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zAbsite Final 2019 > True Learn Absite - 2020 COPY > Flashcards

True Learn Absite - 2020 COPY Flashcards

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1
Q

Indications for ppx abx for SBP

A

GI HMHG, low protein ascites (< 15 g/L), hx of SBP

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2
Q

Tx desmoid tumor

A

WLE

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3
Q

Tx mesenteric cyst

A

enucleation

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4
Q

Tx appendicitis

A

Perforated w/ abscess → drain and tx medically
Perforated w/out abscess → medical management or OR; no consensus
Non-perforated → lap appe

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5
Q

Indications for local excision of rectal cancer

A

< 3 cm, <30% circ, mobile, no nodes, SM only, no high risk histo

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6
Q

Tx with least incontinence for anal fissue

A

LATERAL, INTERNAL sphincterotomy

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7
Q

Treatment of anal melanoma

A

WLE (DO NOT respond to chemo-XRT)

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8
Q

Tx melanoma

A

resect w/ proper margin, avoid Mohs, resect palpable/SLN+

goal to resect nodes (not stage)

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9
Q

Tx of rectal abscess

A

supralevator- transrectally

all others- drain to the skin

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10
Q

Tx of HMHD

A

1-2: sclerotherapy, infrared coag
2-3: rubber band ligation
3-4: HDHD’ectomy (less recurrence), stapled HMHD’pexy (less painful)

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11
Q

HMHD grading

A

1- bleeding, 2- prolapse w/ spon reduction, 3- prolapse w/ manual reduction, 4- irreducible

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12
Q

condyloma types

A

acuminatum- HPV ( 6, 11- benign; 16, 18- Ca)

lata- syphilis

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13
Q

Anal verge
Anal margin
Anal canal

A

Anal verge: separates anal canal/anal margin. hair bearing to non hair-bearing; ext anal sph ends
Anal margin: below anal verge
Anal canal: above anal verge

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14
Q

Tx of High grade AIN/bowen’s disease of anal margin

A

lifetime surveillance even if tx!; excise if > 3cm, sxatic, atypical

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15
Q

Tx of SqCC of anal margin

A

tx like SqCC of the skin

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16
Q

Tx SqCC of anal canal

A

Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC; Recurrence- APR
SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid

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17
Q

Tx Melanome of anal canal

A

unresponsive to chemo-RT; 5y-S is 20% w/ R0; WLE = APR

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18
Q

Tx of Thrombosed external HMHD

A

w/in 48h- excision

after 48h- medically manage

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19
Q

Tx of rectal prolapse

A

rectopexy (presacral facia) + sigmoidectomy if const’n/slow transit
old/sick- perineal

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20
Q

Tx of anal fissure

A

itz/fiber; chronic- add nitro/dilt; failed medical- lateral internal sphincterotomy

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21
Q

Tx anal incontinence

A

1st line- fiber/bulking, exercises

refractory- overlapping sphincteroplasty

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22
Q

Tx of Pilonidal cyst

A

leave open!; midline- longer healing/lower recurrence; off midline- less comps (preferred)

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23
Q

Tx of CBD stone intraop

A

transcystic/transductal (larger stones) lap bile duct exploration; ERCP if unable

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24
Q

PSC

A

M; intra/extra hepatic; onion fibrosis; chain of lakes; a/w UC, cholangioca; tx- trx, cholesty., UDCA

