)

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5
Q

Amputation

A 
gangrene/CLI
severe infection
massive trauma
malignancy
intractable pain/malformation

toes/transmeta/transmall (Syme’s)/transtib/throughknee/transfem

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6
Q

HTN stages

A

stage I: >140/90 (135/85 ABPM)
stage II: >160/100 (150/95)
stage III: >180/110

isolated systolic:
grade I: 140-159 (DBP <90)
grade II: >160 (DBP <90)

Malignant/accel: >200/120 + retinal hge
*headache, SOB, palp, CP, PVD, LOC

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7
Q

Secondary HTN (5%)

A

renovascular disease: RAAS; surgery
Renal disease: PCKD, DM, GN, pyelo
Coarctation: proximal HTN; rad-fem delay, CXR
Endocrine: Phaeo, Conn’s, Cushing’s, hyperPTH, acro, thy
Neurogenic (ICP)
drugs: OCP, alc, CST, NSAID, ADD, MAOI
pregnancy/pre-eclampsia

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8
Q

HTN complications

A

CVS: CAD/IHD, PVD, AAA, dissection, HF
Brain: ICH, CVA, vasc. dementia
Renal: sclerosis, nephritic, nephrotic, CKD
eyes: silver-wiring, AV nipping, hge/CWS, papilloedema

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9
Q

HTN Ix

A

first line: diagnose, ?2nd, damage/risk

UA, MSU, FBC, U&E, LFT, Ca, lipids, glucose, CXR and ECG

second line (<45yo - ?2nd)
abdo US, 24h catechole, renin, cortisol, aldosterone, echo, MRA (?coarctation)
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10
Q

HTN Mx

A

treat if stage III, high CV risk, vascular disease, organ damage

lifestyle + RF: incl. DM and lipids, antiplatelet

A/C rules: A/C, A+C, A+C+D, ACD +other

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11
Q

Primary Cardiac Prevention

A

lifestyle: weight, diet, exercise, alc, smoke

regular risk review for >40yo
QRISK: DM, HTN, BMI, demo, chole, PMH/FH, smoking

atorvastatin 20mg if >10% risk, or DMT1, or CKD

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12
Q

Secondary Cardiac Prevention (in PVD)

A

lifestyle and DM
anti-plt: aspirin
anti-lipids: statin (atorva 80)
anti-HTN: ACEI (caution in PVD)

*statin: LFTs (3x)/CK (5x) + Sx = stop + restart lower

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13
Q

Hyperlipidaemia

A

primary: apoproteins/enzymes
secondary: DM, obesity, alc, nephro/nephritic, hypothy

VLDL/TAG: atheroma risk
apolipoA: IHD/CVD

Statins (aim <4-5, LDL <3), fibrates (ppar-a; TAG), ezetimide (absorption)

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14
Q

Statins

A

anti-thrombo, anti-inflam
stabilise plaques
reduced cholesterol
take ON

SE: myalgia, abdo pain, LFTs, CK, rhabdo

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15
Q

Atherosclerotic Aneurysm

A

> 150% normal diameter (>4cm aorta)

RF: age, male, FHx, CTD, athero, mycotic, injury, Takayasu aortitis

sites: abdo, asc/arch, cerebral, mycotic wall (Any)
effect: mass effect (pain, Fx), rupture, thrombosis/emboli

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16
Q

True vs. false aneurysm

A

true: all wall layers; sacular/fusiform;
* aorta > iliac > popliteal > femoral > thoracic

false/pseudo: surrounding tissue; trauma + pulsing haematoma
*firm, enlarged, pulseless vessel

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17
Q 
AAA presentation
(always rule out if abdo pain)
A

infra > juxta or suprarenal

aSx until expanding/leaking/rupture
epigastric/back/groin pain
pulsatile expansile mass
HD instability, anaemia, haematemesis
trash feet: dusky toes (emboli)
sudden death
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18
Q

Popliteal aneurysm

A

present in 40% of AAA; also check femoral
pulsatile fossa mass

acute ischaemia (T/E clot), chronic isch (thrombus),
‘DVT’/compression (swelling, cyanosis)
rupture (pain, swelling, ischaemia)

