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Surgery and EM Flashcards

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1
Q

Post surgery

Develops facial pain and inability to open mouth

Fever

Prevented by?

A

Suppurative parotitis

Avoid with hydration and oral hygiene

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2
Q

Glasgow Coma Scale

A

Less than 8 intubate

Motor Response
6 Follows commands
5 Localizes pain
4 Withdraws to pain
3 Flexion
2 Extension
1 None
Verbal Response
5 Oriented
4 Confused speech
3 Inappropriate words
2 Incomprehensible
1 None
Eye Opening response
4 Spontaneous
3 Opens to command
2 Opens to pain
1 None
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3
Q

Unilateral breath sounds on right after intubation

A

Right main stem bronchus cannulation

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4
Q

Shock

A

BP < 90

Fast and weak pulse

Pallor

Diaphoresis

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5
Q

Suspect Cardiac tamponade if

A

Hypotension
Muffled heart sounds
JVD

Confirm w/ ultrasound

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6
Q

Causes of shock (4)

A
  1. Hemorrhage
  2. Tension pneumothorax
  3. Cardiac tamponade
  4. Neurogenic shock
    - High spinal cord injury
    - Decreased total peripheral resistance
    - suspect after ruling out other three
    - Vasopressors and increased TPR
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7
Q

ABCDE

A 
Airway
Breathing
Circulation
Deformities
Exposure
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8
Q

Previously stable chest trauma becomes rapidly unstable suspect

A

Air embolism

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9
Q

New diastolic murmur in chest trauma suggests

A

Aortic dissection

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10
Q

Massive air leak in chest tube

A

Suggest tracheobronchial injury

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11
Q

Chest injury between nipples order

A

Echo for heart
CTA for aorta and its branches
Bronchoscopy for upper airways
Esophagograph/ esophagogram for esophagus

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12
Q

Gun shot wounds that require immediate laparotomy

A

Gun shot wounds below nipple (fourth intercostal space)

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13
Q

Separate body part what to do

A

Place in gauze moistened with saline

Sealed inside a plastic bag

Place on ice

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14
Q

Tx Increase cranial pressure

A

Head elevation
Hyperventilation
IV mannitol

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15
Q

Epidural hematuria due to what vessel

A

Middle meningeal artery

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16
Q

Subdural hematuria due to what vessel

A

Briding beins

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17
Q

Respiratory compromise in flail chest

A

Due to pulmonary contusion rather than flail chest

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18
Q

Tx Flail chest

A

Pain control
Positive pressure

Fixed in severe cases

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19
Q

Blunt trauma to first rib, scapula or sternum

A

Think strong bones

Associated with aortic disruption

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20
Q

What tests to do with pelvic fracture

A 
Rectal exam
Proctoscopy
Retrograde cystogram for bladder
Retrograde urethrogram 
Pelvic exam for vagina in women
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21
Q

Most common injury with blunt abdominal trauma

A

Spleen

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22
Q

Fractured left ribs 9-11

A

Spleen

If ruptured remove and give Pneumococcal and HiB and meningococcal vaccine)

