Surgery - Misc (Trauma, Vascular, MS, Repro, Renal) Flashcards Preview

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Flashcards in Surgery - Misc (Trauma, Vascular, MS, Repro, Renal) Deck (274):
1

Meniscal injuries
- most common when?
- signs/symptoms
- physical exam
- diagnosis?

Most often in pts in 30s-40s

Happens when performing activities needing axial loading and rotation

Classic:
- pt feels a pop followed by pain
- joint swelling following 12-24 hrs

PE:
- joint line tenderness
- decreased ROM
- + McMurray's test

MRI to dx

2

Meniscal vs. ligamentous injuries

Meniscal injuries joint swelling over 12-24 hrs

Ligamentous injuries are REALLY RAPID swelling b/c hemarthrosis
- ligaments have more blood supply than menisci
- ex: ACL tear

3

Patellar tendonitis

From chronic overuse (like strenuous athletic activities)

Point tenderness over proximal patellar tendon

4

Anserine bursitis

Anserine bursa = under conjoined tendons of gracilis and semitendinosus muscles
- separates theses muscles from head of tibia

Bursitis --> tenderness over MEDIAL knee
- usually in atheletes and obese middle age --> elderly women

5

Penile fracture
- what happens?
- treatment?

Tearing of tunica albuginea which invests the corpus cavernosum

Hematoma rapidly forms at site of injury --> bends shaft of penis at fracture site

Tx:
- emergent urethrogram to look for urethral injury
- then emergent surgery to evacuate hematoma and mend torn albuginea

6

Organs lacerated in blunt abdominal trauma

1. spleen
2. liver

7

How to evaluate blunt ab trauma

Hemodynamilcaly unstable + unresponsive to fluids --> exlap

Responds to fluids: CT scan is next best step


1. assess for intraperitoneal free fluid or hemorrhage
- use US
+ eval pericardium = focused assessment w/ sonography for trauma (FAST) exam

2. Exploratory laprotomy if diagnostic peritoneal lavage or FAST is +

OR

2. Ab CT to see if need ex lap if hemodynamically stable and (-) FAST

8

Focused assessment w/ Sonography for trauma (FAST) exam

US to detect free intraperitoneal fluid + evaluate pericardium

High sensitivity + specificity to detect hemoperitoneum, pericardial effusion, intraperitoneal fluid

9

Sepsis

Response to an infection

= SIRS w/ known infection

10

Systemic inflammatory response syndrome (SIRS)

Response to NONinfectious cause

Need at least 2/4 criteria

Temp > 101.3 or < 95
Pulse > 90
Respiration > 90
WBC > 12,000, < 4000, or > 10% bands

11

Major cause of morbidity and mortality in patients w/ total body surface burns?

Hypovolemic shock

Usually 2/2 sepsis and septic shock

12

Who do you use the following for?
- orotracheal intubation
- laryngeal mask placement
- nasotracheal intubation
- needle cricothyroidotomy

OT intubation = unstable, apneic pts

Laryngeal mask = temporary if OT intubation fails and need to figure out what to do next

NT intubation = blind procedure, pt needs to be breathing SPONTANEOUSLY

Needle CT = good for children in field. Not for adults b/c risk CO2 retention

13

+ psoas sign
no guarding, rigidity, rebound

What could be likely?

Psoas abscess
- usually staph aureus

from furuncles on leg, heme spread of bacteria, etc

Not appendicitis b/c - guarding, rigidity, rebound

CT scan to confirm

14

Steps in diagnosing peripheral artery disease

Usually due to atherosclerosis

1 is normal

1) Ankle-brachial index via Doppler
- ratio < 0.9 (nl = 1-1.3) is very sensitive and specific for > 50% occlusion in major vessel

2) If normal ABI...
- Exercise test w/ repeat ABI

15

Tx peripheral artery disease

Aspirin + cilostazol

Verapamil can improve walking distance but change ABI

Tight glucose control doesn't have significant impact on PAD

16

Most important goal in management of rib fracture?

Ensure proper analgesia

Rib fracture very painful and may cause hypoventilation ---> atelectasis or pneumonia

Can use
- NSAIDs
- opaiates
- intercostal nerve block (some risk pneumothorax)

DO NOT NEED TO DO MECH STABILIZATION OF CHEST WALL

17

Acute febrile nonhemolytic transfusion reaction
- how happen?
- tx

Happens after blood transfusions

Increase 1C + rigors

Ab bind donor cells --> activate complement --> release inflammatory cytokines

Tx:
- stop blood transfusion
- give antipyretics

18

Thigh abduction at hip

Gluteus medius
Gluteus minimus

Superior gluteal N

Palsy: Trendelenburg gait

19

Hip abduction (assists)
Knee extension (maintains)

Tensor fascia lata

Iliac crest --> fascia lata

20

Flex and laterally rotate thigh

Psoas major muscle

Transverse processes of lumbar vertebrae --> lesser trochanter of femur

21

Lateral flexion of trunk
Rib cage fixation

Quadratus lumborum

Iliac crest --> 12th rib and transverse processes of L1-L4

22

Leg extension at knee

Quadriceps femoris

23

Hip flexor

Rectus femoris

24

Most common cause of sepsis in splenectomy patients?

S. pneumo

25

If suspect child abuse...

1) Perform thorough PE + skeletal survey to document abuse

2) Report case to child protective services

3) admit pt for safety

26

How do you manage splenic trauma if patient is
- hemodynamically unstable + responds to fluids
- hemodynamically unstable + unresponsive to fluid administration?

If responds to fluids (SBP > 100
- abdmoinal CT scan

Unresponsive..
- ex lap

27

Compartment syndrome signs

Deep pain out of proportion to injury

Pulselessness

Paresthesias

Cyanosis

Pallor

PULSES present DO NOT rule out compartment syndromeage in an unstable trauma patient if FAST exam is inconclusive

28

Eschar

Firm necrotic tissue formed on exposed tissue following burn wounds

If circumferentially on extremity, can restrict outward expansion of compartment as edema builds --> vascular flow compromised --> compartment syndrome

Need to do escharotomy

Also do escharotomy if muscle compartment pressure > 30 mmHg

29

Abdominal bleeding - diagnostics?