Mx: thrombolysis + surgery

19
Q

thoracic aneurysm pathology

A

intimal tear; false lumen between media/intima

external rupture: lower aorta; fatal haemothorax
retrograde spread to heart: pericardial rupture - tamponade
internal rupture: double channelled aorta (rare)

RF: HTN, pregnancy, degeneration, atheroma, FHx, Marfan’s/ED

20
Q

Thoracic aneurysm: presentation

A

severe central CP, ‘tearing’
radiates to back/arms
can mimic MI

shock, unequal arm pulse/BP
neurology: brain/SC e.g. CVA
AKI, MI, fistulae,
acute ischaemia: lower limb, visceral

21
Q

Thoracic aneurysm management

A

CXR: wide m’stinum/knuckle
MRI: gold standard
TOE/CT: confirms Dx
ECG: rule out MI

XM 10U + urgent cardiothoracic consult
permissive hypotension (100-110 SBP) - labetalol
type A: surgery (stent/replace)
type B: medical unless comlpications
22
Q

EVAR vs. open

A 
mortality: 1.7% vs. 5%
shorter stay: 2-4 vs. 7-10 days
ITU less likely
more expensive
anatomy important: 15cm normal infrarenal
more f/u: CT and USS lifelong
re-intervention likely: endo leak

*open F/u: d/c at 3/12, re-scan at 5-7y

23
Q

PAD - Fontaine classification

A

1) aSx
2) intermittent claudication
3) rest pain:
a/b: ankle >/<50mmHg
c/d: DM, ankle >/<30mmHg
4) CLI: tissue damage (gangrene, ulceration)

24
Q

PAD - Rutherford classification

A

0) aSx
1) mild IC
2) mod IC
3) severe IC
4) rest pain
5) ulceration (toes only)
6) severe ulceration/gangrene

25
Q

Intermittent Claudication

A

common, progression unlikely
angina of the legs; consistent distance
Leriche: ileal aa; erectile dysfunction + thigh/buttock pain

calf = fempop; thigh = iliac

DDx: spinal claudication, OA, neuropathy, venous claudication, aneurysm, pop aa entrapment
pulses

26
Q

Buerger’s disease

A

lifestyle/other RF (e.g. DM)
antiplatelets (all), ACEI (HTN), statins (all), ?iloprost

Percut Transluminal Angioplasty (PTA)
Bypass/reconstruction
Amputation (pain, gangrene, sepsis)

27
Q

Rest pain (vs. neuropathic)

A

burning pain at night (lying down), gravity eases
forefoot; cold, pale, and pulseless

neuro: red, warm, pulses;
glove/stocking, paraesthesia
hyperalgesia, allodynia

28
Q

PAD signs

+RF for progression

A

absent pulses, postural colour change
cold white legs, atrophic skin, hair loss
painful ‘punched-out’ ulcers
Buerger’s angle <20 + reactive hyperaemia
CRT >15s
6Ps if acute; may have bruit

RF: smoking, DM, HTN, lipids, FHx

29
Q

Gangrene DM vs. non-DM

A

drys vs. wet vs. gas (clostridium)

sensation, contracture, hge, focal gangrene

DM: wet more likely; single toes/heels (smaller aa)

30
Q

PAD - Mx

A

FBC, U&E, CRP/ESR, lipids, ECG, clotting + G&S (arteriography)
ABPI, arteriography (e.g. duplex)

lifestyle/other RF (e.g. DM)
antiplatelets (all), ACEI (HTN), statins (all), ?iloprost

Percut Transluminal Angioplasty (PTA)
Bypass/reconstruction
Amputation (pain, gangrene, sepsis)

31
Q

Mesenteric ischaemia

A

arterial/venous/trauma/vasculitis/strangulation
ACUTE TRIAD: pain, shock, no abdo signs

chronic: atheroma + low flow
CHRONIC TRIAD: pain (post-prandial), weight loss, bruit/N&V

ischaemic colitis: chronic IMA; LIF pain +/- bloody dd; ‘thumb print’ enema

32
Q

Ulcers

A

arterial: painfull, small and deep, dry, ABPI, pulseless
* toes, heel, foot, lateral, tibia

venous: painless, large and shallow, wet, pulses
* medial malleolus; NOT foot/leg

neuro: painless, pressure areas, pulses, wet, deep
* other: vasculitic, SCD, infection, cancer, pyoderma, trauma (pressure ulcers)

