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Flashcards in Surgery - Cardiopulmonary Deck (88):
1

S/p CABG a few days
+ fever, tachy, CP, leukocytosis, purulent wound discharge

Acute mediastinitis
- complication of cardiac surgery

Need drainage/debridement + prolonged abx

2

What post op days is atelectasis most common?

day 2 and 3

3

Preventing atelectasis...

pain control
deep breathing exercises
early mobilization
incentive spirometry

4

Reason for atelectasis post-op

Pain and changes in lung compliance post op can cause impaired cough and shallow breathing

Shallow breaths:
decrease recruitment of alveoli at lung bases

Weak cough:
causes small airway mucous plugging

Results in hypoxia --> increase RR --> blow off CO2

5

How do you get hematuria with AAA?

hematuria in AA rupture --> aortocaval fistula w/ IVC --> venous congesion in retroperiteoneal structures (eg bladder) --> fragile and distended veins in bladder can rupture --> gross hematuria

6

Which diaphragm is more prone to injury?

Left
- congenital weakness in diaphragm's left posterolateral region
- also liver protective effects on R side

Can have late presentation of diaphragm injury

Use CT to diagnose diaphragmatic injury

7

How much circulating blood vol can a hemithorax hold?

How much blood is a massive hemothorax?

50% of circulating blood vol

Massive > 1.5 L

Will have FLAT NECK VEINS

8

Characteristics of hemothorax

tracheal deviation
Reduced breath sounds
dullness to percussion over involved side
flat neck veins (if hypovolemic)

9

Takotsubo's cardiomyopathy

is a type of non-ischaemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). Because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up, or constant anxiety, it is also known as broken heart syndrome

10

What kind of heart attack is perioperative MI?

NSTEMI

O2 demand > delivery

Will have increased HR w/ pain, anxiety and also increased contractility --> need more O2 demand but not enough delivery

11

How do you handle MI sx post-op?

EKG before, 1 day post op, 2 day post op, 7 day post op

Troponins day 1, 2, 7

12

How can you try and ppx against NSTEMI peri-op?

+ Beta blocker

13

How do you avoid pulm complications post-op?

Incentive spirometer before and after surgery

DO NOT need PFTs

14

Cardiac cath MAJOR complications

MDS

MI
Death
Stroke/TIA

15

Cardiac cath MINOR complications

CHHAAP

Contrast allergy
Hemostasis @ access site
Hematoma formation (retroperitoneal)
AV fistula
Arterial thrombosis
AKI
Pseudoaneurysm
Perforation of heart or great vessels

16

Which bronchus is more commonly injured w/ tracheobronchial perforation 2/2 to blunt thoracic trauma?

Right main bronchus

Confirm w/ CT scan or surgical exploration

17

Pneumomediastinum causes

Tracheal rupture
Esophageal rupture

18

ARDS vs. pulmonary contusion

Pulmonary contusion usually within first 24 hrs

ARDS usually 24-48 hrs from trauma
- also, b/l lung involvement usually

19

Tension pnsumothorax

Life threatening

Air w/in pleural space displacing mediastinal structures
- air can enter pleural space but cannot excape naturally

Findings:
- SOB
- tachycardia
- tachypnea
- HYPOtn
- distension of neck veins (b/c SVC compression)

1/4 of these in hospital caused by placement of subclavian central venous catheters

Tx: needle thoracostomy + emergency tube thoracostomy

20

When ok to give heparin for aortic dissection?

DO NOT GIVE if it's ruptured

Give if not ruptured

21

How high can diaphragm be?

4th thoracic dermatome on R

5th thoracic dermatome on L (nipples)

22

Cx negative infective endocarditis

HACEK

Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella

23

UTI associated endocarditis

Enterococci (esp fecalis)

24

How much blood needed to cause sudden rise in intrapericardial pressure that compresses cardiac chambers and compromises both venous return and CO?

100-200mL

25

Respiratory quotient
- what is it?
- different values = what?

= Steady state CO2 produced : O2 consumed / unit time

Can be used to make assessments of metabolism in particular organs or in body as whole

RQ = 1 = carbs major nutrient oxidized
RW = 0.8 = protein metabolism only
RW = 0.7 = fatty acid metabolism only

26

Ppx for bacterial endocarditis for these procedures:
- dental/oral
- GI/GU

Dental/oral/resp/esoph: - give 1 hr before procedure
- amoxicillin
- clindamycin / cephalosporin / clarithromycin


GI/GU high risk
- ampicillin + gentamicin before and after
- vanco + gentamicin before ONLY


GI/GU mod risk
- amoxicillin / ampicillin before ONLY
- Vanco before ONLY

27

Cardiac index =

CO / body surface area

CO = SV x HR

28

What does PCWP via swann ganz catheter represent?