Hemodynamically stable --> abdominal CT

Hemodynamically unstable --> FAST US, then DPL

30

Rupture of tendon of long head of biceps

Biceps muscle belly becomes prominent in mid upper arm

Weakness in supination

Forearm flexion OK

31

+ drop arm sign in shoulder injury

Rotator cuff tear

32

Better to dx diffuse axonal injury

MRI

CT will show many minute punctate hemorrhages w/ blurring of grey white interface

33

Nasal septum surgery - complications

Difficult to heal b/c septum poorly perfused cartilage

Can result in septal perforation = whistling noise during repisration

34

Nasal furunculosis

From staph folliculitis

Usually after nose picking or nasal hair plucking

Can be life threatening if spreads to cavernous sinus

Pain, tenderness, erythema in nasal vestibule

35

Best for animal bites

Unasyn (ampicillin + sulbactam)

36

How are hip fractures classified?

By anatomic location and fracture type

Intracapsular
- femoral neck and head
-----> higher chance of avascular necrosis

Extracapsular
- intertrochanteric and subtrochanteric
------> greater need for implant devices (eg nails and rods)

37

Risk factors for VTE

MOIST

Malignancy
Motherhood

Ortho procedures
Oral contraceptives

Immobility
Inflammation (lupus)

Surgery

Trauma
Thrombophilic disorder or previous DVT

38

Can you infuse vanco fast into blood? Why not?

NO!

Will cause thrombophlebitis

39

What to do for hydrocele in newborn?

Nothing!

Most will resolve by age of 12 months
- can be safely observed during that period

Communicating hydrocele needs surgery

40

Kehr sign

L shoulder pain referred from splenic hemorrhage irritating phrenic N and diaphragm

41

Signs of necrotizing infection

Intense pain in wound

Fever, hypotension, tachy

Decreased sensitivity at edges of wound

Cloudy-gray discharge

Tense edema outside involved skin

SubQ gas w/ crepitus

42

Acute pain
Swelling
of midline sacrococcygeal skin + subQ tissues

Infection of pilonidal cyst

Most common in young males w/ larger amts of body hair

Can spread to form abscess

Drain abscess and excise sinus tracts

43

Nerve entrapment features

Radiating pain

Not reproducible usually with palpation

44

Central cord syndrome

Classical w/ hyperextension injuries in elderly w/ degen changes in cervical spine

Selective damage to central portion of anterior spinal cord

Weakness more pronounced in upper extremities than in lower extremities
- arm motor fibers nearer to central part of corticospinal tract

45

Tx scaphoid bone fractures

If nondisplaced, wrist immobilization for 6-10 wks

If displaced (>2mm), open reduction and internal fixation

46

Most common peripheral artery aneurysms

Popliteal > femoral

47

Hemodynamically unstable victim of MVA w/ suspected blunt ab trauma (BAT), management?

C-spine immobilization

IV hydration

FAST

48

Hemodynamically stable victim of MVA w/ suspected BAT, management?

CT scan of abdomen w/ contrast

Quantify amt of blood

Surgeon selects laparotomy or admission and observation based on CT result

49

Drugs increasing cAMP

Increases heart contractility
Relaxes smooth muscle of arteries

Theophylline

PDE-3 inhibitors:
- Millrinone
- Caffeine
- cilostazol
- dipyridamole

50

Drugs increase cGMP

Hydralazine
Nitroprusside
Nitroglycerin

PDE-5 inhibitors:
Sildenafil

51

Next steps in management after a fall showing a hip fracture

1) Stabilization, treatment for pain control, DVT ppx

2) Figure out cause of fall and assess preop risk

In elderly, commonly:
- syncope (arrhythmia, valves)
- ACS
- Heart failure
- CNS pathology (TIA, stroke)
- infection (PNA)
- metabolic (Hypoglycemia)

Get:
- EKG
- trops
- CXR

52

Stasis dermatitis
- pathology

LE venous valvular incompetence --->
Pooling of venous blood and increased P in postcapillary venules --->
Damages capillaries w/ increased P --->
Lose fluid, plasma proteins, RBC into tissue -->
RBC extravasation causes hemosidering deposition -->
get classic color of stasis dermatitis

Xerosis is most common early finding

53

Preeclampsia

Triad of
HTN
Proteinuria
Edema

54

Todd paralysis

Transient unilateral weakness after tonic-clonic seizure that usually resolves

55

What's a common physical sequelae after grand mal seizure?

Posterior dislocations of shoulder

Pt holds arm addudcted and internally rotated

56

Anterior urethra injuries
- where is the injury?
- how does it happen?
- findings

Injury to urethra distal to urogenital diaphragm

Usually due to blunt trauma to perineum (straddle injuries) OR instrumentation of urethra

Exam:
- perineal tenderness/hematoma
- normal prostate
- bleeding from urethra

Findings:
- may not complain of inability to urinate
- delayed presentation can be complicated by sepsis 2/2 to extravasation of urine into scrotum, abdominal wall

Tx:
- immediate surgical repair

57

Posterior urethra injuries
- where is the injury?
- how does it happen?
- findings

Injury to prostatic and membranous urethra

Usually assoc w/ fractures of pelvis

Exam:
- blood at urethral meatus
- high riding prostate (b/c displaced by pelvic hematoma)
- scrotal hematoma
- pelvic fracture

Findings:
- suprapubic pain
- inability to void following major trauma

Tx step 1:
- retrograde urethrogram

58

Where are most clavicular fractures?

In middle 1/3 of bone

Shoulder of affected side is displaced inferiorly and posteriorly

59

Clavicular fracture ID'd - what do next?