33
Q

Acute PAD (6Ps)

A

RF: dehydration, hypoTN, posture, cancer, hypervisc, IVDU, thrombophilia

aetio: thrombo, embo, iatro (graft), trauma, dissection, pop aneurysm

thrombo: Virchow’s, acute-on-chronic, abn pulses, bruit, calcified
embo: AF/AAA thrombus; acute, normal pulses, no PMH

34
Q

Acute PAD: Mx

A

non-viable: stained, blanches, rigor mortis
*amputate

threatened: anaesthesia, passive pain/calf squeeze
* revasc <6h: embolectomy, tPa, amputation

non-threatened: normal fx
*RF/meds + LMWH + semi-elective revasc

35
Q

Raynauds Syndrome (secondary)

A

CTD: SSc, mixed, SLE, Sjogrens, myositis
CVD: atheroma, Buerger’s, thoracic outlet
occupational: vibration, chemical, cold, compression
drugs: cytotoxic, BB, ergotamine
other: Ca/paraneo; causalgia, livedo

3 phases (white, blue, red)
reperfusion pain/burn/numb
severe: infarction and emboli
Ix: FBC, U&E, PT/APTT, glucose, TFT, specials
Tx: warm, smoking, nifedipine, ARB/AB/SSRI/iloprost

36
Q

thoracic outlet syndrome (TOO)

A

cervical rib, clav#, muscle, fibrous bands

neuro T1 root: hand mm + inner arm sensory
arterial: claudication, aneurysm, emboli/ischaemia

Ix: BP (lower), arteriography, CXR (rib), bruit

37
Q

Varicose veins

A

1: DTSI (deep to superfical incompetence)
2: obstruction (DVT), inflam/destruction (AVF),

RF: standing, pregnancy, obesity, FHx, OCP

ache, worse on ex, pain, eczema, thrombophleb (‘cords’), ulcers

decreased capps, increased wcc trapping and fibrin

38
Q

Venous disease - VVV LAPS

A 
varicose veins: great/small saph
venous stars/spider veins
venous ulcers
lipodermatosclerosis, eczema, 
atrophy blanches, haemosiderin
pitting oedema and skin thickening
scars/fibrosis - champagne legs
39
Q

venous Ix

A

doppler: flow direction; DTSI at SFJ/Pop fossa
* compression = upflow, release stops (compentent valve)

duplex: direction + anatomy; blue forward, red reflux/back

trendelenburg/tourniquet: SLR to empty veins, tourniquet, test refilling
*fillinf from above = incompetent, below = problem lower down

40
Q

venous ulcer Mx

A

nutrition and RF

compression bandages (ABPI >0.8)

  • I: ‘tired legs’, mild VV/oedema
  • II: severe VV/oedema, prevent ulcers
  • III: ulcers, ‘itis’, lymphoedema

cellulitis: ABx, debride, soak, cressing

41
Q

varicose veins Mx (pain, bleed, ulcer, thrombopleb, QoL)

A

education, weight, exercise, support/bandage

endovascular surgery: RFA, endovenous ablation/coag, injection sclerotherapy

open: ligation, avulsion, stripping

post-op: tight bandages + 24h elevation, then reg walking

42
Q

Lymphoedema

A

swelling, non-pitting, cobblestone skin

primary: young, inherited
secondary: obstruction (Ca, post-op), tumour, RDT (fibrosis), injury/inflam

Mx: compression, massage, ABx (cellulitis), avoid surgery

43
Q

Arterial Injury Sx

A

pulsatile bleed, bruit/thrill, distal ischaemia, haematoma

Ix: doppler, angio, ABPI, visualistion (theatre)

beware reperfusion injury/compartment syndrome

44
Q

Arterial Injury types

A

dissection, aneurysm (T/F), transection, AVF

transection Mx: pressure + gauze; image + repair (may need graft)

AVF: trauma, erosion, or iatro (dialysis); heavy + pain
support stocking, sclerotherapy, surgery (embolise)

Key Points (20 decks)

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