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25
PBC
F; intra hepatic; granulomas; +AMA; a/w Sjogren, RA; tx- trx, cholesty., UDCA
26
Tx for cholangiocarcinoma
Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe; consider neoadj + trx if unresectable Middle ⅓: hepaticojejunostomy Lower ⅓: pancreaticoduodenectomy (Whipple)
27
Strasburg classification of bile duct injuries
``` A- leak B- ligation of aberrant R hepatic C- transection of aberrant R hepatic D- lateral injury to major duct E- complex injury with complete bile duct transection ```
28
Replaced hepatics
R hepatic: posterior to cystic duct; off of SMA | L hepatic: within hepatogastric ligament; off of L gastric; medial to portal triad
29
CBD exploration techniques
transcystic- small stones or large CD transductal- large stones or small CD Leave T-tube- avoid spasm and back pressure that could blow out your stump
30
Lap chole w/ intraop choledocho
1. Saline flush, 2. Glucagon, 3. Lap CBD exploration (TC or TD)
31
Tx CO poison
1st 100% 02 NRB, then hyperbaric O2 (most effective); intubate if comatose, severe acidosis
32
Tx thoracic eschar
early intubation then escharotomy along ant. ax lines (b4 CT)
33
Burn degrees
1D: red without blisters 2D superficial: papi dermis; blisters; most painful; blanches +hair; no surg 2D deep: red/white; ret dermis; mild pain; no blanch; surg if not healed >3w 3D burn: white/waxy; leathery skin; insensate; early surg/graft 4D: fat/muscle/bone; surg
34
Tx of Hypothermia
Mild- <94: shivering, AMS; tx- passive ext (remove wets, blankets) Moderate- <89: combative, mydriasis, afib; tx- active ext (warm blankets/air/bath) Severe-<84/29: long QRS, osborne waves, VFib; coma; tx- active int (warm O2/IVF, bypass/lavage) Profound-<70: loss of vital signs, cardiac activity, EEG; tx- ACLS, active internal
35
Tx of freezing
Frostnip: ice crystal on skin; pain, numbness; tx- rewarming 1D frostbite: frozen below skin; numbness/edema; firm plaque; tx- 1-2 wks to heal 2D frostbite: milky white blister; tx- 2-4 wks to heal 3D frostbite: hemorrhagic blister; tx- 3m to heal 4D frostbite: bone; black mummified tissue;
36
Parkland Formula
4 x TBSA x wt; ½ in 1st 8 hours; modified Brook’s formula: use 2 instead of 4
37
Rule of 9s
ant/post C/A-18 each; ant/post leg-9 each; ant/pos arm- 4.5 each; H/N- 9; genital-1
38
Indication for APR
w/in 2cm of anal verge (levators), baseline sphincter dysfxn, recurrent SqCC (s/p Nigro)
39
Tx GIST
resect ALL (any size) w/ -MICRO margin Imatinib post op if C-Kit+ neoadj if inoperable
40
FAP Tx
TAC w/ IRA→ q1y scope post op → polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
41
Elective UC Tx
TAC w/ IJP; indications- ANY dysplasia, refractory incontinence is a c/i Surgery reduces: erythema nodosum, arthritis; no effect on PSC!
42
Hinchey
1- pericolic abscess, 2- pelvic abscess, 3- purulent, 4- feculent; scope 6-8w post dc
43
Neoadjuvant therapy related to T stage
esophagus- t1b+, stomach- t2+, colon- t4b, rectum t3+
44
``` LN harvest/margin eso stomach colon rectum ```
eso- 15/7cm stomach- 15/5cm colon-12/5 cm rectum- 12/5 cm
45
APC gene
chrom5; mc mutation in colon ca; 1st mutn in adenoma to carcinoma; a/w FAP
46
Lynch Syndrome
DNA mm repair- MLH1, MSH2/6, PMS2 scope @ 25 or 10yrs before relative any ca → TAC IRA
47
Infliximab
monoclonal Ab to TNF | use- moderate crohns, recurrent perianal fistula!