Careful neurovascular exam b/c clavicle close to subclavian A and brachial plexus

Angiogram if hear bruit in clavicle area

60

Fixing clavicle fractures

middle 1/3 --> nonoperative w/ brace, rest, ice

distal 1/3 --> open reduction + internal fixation

61

Thessaly test

Pain or locking w/ internal and external rotation of knee while standing on 1 leg w/ knee flexed to 20 degrees

62

McMurray test

Painful clock w/ passive flexion and extension of knee w/ examiner's thumb and index finger placed on medial and lateral joint lines

63

Apley test

Pain w/ pressing heel toward floor while internally and externally rotating foot w/ knee flexed to 90 degrees

64

What to use to dx meniscal injuries?

MRI

65

Manage traumatic spinal cord injuries

1) Hemodynamically stabilized
2) proper airway management
3) stabilize neck until spine injury r/o
4) Urinary catheter placement to assess urinary retention and prevent bladder distention and damage

66

Fat embolism signs

Severe respiratory distress
- increasing diffuse b/l pulm infiltrates on serial CXR
Petechial rash
Subconj hemorrhage
Tachycardia
Tachypnea
Fever

Dx w/ fat droplets in urine or intraarterial fat flobules on fundoscopy

Happens 12-72 hrs after fracture injrueis

67

Tx fat embolism

Respiratory support

Controversial:
- heparin
- steroids
- LMW dexxtran

68

Kidney stones in Chrons disease?

Hyperoxaluria

Usually Ca binds oxalate in gut and prevents absorption
In fat malabsorb from Crohns, Ca bound by fat and oxalate is unbound and free to absorb in blood

ALSO, failure of reabsorb bile salts can damage colonic mucosa and cause more oxalate absorption

69

What kinds of catheters have higher rate of infection?

Femoral > subclavian

Usually due to Staph but femoral catheters can also be due to Gm - bacteria

70

Dx ACL tears?

Lachman's test (like anterior drawer but 30 degree flexion)
Anterior drawer test
Pivot shift test

71

What is GCS used for?

Predicts prognosis of coma and other medical conditions (bacterial meningitis, TBI, subarachnoid hemorrahage)

NOT used to diagnose coma

72

Findings used to dx coma

Impaired brainstem activity (disruption of pupillary light, Extraocular, and corneal reflexes)

Motor dysfunction (decorticate or decerebrate posturing)

Impaired level of consciousness

73

Slipped capital femoral epiphysis

Displacement of femoral head on femoral neck b/c disrupt proximal femoral growth plate

Usually seen in obese adolescent boys
- obesity increases shear stress and physis (physical junction b/n femoral head and neck) fractures and femoral head slips POSTERIORLY + MEDIALLY relative to neck

PE
- loss of abduction and internal rotation
- + external rotation of thigh while hip flexed

Tx: surgical pinning of slipped epiphysis to lessen risks of avascular necrosis or chondrolysis

74

Most common carpal bone fracture

Scaphoid

ON radial side of wrist

Usually get max pain in anatomic snuffbox, min dec ROM, decreased grip strength, possible swelling

75

Suspected scapohid fracture but not present on xray - what do you do?

Can take up to 10 days to show abnormalities on xrays

Immobilize wrist w/ thumb spica cast for 7-10 days followed by repeating xrays

CT or MRI of wrist can distinguish b/n fracture and ligament injries

76

Needle shaped crystals on urinalysis + ileus - what do you do next/

CT scan of abdomen or intravenous pyelography

Probably have uric acid stones, not seen on xray

Ileus probably due to vagal rxn from ureteral colic - ileus over when ureterolithiasis is treated

77

Part of bladder that is covered by peritoneum and is most susceptible to rupture

Dome of bladder

Can get irritation of peritonitis and irritation of diaphragm

78

Most common site of extraperitoneal bladder rupture

Bladder neck

79

Ludwig angina

Rapidly progressive bilateral cellulitis of submandibular and sublingual spaces

Usually from infected 2nd or 3rd mandibular molar

Usually Strep and anaerobes

Sx:
Fever
Dysphagia
Odynophagia
Drooling
--> due to swelling of submandibular space + posterior displacement of tongue

COD: asphyxiation

80

How does hearing loss happen in Paget's?

Cochelar N damage
- enlargement of temporal bone --> impinge on internal auditory meatus

81

Carcinomas that love to spread hematogenously

RCC
HCC
Follicular thyroid carcinoma
Choriocarcionma
Prostate adenocarcionma

82

Opioid agonist

Activate all 3 receptors

Fentanyl
Morphine
Hydromorphone

83

Agonist-antagonist opioids

Mixed: Butorphanol, nalbuphine, pentazocine
- block mu but activate kappa receptor

Partial: Buphenorphine
- block kappa, weak mu receptor activator

84

Antagonist opioids

Antagonist at mu receptors

Naloxone
Naltrexone
Alvimopan
Methylnatrexone

85

Cancers w/ osteolytic lesions (and hypercalcemia of malignancy as a result!)

BLT with a Kosher Pickle, Mustard & Mayo

B = breast cancer
L = lymphoma, lung cancer
T = thyroid cancer
K = kidney cancer
P = prostate cancer
M & M = multiple myeloma

86

How are opioids (morphine, hydromorphone, fentanyl) eliminated?

Renal

Hydromorphone is metabolized via glucuronidation (not lost as much w/ age) so can have inactive metabolite (vs morphine and fentanyl which are CYP metabolized so may have accumulation if CYP enzymes lost)

87

Acute limb ischemia
- signs

- Pallor
- Paresthesias
- Pain
- Pulselessness
- Poiklothermia
- Paresis/paralysis

88

3 layers of blood vessel

Adventita
Media
Intima

Adventitia is strongest

89

Time before acute limb ischemia causes necrosis of tissue

6 hrs

90

1/2 life of heparin

90 min

91

If rutherford classification I, what do you do?

Time to work up

+ heparin ASAP

92

If rutherford classification IIa, what do you do?

still have some time but need to be quicker than I

+ heparin asap

93

If rutherford classification IIb, what do you do?