L atrial P
L ventricular EDP

Pulm vasc disease can increase PCWP independent of LAP or LVEDP

Mitral stenosis and regug increase LAP and PCWP and falsely elevated LVEDP in swann ganz catheter reading

PEEP/CAP can alter PCWP on SG catheter

29

Tx gastric aspiration into tracheal tree

Tracheal intubation and suctioning

30

Tracheostomy - tips

Trachea should be entered at 2nd or 3rd cartilaginous ring

31

Central venous pressure
- increasors
- decreasors

Increase
- vasoconstrictor
- PEEP
- mediastinal compression
- hypervolemia
- acute PE (RV overload --> increase RAP0

Decrease
- sepsis

32

1st branch of ascending aorta

Coronary A

33

1st branch off internal carotid A

Ophthalmic A

34

Internal and external carotid relationship

Internal carotid is always posterior

Internal carotid is lower resistance b/c it perfuses the brain

35

A-a gradient

= PAO2 - PaO2

PAO2 = 150 - PaCO2 / 0.8

36

Tx hemothorax

Chest tube

Don't need surgery to stop bleeding usually - will stop by itself if it is the lung bleeding

Need thoracotomy if systemic vessel (intercostal A) is bleeding

Surgery if:
- >1500 mL blood when chest tube put in
- > 600 mL blood / 6 hrs with CT

37

Danger of pulmonary contusion and how that plays for tx

Very sensitive to fluid overload

Tx = fluid restriction + diuretics

Can happen from flail chest

38

Tx myocardial contusion

Troponins are specific - get when sternal fracture

Tx focuses on complications (like arrhythmias)

39

Ddx subQ emphysema

Rupture of trachea
Rupture of esophagus (usually w/ endoscopy or vomiting)
Tension pneumo

40

Sudden death in chest trauma pt who is intubated + on respirator

Tx?

Prevent?

Air embolism

also happens when subclavian opened to air (eg central line placement, supraclavicular node bx)

Tx:
- cardiac massage w/ pt L side down

Prevent:
- Trendenlenburg if putting in central line

41

Vascular ring

congenital defect in which there is an abnormal formation of the aorta and/or its surrounding blood vessels.

The trachea and esophagus are completely encircled and sometimes compressed by a "ring" formed by these vessels, which can lead to breathing and digestive difficulties.

42

1d old child w/ cyanosis - what do they have? What do you do next? what keeps them alive?

Transposition of great vessels

Echo next

ASD, VSD, or PDA keeps them alive

43

When do you do a valve replacement for aortic stenosis?

Gradient > 50 mm Hg

1st indication of CHF, angina or syncope

44

Repair for chronic vs acute aortic regurg?

Chronic - repair when see signs of LV dilatation

Acute - immediate repair! Long term abx needed. Usually 2/2 endocarditis via drugs

45

What's the best surgery for mitral regurg?

Valve annuloplasty (preferred over prosthetic replacement)

46

CAD intervention indication?

If >=1 vessles have > 70% stenosis and the distal vessel is still ok
--> do angioplasty + stent

Triple vessel disease - best to use bypass via internal mammary

47

Post op care of cardiac pt - if the CO is low, what do you do next?

Find out the PCWP

If it is low, then need more IVF
If it is high, then you have ventricular failure

48

1st thing you do after pt has a coin lesion on CXR?

Find old xray and compare to see if it was there before, got bigger, etc

49

Tx central vs peripheral lung cancer.

Indications?

Central = pneumectomy

Peripheral = lobectomy

A minimum of FEV1 = 800 mL is needed post op. Tx w/ chemo and radiation if pt is not a surgical candidate

50

Subclavian steal syndrome
- pathophys
- signs
- dx
- tx

Arteriosclerosis plaque at origin of subclavian (before vertebrals branch off) lets arm have enough blood at rest but not w/ activity

Arm will try to steal enough to meet higher demands
--> arm will steal blood from brain by reversing flow in vertebral

Signs:
- claudication of arm
- posterior neuro signs (visual sx, equilibrium problems) when arm exercised

Dx:
Duplex scanning when it shows reversal of flow

Tx:
Bypass

51

When repair AAA?

> 5-6 cm --> elective repair

If grow 1cm/year or faster --> elective repair

Tender AAA (impending rupture)

Back pain in AAA pt (aneurysm is already leaking, rupture is imminent)

52

Best way to dx thoracic aortic dissection

spiral CT scan

Will have wide mediastinum on CXR

Manage ascending surgically
Descending --> medically w/ HTN control in ICU

53

Pulmonary contusion

Can be caused by severe blunt chest trauma

Dyspnea
Tachypnea
Chest pain
Hypoxemia WORSENED by intravascular volume explansion

Patchy, irregular alveolar infiltrates in CXR

54

Square root sign

Constrictive pericarditis

Equalization of pressures in RA, RV, LA, LV

55

The deep sulcus sign

is when one costophrenic angle appears much 'deeper' and more lucent than the other. Additionally, that hemidiaphragm or the adjacent cardiac border may appear much crisper (clearly defined) than the other. It can be confirmed by performing a decubitus film on which air should ascend to the abnormal side.

When a patient is supine, the air rises to the highest part of the thorax, namely the anterior costophrenic sulcus. Instead of seeing the typical lucency around the lung apex, as with an upright CXR, you see it at the base.

56

Pt has a fall and suspected rib fx. What imaging do you get?

You can just get CXR to r/o any hemithorax, pneumothorax.