48
Sulfasalazine/5-ASA
COX/LOX inhibitor suppress inflammation quiescent crohn’s
49
Azathioprine/6-MP
inhibit DNA synthesis | immunosuppression by blocking Cyto T and NKC
50
MEN 2A
RET gene | thyroidectomy b4 5 (age 2 for 2B)
51
Mucinous cystic neoplasm
malig potential; viscous, “string like” high CEA, low Amylase tx- resect
52
Cystadenoma
serous aspirate low CEA, low Amylase tx- resect if sxs
53
IPMN
high CEA, high amylase in communication w/ panc duct main vs. branched
54
Pseudocyst
low CEA, high amylase | tx- wait 6 weeks then drain or resect
55
Von Hippel Lindau
VHL gene upreg. of VEGF CNS/retinal hemangioblastoma, clear cell RCC, pheo
56
Li Fraumeni S
breast cancer, soft tissue sarc
57
Esophagus blood supply
Cervical- inf thyroid Thoracic- aortic branches Abd- L gastric/inf phrenic
58
Heller myotomy margins
5cm proximal, 2cm distal
59
DeMeester score
pH <4 , changes in position, duration, # of episodes; > 14.7 is positive
60
Eso dysplasia tx
``` LGD- scope q6-12m lifetime (even if fundoplication) HGD- ablation + Q3m scope T1a- ablation t1b- esophagectomy *Fundop does not decrease cancer risk ```
61
Fundoplications
dor- ant 200 toupet- post 180 belsey/mark IV- transthoracic ant 270
62
GERD alarm sxs
wt loss, early satiety, blood, dysphagia, odynophagia → EGD
63
Zenker’s tx
left C incision; cricopharyngeal myotomy + staple channel (large) or diverticulectomy (small)
64
Tx acute variceal HMHG
octreotide + antibiotics → endoscopic intervention (ligation/sclerotherapy) → TIPS
65
Transhiatal esophagectomy
C+A incision | gastric conduit supply- R gastroepiploic (off GDA/CHA)
66
DES tx
CCB (+TCA if chest pain) → botox; surgical management is last resort
67
Corrected Ca
[0.8 x (4 - patient's albumin)] + serum Ca level
68
Metabolic alk
Cl responsive- temporary loss, replaceable - vomiting Cl resistant- hormonal, continuous loss - conn’s, steroids, hyperaldosterone
69
Serum osmolarity
Osm = 2xNa + Glu/18 + urea/2.8
70
MC etiology of ESRD leading to kidney trx
1. DM, 2. HTN, 3. PCKD
71
AG
Na - (Cl+Bic) | NaCl = non-AG, metabolic acidosis
72
Ferritin
storage, intra/extra cellular | low in IDA/high in ACD (2/2 inflammation)
73
Tumor lysis syndrome
hyperU, K, Ph w/ hypoCa; CaPh crystal—> renal failure + hypoCa
74
Vit D vs. PTH
Vit D: increase Ca and Ph | PTH: increase Ca and decrease Ph
75
4-2-1 rule
4 cc/kg/hr for 1st 10 kg, then 2 for 10-20 kg, then 1 for everything above 20
76
Free water def
.5/.6 x kg x (Na - IdealNa)/(IdealNa)
77
Sodium def
.5/.6 x kg (Na ideal - Na)
78
Rectovaginal fistula tx
wait 3-6m; low- endorectal advancement flap; high- abdominal approach
79
Tx of cervical ca
conization/LEEP for 1a; primary chemoRT, brachytx B4 surg | pelvic/aortic LN’s
80
Tx of endometrial ca
TAH+BSO, peritoneal w/o (for cytology), LN sampling
81
TRALI
DONOR Ab attacks recipient WBC
82
ADP antagonists
clopidogrel, prasugrel, ticagrelor (reversible)
83
TXA2 antagonist:
ASA (via Cox-1); irreversible
84
Reversible DTA:
dabigatran
85
tx VWD
tx- DDAVP (ineffective for t3), cryo
86
Tx ESRD PLT dysfxn
2/2 uremia; tx w/ desmo; cryo 2nd line; don’t use PLTs → become dysfxn
87
Consider bridging if
troke/TIA w/in 1 month, mechanical valve, high CHADS-VASC
88
Acute hemolytic trx reaction
rapid RBC destruction by host IgM/IgG | +direct coomb’s
89
Amphotericin