Now have only 6 hrs before necrosis of tissue
- ASAP emergency
- very acute emergency

+ heparin

94

Rutherford classification

Urgency need to tx acute limb ischemia

o I = No pulse, OK sensory and motor
o IIa = No pulse, no sensory, OK motor
o IIb = No pulse, no sensory, no motor
o III = Rigor (dead extremity)

95

If rutherford classification III, what do you do?

DO NOT reperfuse! Will get reperfusion injury from all the dead cell released products

Get an amputation

96

1st sign of compartment syndrome

paresthesia in 1st web space
- deep peroneal N innervates this and is in ANTERIOR compartment

REMEMBER: compartment syndrome is a clinical diagnosis

97

Compartment of leg most susceptible to compartment syndrome

Anterior compartment

98

Risks after vascular surgery after acute limb ischemia blood flow restoration?

Reperfusion injury
Edema
Compartment syndrome

99

Pulse volume recording

 BP cuffs on whole leg (Thigh, calf, foot)
 Increase cuff pressure to 60 mmHg to obstruct venous flow
 Will give tracing of pulses
 Height of tracing will tell you amount of blood flow going through.
 Can tell you ~where obstruction is

100

What is utility of PVR?

 Ex: if diabetic, can have falsely elevated ABI b/c not compressible vessels (they are calcified)
 PVR will eliminate that problem with ABI

101

When do surgery on claudication of leg?

If have extreme impact on lifestyle (QOL) if there is relatively low risk

102

What are the components of a duplex ultrasound?

B mode imaging (architecture of vessels)
• Can see stenotic area

Color flow (velocities), in cm/s
• Will have increased velocity in stenotic areas
• Want to compare the increased velocity area with areas before and after – how hemodynamically unstable is this area based on how much increase in velocity?

103

Glasgow Coma Scale (GCS)

Eyes (4)
1 - No eye opening
2 - Eye opening in response to pain stimulus
3 - Eye opening to speech
4 - Eyes opening spontaneously

**if awaken sleeping pt w/ speech, this is a 4, not a 3

Motor (6)
1 - No motor response
2 - Decerebrate
3 - Decorticate
4 - Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5 - Localizes to pain.
6 - Obeys commands (thumbs up, wiggle toes)

Verbal (5)
1 - No verbal response
2 - Incomprehensible sounds. (Moaning but no words.)
3 - Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4 - Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5 - Oriented. (AAOx3)

104

Decerebrate posturing

extensor posturing:
abduction of arm,
external rotation of shoulder,
supination of forearm,
extension of wrist

105

Decorticate posturing

flexor posturing:
adduction of arm,
internal rotation of shoulder,
pronation of forearm,
flexion of wrist

106

CPP =

MAP - ICP

CPP should be > 50

If CPP too high, increase risk of HTN hemorrhage
- cerebral blood flow vs. CPP should be constant ratio

107

What happens when you have too much CO2 in brain?

Increase blood flow for O2 delivery, increase pressure in brain

108

What's the most sensitive test for weakness?

Pronator drift

Supinator muscle is smallest muscle in arm --> if have weakness, will pronate drift down

109

Hoffman's reflex

Flick middle finger, thumb will move up and down

110

How can you grossly test urinary function?

Cremasteric reflex

111

Why is blood hyperdense on CT?

Because of the iron! that's why it will become hypodense when the iron gets out of the blood in the brain on CT

112

Why is dura hyperdense on CT?

B/c it is very vascularized

113

CSF drainage path

Choroid plexus
Lateral ventricle
Interventricular foramen of Monro
3rd ventricle
Aqueduct of sylvius
4th ventricle
Foramen of Luschka and Magendie
Subarachnoid space around spinal cord
Arachnoid granulations
Venous sinuses

114

Why should you hyperventilate in brain injury?

Will decrease CO2
Brain will think it has too much blood perfusion
Will decrease arterial blood flow to brain
This will decrease ICP

115

Morton neuroma

Happens in runners

Mechanically induced neuropathic degen w/ sx of numbness, burning of toes, achin and burning in distal forefoot radiating forward from metatarsals to 3rd and 4th toes

PE
- pain b/n 3rd and 4th toes, plantar surface
- clicking sensation (mulder sign) w/ palpating space and squeezing metatarsal joints

Tx;
metatarsal support w/ padded shoe inserts
- surgery if conservative tx fails

116

Tarsal tunnel syndrome

Compression of tibial N as passes through ankle
- caused by fracture of bones around ankle

117

Malignancy on chronically wounded, scarred or inflamed skin

Squamous cell carcionma

Is Marjolin ulcer if SCC arises in burn wounds

118

Where should central venous catheters be to avoid myocardial perf?

Tip should be proximal to cardiac silhouette

OR

Angle b/n trachae and R mainstem bronchus

Catheter should be in SVC

Always do CXR after get catheterized

119

Effect of + pressure mech ventilation

Increases Intrathoracic P -->
Inc R atrial pressure -->
Decrease systemic venous return

Can cause circulatory failure and death

120

Diffuse axonal injury

Result of traumatic acceleration/deceleration-shearing forces

Damage axons in brain

Head CT: nl or diffuse small bleeds at grey-white matter junctions

121

Leriche syndrome

Arterial occlusion @ bifurcation of aorta into common iliacs

Bilateral hip, thigh, and buttock claudication
Impotence

122

Psoas test

passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip

The pain results because the psoas borders the peritoneal cavity, so stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the muscles causes friction against nearby inflamed tissues

123

Volkmann's ischemic contracture

Final sequel of compartment syndrome

Dead muscle replaced w/ fibrous tissue

124

Causes of hypocalcemia

Hypoalbumin

HypoMg

HYPERcitrate (eg blood transfusion)

125

1st physio signs of hemorrhage

Tachycardia

Peripheral vascular constriction

126

High PTH, normal Ca --- what does person have?