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23
Q

Right lower rib fractures

A

Liver trauma

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24
Q

Child falls on handle bars

Epigastric pain
Bilious vomiting

Retroperitoneal air on X ray

A

Duodenum injury

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25
Diaphragm ruptures on
Left side (since liver protects right)
26
Tx Pelvic fracture
External pelvic binders and angiographic embolization
27
Acute abdominal pain with blood in rectum
Mesenteric ischemia
28
McBurneys point
Appendicitis
29
Appendicitis tx
IV antibiotics - cefoxitin - cefazolin plus metronidazole
30
Chemical burns
Copiously irrigation for 20-30 minutes before transferring to hospital
31
Complications of electrical burns
Rhabdomyolysis Compartment syndrome Thrombosis of blood vessels —> limb ischemia Arrhythmias
32
Infection in burns caused by
Pseudomonas or Gram + occi
33
Abdominal pain Rigid to palpation Free air on Xray
Surgical exploration Perforation
34
Formula for fluids
First 24 hours 4 x patient's weight in kg x % BSA body surface area Give 50% of fluids over first 8 hours and remaining 50% over following 16 hrs
35
Measuring body percentage
Entire head 9% Anterior torso 9% Upper back 9% Entire arm 9% Anterior abdomen 9% Lower back 9% [Abdomen in total 36%] Perineum 1% Entire leg 18% ``` Head 9% Torso 36% Arm 9% Perineum 1% Leg 18% ```
36
Burns what to use topically
Topical antimicrobials if no epidermis intact Mafenide acetate (fulfamylon) Silver sulfadiazine
37
Hypotension and vasopressors
Only give vasopressors once adequate fluid resuscitation Cause vaso constriction of extremities and digital ischemia
38
Fever POD 1-3
Atelectasis Pneumonia (day 3)
39
Fever POD 3-4
UTI
40
Fever POD 4-5
DVT | PE
41
Fever POD 7+
Surgical site infection
42
Pulseless electrical activity tx
CPR Epinephrine Vasopressin
43
Ventricular fibrillation tx or pulseless ventricular tachycardia
CPR ``` Defibrillate —> Defibrillate —> Epinephrine —> Defibrillate —> Amiodarone —> Defibrillate —> Epinephrine ```
44
Tx Supraventricular tachycardia
Unstable —> synchronized electrical cardiovesion Stable —> vagal maneuvers If resistant= adenosine
45
Tx Atrial fibrillation/ flutter
Unstable —> synchronized electrical cardioversion If stable —> diltiazem or beta blocker
46
Hypovolemic shock CO PCWP PVR CVP
CO Down PCWP Down PVR Up CVP Down ``` Trauma Blood loss Dehydration Third spacing Burns ```
47
Cardiogenic shock CO PCWP PVR CVP
CO Down PCWP Up PVR Up CVP UP CHF Arrthymias Structural heart disease MI
48
PCWP PVR
pulmonary wedge pressure= left atrial pressure Peripheral vascular resistance
49
Obstructive shock CO PCWP PVR CVP
CO Down PCWP Up or Down PVR Up CVP Up Cardiac tamponade Tension pneumothorax Massive PE
50
Distributive shock CO PCWP PVR CVP
CO Up PCWP Down PVR Down CVP Down Septic Anaphylactic
51
Hypothermia
32-35 passive rewarming 28-32 active rewarming, warm blankets, warm water (external) <28 active internal rewarming, warm IV fluids
52
Hypothermia and death
Can not pronouced until rewarmed to 32 degrees
53
Tx bites
Amox-clav
54
Tx Black widow
Antivenin
55
Tx Brown recluse
Cold compresses to slow necrosis Dapsone
56
Tx Scorpion sting
If neuromucular toxicity: antivenin If not: benzodiazepines and analgesics
57
Tx Vibrio ulnificus
Severe necrotizing fasciitis and hemorrhagic bullous lesions Increased in those with preexisting liver disease Tx IV doxycycline and ceftriaxone
58
Tetanus algorithm
Clean minor wound < 3 lifetime toxoids or > 10 years ago= Id (or Tdap) other wise no prophylaxis Other wounds < 3 lifetime toxoids —> Td/Tdap + Tetanus Ig Last toxid > 5 years —> Td (or Tdap) Othersie —> no prophylaxis
59
toxicity tx
EDTA Dimercaprol Succinmer LEADS
60
SE Aminoglycosides
Gentimicin Neomycin Ototoxicity Nephrotoxicity (acute tubular necrosis)
61
Amiodarone SE
Acute: AV block Hypotension Bradycardia Chronic: Pulmonary fibrosis Arrhythmias Corneal deposition
62
Cyclophosphamide SE
Myelosuppression Hemorrhagic cystitis Bladder cancer
63
SE Furosemide
Ototoxicity Hypokalemia Nephritis Gout
64
SE Gemfibrozil
Myositis | Reversible increase in LFTs
65
SE Metformin
Lactic acidosis AKI Dehydration Sepsis