antifungal lipid soluble- penetrates CNS ↑ s/e- hypoK/Mg, hepatotoxic, anemia, arrhythmia
90
HS reactions
``` 1- IgE mediated; allergic rxn 2- aB mediated rxn 3- immune cx; ex- serum sickness 4- delated; t-cell mediated 5- auto-immune ```
91
IF-gamma
NKC, macrophage activation
92
TGF-B
inhibits T-cell activation
93
Tx liver lesions - Hemangioma - FNH - Adenoma
- Hemangioma: resect if sxs - FNH (+kuppfer): resect if sxs - Adenoma (-kuppfer): <5cm- stop OCP, observe; > 5cm- resect
94
Functional Liver Remnant
minimum 20% if normal liver; pre-op chemo/some dysfxn = 30%; cirrhosis = 40%
95
Tx and dx of SBP
3GC abx AND albumin (survival benefits) | dx- ↑ascitic PMN and + culture;
96
Sorafenib
TK inhibitor; tx of HCC
97
Tx of liver abscess: - fungal: - hydatid cyst: - amoebic: - pyogenic
- fungal: perc drain + micafungin (ampho is 2nd line) - hydatid cyst: albendazole qwks then drain - amoebic: metronidazole - pyogenic:
98
Indications for trx
ALF- INR > 1.5 | CLF- MELD >=15, INR > 1.5
99
Enterohepatic circulation
Liver → P BSalts → hepatocytes → conjugated BS → 80% active ileum absorbed 20% deconjugated by bacteria → passive colon absorbed; 5% out in stool
100
Maneuvers
Kocher- lateral peritoneal attachment of D2 Maddox- white line from sig to splenic flex Cattell- continuation of kocher; from D2 to sigmoid
101
Tx of GB polyps
surg if- any size w/ lithiasis, > 1cm | < 1 cm w/out stones can observe
102
Tx of pancreatic necrosis
ICU, fluid, pain meds → MRCP (no cholangitis) or ERCP (cholangitis) → delay OR If evidence of fluid infection (w/out cholangitis): proceed with CT guided drain placement
103
S/e of trx meds - Tacro - Azathioprine - Mycophenolate - Sirolimus
- Tacro: neuro sxs (tremor), neph’tox, HTN, alopecia, hyperK, hypoMg, GI sxs - Azathioprine: marrow suppression, leukopenia, hep’tox, pancreatitis, pulm fibrosis - Mycophenolate: GI sxs, leukopenia - Sirolimus: hypterTG, impaired wound healing,
104
Wt loss/surgery
lap band 50-55 sleeve 55 REY 60 Duo switch 70
105
``` Mineral def: Zn Sel Chromium Copper ```
Zn- wound heal/skin Sel- cardiomyopathy Chromium- hyperglycemia Copper- micro anemia
106
B1 def:
cardiomyopathy, wernicke’s encephalopathy, p. Neuropathy
107
T1/2 albumin vs. pre-albumin
Albumin- 20 days, prealbumin- 2 day
108
N balance
(protein intake/6.25) - (protein in urine + 2); 6.25 = g of N/g of P 2 = insensible loss
109
Cori cycle
recycling of lactate and pyruvate for gluconeogenesis | provides 40% of glu when starving
110
Gluconeo precursors
lactate , pyruvate, AA
111
UE Injuries
supracondylar humerus- brachial a DRF- median n ant shoulder disloc’n- ax. n post shoulder disloc'- ax. a
112
LE injuries
post hip disloc’n- sciatic n. (peroneal branch) | post knee disloc’n- popliteal a.
113
Interossei innervation
palmar- ulnar n, adduct dorsal- ulnar n, abduct lumbricals- median (1-2)/ulnar (3-4)
114
Pancreatic mucinous lesions
Pseudocyst- high Am, low CEA, KRAS neg Serous cystadenoma- low Am, low CEA, KRAS neg MCN- low Am, high CEA (>200), KRAS pos IPMN- high Am, high CEA (>200), KRAS pos
115
Tx pseudocyst/WON
wait 4wks; < 6cm- NTD (unless sxs); >6cm and asx- NTD; > 6cm and sxs- drain attempt endoscopic 1st; near stomach/duo- cystenterostomy; otherwise REY cystojej
116
Tx infected pseudocyst
aspirate/gram stain to dx → drainage (internal, external, endoscopic)
117
Tx Infected panc necrosis