Vitamin D deficiency if getting Ca supplements

127

Dx urinary stones

non-contast sprial CT of ab + pelvis

128

Most commonly injured metatarsal in hairline fractures of metatarsals

2nd

Tx: rest, analgesia, hard-soled shoe

129

Valgus vs varus

Valgus = abducion at knee

Varus = adduction at knee

130

Tx MCL tears

Surgery rarely necessary

Bracing and early ambulation preferred

131

When is brachial artery usually injured

supracondylar fracture of humerus (esp in children)

Can get ischemia - pain, pallor, pulselesness, pressure, paresthesia

132

Tx subluxation of head of radius

Extend and distract elbow
Supinate forearm
Hyperflex elbow w /thumb over radial head to feel reduction as it occurs

133

Artery of adamkieqicz spans...

T9 -T12

ASA

134

Nasopharyngeal carcinoma associations

EBV
Smoking
Chronic nitrosamine consumption

135

Legg-Calve-Perthes disease

Idiopathic avascular necrosis of femoral capital epiphysis

Usually in boys 4-10yo

Sx:
Unilateral subacute hip pain
Antalgic gait
thigh muscle atrophy
dec ROM
Collapse of ipsilateral femoral head on plain pelvic xrays

Tx:
Conservative
Observation + bracing

136

What are these?
abl
cmyc
bcl2
Her2/neu
ras
L--myc
N-myc
ret
c-kit

Oncogenes

abl = CML

cmyc = Burkitts lymphoma

bcl2 = follicular lymphoma

Her2/neu = breast, ovarian, gastric

ras = colon carcinoma

L--myc = Lung tumor

N-myc = Neuroblastoma

ret = Men 2A and 2B

c-kit = GIST

137

What are these?
Rb
p53
BRCA1
BRCA2
p16
BRAF
APC
WTf
NF1
NF2
DPC4
DCC

Tumor suppressor genes
- lose function, increase cancer risk

Rb = retinoblastoma, osteosarcoma

p53 = li-fraumeni, most human cancers

BRCA1 = breast + ovarian
BRCA2 = breast + ovarian

p16 = Melanoma
BRAF = Melanoma

APC = Colorectal cancer

WTf = Wilms Tumor

NF1 = NF-1
NF2 = NF-2

DPC4 = Pancreatic cancer

DCC = Colorectal cancer

138

Trousseau's sign

Carpal spasm

OR

Use BP cuff to cut off brachial A flow

In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm.

The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.

139

Chvostek's sign

When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia with resultant hyperexcitability of nerves

Will get spasm of obicularis muscle
Can also happen w/ hypoMg

140

What do you watch out for in P vera surgical pt?

Usually are thrombocytosis but have hemorrhagic tendency b/c qualitative deficiency of platelets

Can use busulfan or chlorambucil to decrease Hct levels

141

1/2 life of FFP

4-6 hrs

b/c factor 7 is most stable 1/2 life at 4-6 hrs

142

Body water distribution

60-40-20

60% TBW
40% ICF (2/3 of TBW)
20% ECF (1/3 of TBW)

50% TBW ---> 2/3 ICF, 1/3 ECF --> 1/4 plasma volume, 3/4 interstitial volume

Plasma volume measured by albumin
Extracellular volume measured by albumin

143

Serum osmolality =

2Na +
BUN / 2.8 +
Glucose / 18

144

If you give normal saline in huge amounts for resuscitation, what can happen?

Hyperchloremic metabolic acidosis

145

What is in lactate ringers?

Less Na, Cl

BUT also has K, Ca, Bicarb

Be careful with hyperkalemia!

Good for hyperchloremic metabolic acidosis

146

Replacement strategies for losses in:
sweat
gastric
biliary/pancreatic
small bowel s/p NGT
colon
3rd space losses

Sweat - D5 1/2 NS + KCl
Gastric - D5 1/2 NS + KCl
Biliary/pancreatic - LR
Small bowel - LR
Colon - LR
3rd space losses - LR

147

Indicators of successful resuscitation

Tachy gone

UO

Clearance of lactate

Resolution of base deficit

SvO2 = 70%
- [ O2] at pulmonary A port and is most deO2 blood in body

BP IS BAD INDICATOR!

148

Major drawbacks of general anesthesia

Increase incidence of pulm complications
Mild cardiodepression from anesthetic

149

Effect on platelets of aspirin and NSAIDs?

Aspirin = irreversible on plt aggregation for 7-10 days

NSAIDs = reversible

D/c aspirin for 7-10 days before surgery
D/c NSAIDs 2 days before surgery

150

Should hypercholesterolemia alone postpone surgery?

NO!

151

w/ PAD, how do you do a stress test?

Persantine thallium stress test

Dobutamine echo

152

BK virus

Specific to kidney transplant

"bad kidney"

In same family as JC virus
Will attack kidney

153

Does platelet transfusion in a pt w/ plt dysfunction due to uremia help?

NO!

Use
demopressin (ddAVP)
FFP
Conjugated estrogens (slower)

154

Most common physio cause of hypoxemia is

Ventillation perfusion inequality

155

What to do after hemolytic reaction caused by ABO incompatability happens?

Stop transfusion
Put in foley catheter and monitor UO hourly
Give mannitol + alkalinze urine to prevent precipitation in kidneys
Restrict fluids and K in presence of severe oliguria or anuria

156

Which anesthetic has low solubility and fills air spaces during prolonged anesthesia?

Nitrous oxide

157

Dopamine actions on receptors

Low doses --> D receptor --> increase renal flow, slight increase

Med dose --> B1 receptor --> inotropic effect on heart to increase CO and BP

High dose --> a1-receptor --> periph vasoconstriction, decreased kidney fxn, HTN

158

In blood, where is CMV?

Blood leukocytes

Blood products not routinely tested for CMV

159

Most common viral transfusion in blood transfusion?

non A non B hepatitis (usually hep C)

CAn cause chronic hepatitis in ~16% of pts

160

Foster Kennedy syndrome

refers to a constellation of findings associated with tumors of the frontal lobe.