66
SE Methotrexate
Hepatic fibrosis Pneumonitis Anemia
67
SE Vincristien
Peripheral neuropathy | Paralytic ileus
68
Vitamin deficiency Dermatitis ALopecia Enteritis Adrenal insufficiency
Vit B5 pantothenate
69
Vitamin deficiency Peripheral neuropathy Anemia Convulsions
Vit B6 pyridoxine
70
Megaloblastic anemia deficiency of
Folic acid more common Liver stores of B12
71
Vitamin deficiency Impaired taste Impaired wound healing Alopecia
zinc
72
Abdominal pain Metabolic acidosis Elevated amylase Elevated glucose
Bowel ischemia
73
Provides best assessment of postoperative pulmonary morbidity in patient with lung cancer and resection
FEV1
74
How does hyperventilation lower ICP
Cerebral vasoconstriction
75
How does head elevated change ICP
Increased venous outflow from head
76
New onset hyperglycemia in elderly patient with temporal wasting
Pancreatic adenocarcionma Due to islet cell destruction with tumor invasion
77
Bluish hugh behind ear drum Hearing decreasing over time Can hear better in noisy room
Otosclerosis
78
Fever chills dysphagia Drooling Muffled voice Tongue is posteriorly displaced and superior Submandibular area is tender with palpable crepitus
Ludwig angina Rapidly progressive cellulitis of submandibular space From Dental infxn commonly
79
Seen with Black widow bites
Muscle pain Abdominal rigidity Muscle cramps
80
Gastric dilation on x ray
Paralytic ileus
81
Pelvic fracture with pelvic ring distruption what to do
Can cause life threatening hemorrhage from vascular injury Plevic binder application to decrease pelvic volume and promote tamponade of bleeding
82
Turner syndrome Sudden severe chest pain Constant pain Sinus tachycardia Pregnant
Aortic dissection
83
Giving blood products develops difficulty breathing Transfusion stopped now what?
Transfusion related acute lung injury (TRALI) Respiratory supportive care only
84
Prophylaxis coverage for heart surgery
Cephalosporins 1st 2nd - Cefazolin Allergy to pencillin - Vancomycin - Clindamycin
85
Pruritus Bloody stools occasionally RUQ pain Fever Jaundice
Primary sclerosing cholangitis Fibrosis and stricturing of the medium and large intra and extrahepatic bile ducts Associated with UC
86
Primary biliary cholangitis - MOA - Elevated - Two features - Seen in
Immune response against intrahepatic bile ducts Elevated Alk phos Jaundice Pruritius Common in females
87
Sudden onset headache Neck pain Vomiting Low grade fever
Subarachnoid hemorrhage CT scan
88
Blunt chest trauma Pneumothorax tx Pneumothorax reaccumulates and creptius
Bronchial rupture
89
Absence of gallbladder Direct bilirubin GGT Reticulocyte count
Biliary atresia Direct bilirubin: increased GGT: increased Reticulocyte: normal
90
Thymoma located
Anterior mediastinum Myasthenia gravis symptoms
91
Neuroblastoma in chest located
Posterior mediastinum
92
Esophageal leiomyomas located
Posterior mediastinum Submucosal Asymptomatic
93
Mass in middle of mediastinum Recent infxn
Bronchogenic cyst
94
Thyroglobulin
Precursor to active Thyroid hormones (T3 T4) Produced by normal thyroid tissue
95
Diffuse cerebral edema Tx
Elevated intracranial pressure Elevate head Hyperventilation Hypertonic saline
96
Give to reverse warfarin elevated INR
Prothrombin complex concentrate (concentrate of Vit K dependent cofactors) IV vit K
97
Small pneumothorax tx
Oxygen
98
Extensive burns what fluids
Isotonic crystalloid solution | - Lactated ringers
99
Transfusion related acute lung injury vs transfusion associated circulatory overload
TRALI - Bilateral infiltrate - No JVD - Crackles - Normal EF - Normal BNP TACO - Bilateral infiltrate - JVD - Crackles - Decreased EF - High BNP
100
Risk factors ventilator associated pneumonia
``` Acid suppression (PPI) Supine position Pooled subglottic secretions Paralysis & excessive sedation Excessive patient movement while intubated Frequent ventilator circuit changes ```
101
Steps for adenocarcinoma of the stomach
Diagnosis by endoscopy and biopsy Then CT abdomen and pelvis PET/CT CT chest paracentesis Limited= surgical resection Advanced= chemo
102
SE succinylcholine
Depolarizing neuromuscular blocker Triggers influx of sodium ions and efflux of potassium ions Cardiac arrhythmia Severe hyperkalemia