stable- wait 4 weeks, IR retroP drain; unstable- debride | Debride: VARD (video-assist retroP)- utilize retoP drain, DEN (endoscope), open necrosectomy
118
Infected pancreatic abscess
external drainage
119
Step up approach
Infected panc necrosis | IR/endo drain → 2nd drain → VARD → lap necrosectomy
120
Tx Panc fistula:
tx- NPO, TPN x 4-6 wks → ERCP w/ stent → surgery
121
Blood supply panc:
tail pancreatic branches of splenic a, head- super PD (GDA/celiac), inferior PD (SMA)
122
Atlanta classifications:
< 4w- acute pancreatic or necrotic collection; > 4w- pseudocyst or WON
123
Tx Panc divisum
sph’otomy by cutting the minor papilla to enlarge the opening and allow pancreatic enzymes to flow
124
Acute pancreatitis tx:
NPO + IVF; enteral feeds ASAP ( > TPN); NG or NJ; octreotide not useful
125
PMN tx
Branched: resect- malig cells, mural nodularity, > 3cm; 1-3cm re-image q6m; <1cm- q1y Main duct: resect- > 10 mm; 5-9 mm EUS/FNA; < 5mm- surveil
126
Tx Serous cystic neo/cystadenoma
resect if > 4cm or sxs
127
Tx mucinous cystic neo
resect all
128
Puestow
kocherize duo, aspirate duct, split open duct 1-2 cm from duo to > 7 cm, REY panc-jej in 2 layers
129
Whipple
resect panc head, duo, distal stomach; gastro-jej + panc-jej + hepatico-jej
130
``` Tx of pancreatitis masses WON sterile WON infected Pseudocyst: Infected pseudocyst ```
WON sterile: conservatively WON infected: step up Pseudocyst: tx if sxs (infxn, obstruction, pain); 4-6w → internal drain → cystenterostomy Infected pseudocyst: drainage (internal, external, endoscopic)
131
Tx Annular pancreas
duodenojejunostomy
132
Melanoma characteristics: - mc - best prog - AA - worst prog
- mc: superficial spreading - best prog: lentigo - AA: acral - worst prog: nodular
133
Tx Actinic keratosis
topic 5FU. Photodynamics, imiquimod, cautery; no margin
134
Staph species
G+/aerobe/clusters; coag+ → aureus | coag- → epidermidis
135
Strep species
G+/aerobe/chains; a hemo- pneumo, viridans b hemo- GAS(pyo)/GBS(aga) non hemo- enterococci
136
Melanoma tx
MIS- 5mm; <1mm- 1cm; 1-2mm- 1-2cm; >2mm- 2cm; SLNBx | SLNBx: if > 1mm or if .75-1 mm w/ ulceration or high risk features w/ clinically negative nodes
137
BSC tx
SLNBx- only if clinically palpable nodes; tx- WLE w/ .5cm margin
138
Sarcoma prognosis
GRADE used for staging; more important size/depth, nodal/distal mets, mitosis count
139
ITP vs. TTP tx
ITP- steroids (only if PLTs < 30k), splenectomy if unresponsive TTP- plasmaphoresis
140
Tx TCPenia
<10k if asx; <20k if septic, chemo/rads, RF’s; <50K if elective surgery
141
Tx splenic echinococcal cyst
sterilize w/ etoh injection → splenectomy; opening could cause anaphylaxis
142
Splenic vein thrombosis
px- gastric varices w/ normal portal p | tx- ppx splenectomy
143
Vagotomies
truncal- transect ant/post @ distal eso | HSV- transect @ crow’s ft, preserve laterjet, no drainage
144
Posterio and anterior vagal trunk branches
Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet Anterior trunk- hepatic branch, ant laterjet
145
Tx hiatal hernia
t1- PPI x 8-12w → surg | t2-4- repair all sxatic pts
146
Duo vs. stomach ulcer
Duo ulcer: pain 2-3h after meal; 90% H. pylori, 10% NSAIDS | Stomach ulcer: pain right after meal; 75% H. pylori, 25% NSAIDS
147
T3 ulcer: tx
pre-pyloric | antrectomy + Bile1/2 + vagotomy
148
Gastric CA tx
neo-adj chemo for T2+ or N; proximal- total gastrectomy; distal- partial; 5cm margin; 15 nodes