161

Early phase of shock, what is
pH
pCO2
pO2

Mild hypoxia --> low O2

Compensatory hyperventilation --> low CO2

Respiratory alkalosis --> high pH

162

What does epi in lidocaine do for the drug?

Double duration of infiltration anesthesia

Increases max safe total dose by decreasing rate of absorption of drug into bloodstream

DO NOT INJECT into finger, nose, toes, hose (penis), ears

163

Transfusions of blood through
- hypotonic solutions
- ringers lactate

what happens?

Hypotonic (D5W / NS)
- swelling of erythrocytes and lysis

Ringers lactate
- has Ca and causes clotting in IV line --> PE can happen

164

Paradoxical aciduria

Hypokalemic metabolic alkalosis
- kidneys excrete H+ to try and save K+

165

Oxygen demanding organs

Brain
Kidney
Liver
Heart

Kidney is not as metabolically active as brain and heart but gets lots of blood for filtration

Coronary V lowest O2 content in blood because heart really extracts O2

166

S/E: anesthetic causing seizures

Enflurane

HaLi MeKid EnCon
Halothane = liver
Methoxyflurane= Kidney
Enflurane = Convulsant

167

S/E: Halothane

CV depression
Hypotension
decreased peripheral vascular resistance

168

S/E: Methoxyflurane

nephrotoxicity due to free F ions released during biodegradation

169

Carotid body innervated by

CN 9 - nerve of Herring

170

PT measures

Extrinsic path

Factors:
2
5
7
10
Fibrinogen

171

PTT measures

Intinsic path

Factors:
8
9
11
12

172

Bleeding time measures

Interaction of plt and formation of plt plug

Qualitative and quantitative defect in plt fxn

173

Thrombin time measures

Qualitative abnormalities in fibrinogen and presence of inhibitors to fibrin polymerization

174

Lymphangitic inflammatory streaking up a person's limb - what is it caused by?

Strep infection

Penicillin to tx!

175

Early wound management....

Early excision of areas of devitalized tissue with exception of deep wounds of
palms
soles
genitals
face

Staged excision of deep partial thickness or full thickness burns happen 3-7 days after injury

176

Carpal tunnel syndrome
- associations
- surgery - what do you do?

Assoc w/ pregnancy b/c have fluid retention

Surgery will release adhesions of median N and divide transverse carpal ligament

Extensor retinaculum is on DORSUM of the wrist and has extensor tendons -- NOT FOR CARPAL TUNNEL

177

How often is leukoplakia develping into cancer?

5%

178

Cystic hygromas

Mass of lymphatic vessels in the head and neck region

Usually congenital

Surgical excision

179

Hypocapnia and preggers

Caused by direct stim effect of progesterone on central respiratory center
--> leads to increased resp drive and exaggerated resp effort --> primary resp alkalosis w/ metabolic compensation

180

Clotting factors
- where do they come from?

Liver! All do except 8 (come from endothelium too)

Vit K dependent: 2, 7, 9, 10, C, S

181

Anion Gap =

Na - (HCO3 + Cl)

Increased AG met acidosis:
Methanol
Uremia
DKA
Phenacetin
INH
Lactic acidosis
Ethylene Glycol
Salicylates

182

Electolyte abnormalities in chronic EtOH

hypoMg
hypo K
hypo PO4

hypo Mg will cause refractory hypo K

183

Reactive leukocytosis after surgery - causes

Steroids
Infection
Stress

184

What test is best to eval bladder?

Cystoscopy

185

Good markers for ischemia

Lactate

Base deficit
- A base deficit (a below-normal base excess), thus metabolic acidosis, usually involves either excretion of bicarbonate or neutralization of bicarbonate by excess organic acids

186

If need an airway but intubation can't be done for some reason, what do we do?

Cricothyroidotomy

Usually don't do before 12 yo b/c of possible need for future laryngeal reconstruction

187

Trauma - Airway
- how do you know it is there?
- when do you secure one
- how do you secure one?

OK - pt is conscious and speaking in nl tone of voice

Need if:
- pt unconscious
- breathing noisy or gurgly
- inhalation injury

Get airway BEFORE securing cervical spine injury

Secure w/ orotracheal intubation or nasotracheal intubation

Use fiberoptic bronchoscope if there is subQ emphysema in neck --> sign of major traumatic disruption of tracheobronchial tree

188

Trauma - Breathing
- how do you know it is ok?

breath sounds b/l
ok pulse ox

189

Trauma - Circulation
- signs of shock
- causes of shock
- tx hemorrhagic shock

Signs:
- low bp
- fast pulse
- low UO
- pale, cold, shivering, sweating, thirsty, apprehensive

Causes:
- bleeding (CVP low)
- pericardial tamponode (CVP high)
- tension pneumo (CVP high, resp distress)

Tx:
- if big trauma center nearby surgery 1st, then vol replacement
- if not, vol replacement (2L Ringer lactate w/o sugar) + blood until UO = 0.5 mL/kg/hr and CVP not more than 15 mmHg

190

Ways to do fluid resuscitation

2 peripheral IV lines, 16 gauge

Percutaneous femoral vein catheter

Intraosseous cannulation of proximal tibia

191

Tx linear skull fracture

If closed --> leave alone

Open --> wound closure

Comminuted or depressed --> OR

192

Signs of fx @ base of skull

Racoon eyes
Rhinorrhea
Otorrhea
Ecchymosis behind ear

CT scan to see

DO NOT do nasal endotracheal intubation

193

Penetrating neck traumas - tx for:
- upper zone
- middle zone
- base of neck

- when do surgical exploration?

Surgical exploration in all cases where there is an expanding hematoma, deteriorating vital signs or clear signs of esophageal or tracheal injury

Upper = arteriographic dx

Middle = surgery if symptomatic

Base = arteriography, esophogram (barium), esophagoscopy, bronchoscopy to help decide surgery

194

Central cord syndrome

Usually in elderly

Forced hyperextension of neck (ear end collision)

195

Tx rib fracture

Nerve block + epidural catheter

NOT binding!