You will most likely know it is rib fx so no need for imaging

ONly get rib fractures in:
- children w/ suspected hcild abuse + possible posterior rib fx
- patients w/ cancer

57

Pneumomediastinum causes

Spontaneous - usually young, fit, skinny men

Related to high inspiratory or expiratory pressures - asthma, intubated patients (often with high PEEP settings such as acute respiratory distress syndrome)

Secondary to a pneumothorax or pneumoperitoneum (e.g. laparoscopy)

Secondary to esophageal perforation (vomiting, instrumentation, tumor)

Traumatic from a tracheal or bronchial rupture

Complication of free basing cocaine

58

Coin lesions on CXR in lung common in...

areas where fungal disease is prevalent

Coccidio, histo

59

CXR has coin lesion - what is next step?

CT
- defines lesion
- examines if lymph nodes present

Needle aspiration w/ CT

60

If CT guided needle aspiration of coin lesion is malignant or indeterminate on needle bx, what do you do?

What is complicatino of needle bx

Resection

complication - PTX

61

Use of the following in examining lung lesions:
- bronchoscopy
- mediastinoscopy

Bronch = obtain tissue diagnosis and determine location of lesion

Mediastinoscopy = determines state of mediastinal lymph nodes

62

Tx small cell carcinoma of lung

Chemo b/c usually systemic spread

63

Most common non-small cell carcinomas

Tx

adenocarcionma
SCC

Stage 1 + 2:
Should resect + radiation + chemo
- exploratory thoracotomy
- lobectomy OR
- pneumonectomy (removal of all of lung)

Stage 3
- chemo + radiation

64

How can you assess percentage of functioning lung tissue pre-pneumectomy?

How about mechanics of respiration?

Percentage - V/Q perfusion scan

Mechanics - spirometry

65

Suspect pancoast tumor - workup?

CT
Bronchoscopy
Mediastinoscopy
Needle bx of mass

66

Pancoast tumor

lung cancer in extreme apex of lung in the groove produced by subclavian artery

Invades:
- chest wall
- lower cords of brachial plexus
- subclavian A
- sympathetic ganglia

Results:
- brachial plexopathy
- horner's syndrome

67

Tx pancoast tumor

Irradiation for 6 weeks
Surgical resection of invlved chest wall and lung

Pts usually do pretty well

68

Bronchial adenomas

Types:
- carcionid tumor
- adenocystic carcionmas

Can be malignant!
Often cause atelectasis b/c blcok bronchus

Bronch for definitive diagnosis

Tx: lobectomy

69

Pleural effusion in older person - work up?

Thoracentesis + pleural bx

Suspicious for malignancy/mesothelioma!

70

Tx mesothelioma

Very bad prognosis

Extrapleural pneumonectomy

71

What does it mean when you see air bubbles in the water or PleurVac fo PTX?

There is still an air leak in the patient / the patient still has air in his pleura.

72

Tx spontaneous ptx

Thorascopic excision of blebs adn pleural abrasion (pleurodesis)

73

Tx empyema

Abx
Evacuate pus via cehst tube drainage - otherwise risk empyema to become loculated and thoracotomy and decortication is needed to reexpand lung
Reexpand lung

74

Iatrogenic causes of afib

hypokalemia
fluid overload

75

esophageal cancer tx
- cervical +upper 1/3
- middle 1/3
- distal 1/3

Cervical - chemo + radiation, resection

Middle - chemo + radiation, resection

Distal - esophagectomy + proximal gastrectomy

76

Why would someone with suspected esophageal cancer cough constantly?

Could be 2/2 to chronic aspiration from tracheoesophageal fistula b/c tumor erodes into trachea

77

Anterior mediastinum masses

Teratoma
Thymoma
Thyroid cancer
Hodgkin's lymphoma

78

Middle mediastinum masses

Lymphatic tumors
Various cysts (Bronchiogenic)

79

Posterior mediastinum masses

Neurogenic tumos (from nerves and nerve sheaths in the area)
- ex: neurilemoma

80

Who benefits the most from CABG?

3 vessel disease + reduced EF

81

Best gract patency rate for CABG

Internal mammary A graf

82

1st step in management for massive hemoptysis

Worry about asphyxiation, not exsanguination

Patent airway asap!

Bronchoscopy is initial procedure b/c can localize bleeding site

83

Pt w/ recent MI --> EKG later on shows persisten ST elevation and deep Q waves in same leads

SOB -- what happened?

LV aneurysm

84

Systolic diastolic abdominal bruit + HTN + atherosclerosis - what is it?

Renal artery stenosis

NOT ab aorta aneurysm (would maybe have systolic bruit, but not systolic, diastolic)

85

Tx symptomatic sinus bradycardia

IV atropine + transcutaneous pacing

86

Pneumonitis (patchy diffuse infiltrates) + colitis in post-bone marrow transplant pt - what is organism?

CMV

Diarrhea suggests CMV! Can be P jiroveci but does not cause diarrhea

87

Dx pericardial tamponade

US

88

Tx torsades de pointes

Stop offending agents

+ Mg SO4