149
Barrett’s eso surveillance
no dysplasia- 4 quad every 2 cm q 3-5y | dysplasia 4 quad every 1 cm q 3-6m
150
Minimum FEV1 for resections
pre-op → FEV1 > 2L- pneumo, >1.5L; post op: >.8 or 40% predicted
151
SVC syndrome tx
stent, radx, steroids (no chemo/surg)
152
Chylothorax tx
CT and NPO → 7d: thoracic duct lig
153
Transudate
protein (pl/se) < .5, LDH (pl/se) < .6 or ⅔ ULN → CHF, pericarditis, cirhosis, nephrotic s
154
Exudates
protein (pl/se) > .5, LDH (pl/se) > .6 or ⅔ ULN → AI, eso rupture, infxn, malig, pancreatitis, PNM
155
EBUS accesible nodes:
2, 3, 4, 7, 10, 11, 12; innominate seperates level 3, 4; 7- sub-carinal; 10- R/L hilar
156
``` Trx drugs MOA MMF Cyclosporine Azathioprine Tacro Sirolimus ```
``` MMF: purine synthesis inhibitor Cyclosporine: calc inhibitor Azathioprine: purine synthesis inhibitor Tacro- calc inhibitor Sirolimus- mTor inhibitor ```
157
Post trx lymphoproliferative disorder
B sxs; 2/2 EBV+ B cells; may cause l’oma | tx- reduice IS, rituximab
158
Bladder ca tx
Ta/T1- no muscle, tx- trans-U resexn + transU BCG/mitoM | T2a- invasive, tx- cystectomy +/- chemo
159
``` Cause of stones: CaOx Uric Acid Cysteine CaPh MgAmPh ```
``` CaOx- diet Uric Acid- protein Cysteine- AA metab. error CaPh- high pH MgAmPh- urease infxn ```
160
Stages of healing:
stasis (1-3d), inflammation (3-20), proliferation (1-6w), remodeling (6w-2y)
161
Order of cells in healing:
PMNs (24-48h) → macro (48-96h) → lympho (3d) → fibro (10d)
162
Fibroblasts
dominant cell during proliferation AND remodeling
163
Inflammatory phase
macrophages are most important (phago + cytokines); PMNs come first
164
Proliferative phase
neovascularization, collagen syntehsis; mphasges intially but fblasts dominant; HIF-1
165
Stages of graft healing
imbibition (direct diffusion) → inosculation (cap beds meet) → revascularization
166
Increased ETCO2
MC hypoventilation, atelectasis; malig hyperthermia, meta acid, hypermetab, pneumo
167
c/i to epidural
high ICP, therapeutic acoag, AVM, HDUS | SQH- wait 4h; lovenox- wait 24h; ASA is not c/i
168
Ketamine
not c/i with high ICP! s/e- HTN, tachy amnestic + analgesic; no resp depression
169
Tx Post dural puncture headache
after epidural; tx with blood patch
170
Tx fat necrosis
no trauma- bx | trauma- watch
171
Tx Galactocele
dx/tx- aspiration; no tx if asxatic, continue bfeeding
172
Tx Inflammatory breast ca
neoadj + surg + XRT | SLNBx c/i!
173
Types of mastectomy
Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin BCT = partial mastectomy + XRT MRM: removal of breast parenchyma, NAC, skin, and level 1-2 nodes
174
LCIS Tx
surv + tamox OR bilateral l’omy; DUCTAL ca; no (-) marg
175
Tx male breast ca
usually simple mastectomy w/ SLNBx; BCT usually can’t be done b/c not enough tissue
176
DCIS tx
lumpectomy (2mm) + XRT +/- boost (no SLNBx) | if XRT c/i → mastectomy AND SLNBx
177
Tx Phyllodes
WLE w/ 1mm margin
178
Tx Malig BC in preg
1t- MRM 2/3t- lumpectomy, SLN (no blue dye), chemo (6w later), RT post-delivery
179
Breast nerves:
``` TD- LD, ADduct ICB- hypesthesia LPN- p major MPN- p major/minor LTN- SA, wing scap ```
180
Breast lesions that require bx
radial scar, any atypia, any invasive ca, vascular proliferations, discordant bx
181
DCIS SLNBx:
not w/ l’omy unless >4cm, multicentric, palpable, high grade | required w/ mastectomy
182
Thrombophlebitis (Mondor’s disease) tx