103
Black purple patch that develop on abdomen after CABG | Receiving heparin
Antibodies against platelet component Heparin induced thrombocytopenia
104
Trouble seeing at night Opacification of lens
Cataracts Surgically remove lens
105
Lower extremity tingling and numbness Hair loss Gait ataxia Loss of vibration and position Skin depigment Microcytic anemia
Copper deficiency
106
SE corticosteriods (6)
``` Acute mania Immunosuppression Thin skin Osteoporosis Easy bruising Myopathies ```
107
Tx Benzo overdose
Flumazenil
108
Tx Malignant htn
Nitroprusside
109
Macrocytic megaloblastic anemia with neurologic symptoms
Vit B12 deficiency
110
Macrocytic megaloblastic anemia without neuro symtoms
Folate deficiency
111
Calculating fluid repletion in burn patients
24 hr fluids = 4 x kg x %BSA
112
Acceptable urine output in trauma patient
50 cc/hr
113
Acceptable urine output in stable patient
30 cc/hr
114
Decreased CO Decreased PCWP Increased PVR
Hypovolemic shock Fluid and blood repletion
115
Decreased CO Increased PCWP Increased PVR
Cardiogenic or obstructive shock Tx Identify cause Inotrpes (dobutamine)
116
Increased CO Decreased PCWP Decreased PVR
Distrubitve shock Septic Anaphylactic
117
Supportive tx ARDS
Low tidal volume ventilation
118
3 large bloody stools Mild abdominal cramps Radiation therapy for hysterectomy for cervical cancer 12 months ago Anemia Mucosal pallor Friability Multiple telangiectasias which are confined to rectum
Radiation proctitis Acute <= 8 weeks - direct mucosal damage - diarrhea, minimal bleeding - Antidiarrheals (loperamide) - Butyrate enemas ``` Chronic > 3 months to years - severe bleeding - strictures with constipation, and rectal pain - multiple telangiectasias - mucosal pallor & friability Tx Endoscopic thermal coagulation Sucralfate or glucocorticoid enemas ```
119
Fracture ribs 1-3
Subclavian vessels Brachial plexus Mediastinal vessels (aorta)
120
Fracture ribs 3-6
Cardiovascular
121
Fracture ribs 9-12
Intraabdominal Liver (right) Spleen (left) Kidney (posterior ribs 11 & 12)
122
Surgery of AAA Develop LLQ pain and bloody diarrhea Gross blood on rectal exam Thickening of colon at rectosigmoid junction Ulceration in same area, but colon above and below is normal
Ischemic colitis | Form of mesenteric ischemia limited to colon
123
Melena RUQ pain Vomiting Had liver biopsy 5 days ago Hypotensive Slight fever Jaundice Anemia Elevated platelets Leukocytosis Elevated bilirubin
Hemobilia Bleeding into biliary tract Rare cause of Upper GI bleeding
124
Elderly patient chronic constipation that has slowly progressive abdominal distension over 3 days
Sigmoid volvulus Closed loop obstruction Dilated inverted U shaped loop
125
Brain image with dark brain tissue with white/gray mass in center
Hemorrhage Surgery
126
Decreased systemic vascualr resistance
Distributive shock
127
Cause of hypovolemic shock
Decrease right ventricular preload
128
Increase in pulmonary vascular resistance
PE can cause cardiac arrest due to rapid increase in pulmonary vascular resistance Leading to acute right side heart failure
129
Multiple lesion in liver check what
Colonoscopy
130
Endophthalmitis
Bacterial or fungal infection within the eye, particularly the vitreous part occurs 6 weeks post surgery Pain and decreased visual acuity Swollen eyelids and conjunctiva Corneal edema Hypopyon (inflammatory cells in anterior chamber)
131
Conjunctivitis
``` Excessive tearing Burning sensation Mild pain Conjunctival Eyelid edema ``` Vision not affected
132
Uveitis
Viral or parasitic infection within the eye Blurred vision Moderate pain Conjunctival injection Constricted pupils* May see keratic precipitates (mutton fat) and iris nodules HLA-B27 related conditions
133
Cavernous sinus thrombosis
Proptosis (protrusion of eye) Ophthalmoplegia (inability to move eye muscles) Chemosis (swelling and edema of conjunctiva) Visual loss
134
Post operation N/V Tachycardia HTN Fever Delirious Fine tremor Mild lid lag
Thyroid storm Tx Propranolol Propylthiouracil
135
Bilious vomiting Abdominal pain Passage of gas but no stool for 2 days Crohns disease
SBO due to fibrotic stricture
136
Adynamic ileus