196

Rare potential sequelae of injuries affecting renal pedicle in blunt trauma..

AV fistula --> CHF

197

Extent of burns in adult

Rule of 9's

9 = Head, each of upper extremities
18 = each LE
36 = trunk

198

Fluid replacement in burns

Aim for hourly UP of 1-2 mL/kg/hr while avoiding CVP > 15 mmHg

Usually 1000 cc/hr Ringer lactate (w/o sugar) if burns > 20%
- don't use sugar b/c will induce osmotic diuresis from glycosuria which would invalidate the UO measurement

199

Extent of burns in babies

18 = head
27 = both lower extremities

200

Tx burns

Tetanus ppx
Clean burn areas

Topical agents:
- silver sulfadiazine
- mafenide acetate (for deep penetration)
- triple abx if burns near eyes

2-3 wks wound care -- >if not regen, grafting needed

201

When do you graft asap for burns?

Limited burns that are obviously 3rd degree

202

Snakebites
- dosage of antivenin?
- first aid at site?

Dosage relates to size of envenomation, not size of pts

First aid = splint extremity during transport

DO NOT suck out venom, wrap with ice, touniquet, or make cruciate cuts

203

Tx black widow bite

IV calcium gluconate

204

Tx brown recluse spider bites

Dapsone

Surgical excision may be needed- tx

205

Developmental dysplasia of hip
- dx
- tx

Signs:
- uneven gluteal folds
- hops easily dislocated posteriorly w/ jerk and click

Dx: US (NO Xray as babies hips are not calcified)

Tx: abduction splinting w/ Pavlik harness for 6 mo

206

Dx osteo

MRI

207

Osgood Schlatter disease

IN teens w/ persisten pain over tibial tubercle
- aggravated by contraction of quads

No knee swelling

Tx: Rest, Ice, compression, elevation (RICE)
extension or cylinder cast if RICE doesn't work

208

Scoliosis

Usually girls

Thoracic spines curve towards right

209

Fractures:
- Colles
- Monteggia
- Galeazzi

Colles = wrist fracture, usually on old women

Monteggia = direct blow to ulna (protect yourself from cop with stick) --> fx proximal ulna, anterior dislocation of radial head

Galeazzi = Hit distal radial

210

Open fx treatment

Cleaning in OR
suitable reduction w/in 6 hrs of injury

211

DeQuervain tenosynovitis

Usually in women w/ babies

Pain along radial side of wrist and first dorsal compartment

Get pain w/ thumb inside closed fist and forcing wrist into ulnar deviation

Tx w/ steroid injection best

212

Jersey finger vs Mallet finger

Jersey = injured flexor tendon; can't flex
"Jersey can't flex"

Mallet = injured extensor tendon

213

Tx amputated fingers

clean w/ steroile saline
wrap in saline gauze
put in sealed plastic bag on icee

DO NOT allow to freeze, do not put antiseptic solutions on

214

Lumbar disk herniation usually...

L4-L5

L5-S1

+ Straight leg test

MRI to dx

215

What is a sign of sepsis in babies?

Rapidly dropping platelet count

216

Branchial cleft cyst

Along anterior edge of SCM

217

Cystic hygroma

at base of neck as large, mushy ill definied mass

Usually takes up entire supraclavicular area and can extend deeper into chest

CT scan before surgery is best so know how far lesion goes

218

Epistaxis in juvenile - what do you suspect?

Cocaine abuse or juvenile nasopharyngeal angiofibroma

WIll be posterior septum problem (vs anterior septum in nosepicker).

Resect the angiofibroma b/c it is benign but can eat away at nearby structures

219

Dizziness 2/2 inner ear vs brain

Inner ear = room is spinning around them
- tx w/ meclizine, Phenergan or diazepam

Brain = room is steady but pt is unsteady

220

Tx reflex sympathetic dystrophy (causalgia)

Sympathetic block is diagnostic

Surgical sympathetctomy to cure

221

TEsticular torsion vs. acute epididymitis

Very similar in presentation

Torsion - no imaging needed. Surgery + orchiopexy to tx

Epididymitis - fever + pyuria, testis in normal position
- use sonogram to r/o torsion just in case

222

Urologic workup

IV pyelogram used to be in favor but limitations include allergic rxn and contraindication if Cr > 2

CT for renal tumors

US for obstruction in kidney

Cystoscopy for cancers in blader mucosa

223

#1 cause for newborn boy not to urinate in 1st day of life

Posterior urethral valves

Voiding cystourethrogram is dx

Tx: endoscopic fulguration or resection

224

Hypospadia

urethral opening on ventral side (underside) of penis

DO NOT do circumcision as will need tissue for plastic reconstruction

225

Workup of hematuria

Whn do you not work up?

CT scan
Cystoscopy (r/o bladder ca)

Dont work up if hematuria (trace) after significant trauma

226

Tx bladder ca

Surgery

Intravesical BCG

F/u closely b/c local recurrence is high

227

When does a man w/ urinary retention get worse?

During a cold

W/ use of antihhistamines adn nasal drops + abundant fluid intake

228

What is a contraindication to organ donation

HIV status is only absolute contraindication

229

Severe nutritional depletion signs
- can you have surgery?

Loss of 20% of body wt
Albumin < 3
Anergy to skin antigens
transferrin < 200

Very high risk surgery but can undergo if get 7-10 days (optimal) of TPN

230

tx penetrating urologic injuries

Surgical exploration - do for all!

231

When can femoral fractures cause shock?

If bilateral and comminuted (smashed into a million pieces!)

232

What happens when a person trying to pass a stone (kidney) spikes a fever or white count?