Small bowel motility is disrupted Leading to intestinal dilation, obstipation and bilious emesis Presents similarly to SBO But only develops after exposure to an insult that "Stuns" the bowl - Surgery - high dose opioids
137
D dimer elevation
Presence of fibrin degradation products
138
Infection of retropharyngeal space can spread where
Superior mediastinum Acute necrotizing mediastinitis
139
Increasing abdominal pain for the past several hours Worsened by cough or movement Fullness with tenderness and guarding just lateral to the umbilicus on the left side Anemia Leukocytosis
Rectus sheath hematoma Rupture of inferior epigastric artery Patient receiving anticoagulation therapy
140
Tx Staphylococcal toxic shock syndrome
Vancomycin plus clindamycin
141
Tx Necrotizing otitis externa
Pseudomonas Tx Ciprofloxacin Granulation tissue
142
Slurred speech Unsteady gait Drowsiness Normal pupil size ``` A. Benzo overdose B. Lithium toxicity C. Opioid intoxication D. Phenytoin toxicity E. Serotonin syndrome ```
A. Benzo overdose
143
Horizontal nystagmus Cerebellar ataxia Confusion
Phenytoin toxicity
144
IV naloxone
potent opioid antagonist used for patients with opioid intoxication
145
Burns Develops fever Tachycardia HTN No infection
Hypermetabolic state 5 days post injury Triggered by profound release of inflammatory mediators from damaged tissue Leading to increased levels of catecholamines and glucocorticoids
146
GI bleeding from no identifiable source on upper and lower endoscopy
Bleeding in the distal duodenum, jejunum or ileum not well visualized Due to vascular malformations in bowel wall (angiodysplasias) Calcific aortic stenosis
147
Five Whys analysis
Root cause anaylsis Also systematically assess the general safety culture at the hospital
148
Fialure modes and effects analysis (FMEA) (6)
Form multidisciplinary team Define process to be studied Develop a flowchart Analyze error risk at each step Identify potential corrective actions Implement plan
149
Pill overdose Facial flushing Dry mouth Prolonged QRS Tx
Tricyclic antidepressant TCA can block cardiac fast sodium channels Tx: Sodium bicarbonate
150
Atropine fixes what type of overdose
Organophosphate toxicity ``` Salivation Lacrimation Urination Diarrhea Bradycardia ```
151
Calcium chloride tx for
Severe hyperkalemia
152
Hypo and hyperpigmented skin in patchy areas Hyperkeratosis and scaling on palms and soles Worsening burning and tingling sensation in hands and feet Works outdoors on fences
Arsenic poisoning Pressure tx wood Contaminated water (wells) Pesticides/ insecticides QTC prolongation Garlic breath Tx Dimercaprol DMSA
153
Sodium bicarbonate MOA in helping overdose
Will alleviate depressant action on myocardial sodium channels
154
Hypotension Heart sounds muffled Low glucose ``` Overdose on A. Amitriptyline B. Clonidine C. Digoxin D. Diltiazem E. Metoprolol ```
E. metoprolol Beta blocker toxicity Prolonged PR interval
155
N/V Confusion Changes in color vision Everything is yellow
Digoxin toxicity
156
Confused Flank pain Foley catheter place urine is red with calcium oxalate crystals Hypocalcemia AKI Metabolic acidosis
Ethylene glycol poisoning Tx Fomepizole
157
Organophosphate poisoning tx
Remove clothing Atropine Pralidoxime
158
Physostigmine
Acetylcholinesterase inhibitor | Tx anticholinergic toxicity Flushing, mydriasis, anhidrosis, fever, urinary retention
159
House fire what can you inhale
``` Hydrogen cyanide (cyanide poisoning) Tx: Hydroxocobalamin ``` Carbon monoxide
160
Parenteral nutrition makes you at risk for
Central line associated bloodstream infection
161
Suicide attempt Abdominal pain Coffee ground emesis Dark green Diarrhea Hypotension Lethargic Abdomen tender to palpation
Acute iron poisoning Anion gap metabolic acidosis Radiopaque pills on x ray Tx Deferoxamine [Acetaminophen toxicity, GI bleeding uncommon]
162
Suicide attempt ``` Hyperthermia Flushing Tachycardia Hypotension Altered mental status ``` Decreased bowel sounds
Tricyclic antidepressant
163
32 female Vision impairment in right eye, blurry after takin hot shower Occasional headaches in past Dizziness and clumsiness over past 6 months
Multiple sclerosis Worsened by heat exposure

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