Put in stent or nephrostomy tube asap to decompress! This is emergency and kidneys could fail in a few hrs

233

Will aorta look bigger or smaller on lateral xray?

bigger

subtract 20% from size

234

Easiest method to evaluate ab aorta

US

5mm error in measurement

235

Most accurate to assess ab aortic aneurysm

CT

CT angiography

236

F/u s/p endovascular repair of AAA

Annual CT and US exams

Need to make sure no endograft leak (~20% do)

237

If have hematoma s/p carotid endartectomy, what do you do first?

Open up wound at bedside

DO NOT intubate first

238

CN injury in CEA

Glossopharyngeal
- dysphagia
- soft palate dysfunction
- nasal regurg

vagus
- hoarseness

Hypoglossal
- ipsilateral tongue deviation

239

INITIAL trauma series is usually

an AP (supine) CXR on a trauma board

an AP pelvis radiograph

a cross-table lateral c-spine radiograph

240

Eval aortic arch injury without contrast media

MRI is a great means of studying the aorta, but it is a much longer examination and may not be suitable for unstable patients. We also cannot allow any ferromagnetic metal into the MRI scanner and it can be very difficult to be sure there is no metal in or on a trauma emergency patient.

Transesophageal echo would probably be the next choice in this situation - this can be performed in the ED or the operating room, but may require sedation or anesthesia.

Transthoracic ultrasound is not a good option to evaluate Mr. Roger’s aorta. Although it may show the lower portion of the ascending aorta well, it does not display the arch and descending aorta adequately due to the overlying lung.

241

Contraindications to CT contrast

Contraindications to CT IV contrast media:
- Previous allergic reaction to IV iodinated contrast
- Renal failure

Not contraindications:
- Glucophage/Metformin - Metformin is discontinued for 48 hours after the contrast enhanced CT and reinstated after confirming that the creatinine is normal.
- Multiple myeloma
- Thyroid disease
- Seafood allergy - This allergy is to a protein in seafood not the iodine. Actually the ‘allergy’ to contrast is to the compound that the iodine attaches, not the iodine

242

Hematuria evaluation

ivp first then cystoscopy if normal

243

Flank mass eval

do ivp and ct to eval for rcc

244

Asymptomatic prostatic cancer not treated after age..

75

245

Rock hard testicle
- what to suspect
- what do you do?

Testicular cancer

Do not bx. Do orhiectomy ASAP

246

Complicated UTI in men
- management

start with ivp and sonogram instead of cystoscopy as you risk septic shock with instrumenting an infected bladder

247

Pneumaturia
- 2/2
- what do you do?

will be due to a colovesicular fistula

need to do ct scan to rule out cancer in sigmoid

248

Psychogrnic impotence tx

needs psychotherapy ASAP. Will be reversible after 2 yrs

249

Perioperative risk of stroke for CEA

1-3%

250

Most common site of lower body arterial occlusion 2/2 arterial emboli

Common femoral artery (45%)

251

Tx arterial embolism in lower periphery

ballroon cathete embolectomy

252

Most common site for claudication occlusion (long trm process)

superficial femoral artery

253

rest pain ABI

0.3-0.5

254

Why will BP / ABI measurements be incorrect in diabetics?

B/c usually ahve calcified vessels preventing arterial occlusion w/ BP cuff

Reverse flow component can be lost

255

What does it mean that the Doppler waveform is triphasic?

Phases:
1- rapid systolic flow
2- brief reverse flow 2/2 elastic recoil of vesel
3 - long diastolic outflow

If severe atherosclerosis, wafeform can become monophasic as may lose 2 and 3 phases

256

Tx for patiens with claudication in distal lower extremity (peripheral artery disease)?

Mostly don't perform surgery

257

Tx claudication causing absence of femoral pulse

This is suggestive of aortoiliac occlusive diseae

Surgery is considered b/c more progressive than periph occlusive diseas

258

What is a pt with peripheral artery disease likely to die of?

coronary artery disease / MI

259

When do you get an artetriogram for claudication?

If you decide to proceed with surgery

260

Does LVEF predict myocardium at risk for ischemia perioperatively?

No

Good indicator of postop heart failure but does not adequatly predict myocardium at risk for ischemia

261

Complications of AAA repair
- immediate
- later

Immediate:
Ischemia to colon - IMA is disrupted
- sigmoidoscopy to est dx

Anteror spnal syndrome

Later:
- vascular graft infection
- aortoenteric fistula (aorta + duodenum)

262

Tx aortic dissection
- type 1
- type 2
- type 3

Type 1 = ascending + descending aorta
- surgery ASAP

Type 2 = ascending aorta
- surgery ASAP

Type 3 = descending aorta
- beta blockers
- CONTROL HTN!

263

DVT outpatient treatment

Warfarin for 3-6 months

264

Popping in knee + rapid onset of pain and swelling with hemarthrosis - what happened?

ACL tear

265

Most common cause of hypotension adn distended neck veins in trauma pts

Tension PTX

--> Other less likely = cardiac tamponade

266

Pregnant women in trauma - how to evaluate

At basline because of preggers, can have increased HR and hypotension 2/2 uterine compression on vena cava

Evaluate preggers on her left side

267

Findings in fresh spinal cord injury

Priapism
loss of anal sphincter tone
loss of vasomotor tone
bradycardia

268

What can DPL miss?

Retroperitoneal structure injury
- duodenum
- pancreas

269

Most common nephropaathy assoc w/ carcionma

Most common nephropathy assoc w/ hodgkin's

Carcinoma - membranous nephropathy

Hodgkins - minimal change disease

270

Selenium deficiency feature

Cardiomyopathy

271

Zinc deficiency feature

Alopecia
Abnormal taste
Bullous, pustulous lesions around body orifices and/or extremities
Impaired wound healing

272

Places LARGE amt of blood could hide in body

Abdomen
Pelvis
Thigh (femoral fracture)

273

Intraoperative development of coagulopathy

+ FFP

If tehre is hypothermia and acidosis too, need to stop laparotomy and pack bleeding surfances + temporary closure

Resume op after pt warmed and coagulopathy treated

274

Best for human bites

Amoxicillin + clavulanate