NSAIDS
183
Intraductal papilloma dx and tx
MCCO bloody nipple dc dx- contrast ductogram tx- resection
184
Mastodynia tx
cyclic 2/2 fibrocyst dz- OCP/NSAIDS | non-cyc + >30 OR cyclic + mass → mammo
185
Breast abscess tx
US aspiration BEFORE I&D | I&D if refractory
186
Dobutamine
B1 at low dose- inotropy | B2 at high dose- vasodilation
187
Milrinone:
intotropy + vasodilate; PDEi→ decreased cAMP → SR Ca uptake | relaxes smooth muscle
188
Arterial O2 content
(1.34 x Hb x SaO2) + (.003 x PaO2); Hb is most important factor
189
tx for post pneumo empyema
Eloesser flap
190
Tx SVT
vagal → adenosine may unmask” afib/flutter; synch Car’verison last resort
191
qSOFA
tachypnea + AMS + SBP
192
Tx Hypertrophic cardiomyopathy
avoid inotropes; use neo if needed
193
Management of PE
no RH strain → acoag RH strain → IR catheter RH strain + HDUS → systemic tPA
194
MC nosocomial infection | MC nosocomial ICU infection
MC nosocomial infection- UTI | MC nosocomial ICU infection- VAP
195
Tx FMD
angio + balloon
196
Tx acute limb ischemia
Tx: 1- hep gtt 2a- thrombolysis (sensation) 2b- surg (weakness) 3- amputation (paralysis)
197
Tx RA stenosis
perc translumen angio; ACEi unless 1 kidney/bilateral dz | ACEi for renal HTN: dilate efferent arterial but reduce GFR
198
DVT tx:
ileofemoral- cather directed thrombolysis; other- anticoagulation
199
LE arteries:
CF → DF (70%) and SFA (30%); DF → cx, genicular, perforating; SFA → AT (DP), P, PT
200
TXX Pop aneurysm
: >2cm- ligation and bypass; <2cm- observation; avoid stents
201
TX for leriche s
bypass
202
tx venous TOS:
2/2 repetitive exercise; tx- anticoag, thrombolysis → 1st rib/ant scalene resection wks later
203
Tx Failure of maturation of AVF
fistulogram or arterio/veno gram → endovascular intervention → open
204
Tx peripheral PsA
tx- compress 20m → thrombin; immediate surg- infxn, HDUS, pulsatile, skin changes, ischemia, AMS
205
Tx Hemobilia after trauma:
EGD → CTA (if stable) | unstable- angio embolization (no surgery)
206
Cilostazol:
tx for periph claudication; MOA- PDi, inhibits PLT aggregation; c/i in any degree of HF (PDi)
207
Vertebral artery occlusion
posterior circulation sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia
208
Elective surg after DEStent
postpone for 6m, hold plavix 7d b4, c/w ASA; need plavix fat least 6m after DES
209
TOS tx
neurogenic PT → rib resection, scalenectomy, BPlex dissection Venous- catheter directed thrombolysis → surgical decompression Arterial- C7/1r resection, subc artery resection/reconstruction
210
Tx facial nerve inj
relative to lateral canthus of eye; medial- non op OK (arborization); lateral- OR!
211
Tx Pelvic fx HDUS
binder, angio (OR packing if n/a), fixation; refractory bleed after angio → needs fixation
212
Tx Neck trauma
OR if platysma violation + crepitus, odynophagia, pulsatile bleed, expanding h’oma, bruit, thrill Non-op w/up: 4V angio, doppler or CTA, UGI (esophagography) or esophagoscopy, bronchoscopy
213
Tx tracheal inj
ABSORBABLE in 1 LAYER w/ strap; large → tracheostomy, avoid below 3rd ring (TI fistula) can perform primary repair up to 5-6 rings; must mobilize; large ant defect- tracheostomy
214
LE vascular trauma
small- patch plasty large- contralateral GSV limited time/unstable- shunt
215
Grading BCVI
anti-PLT + angio/OR if sxs; g4/5 require OR (no angio) 1- <25% narrowing, 2- > 25% narrowing, 3- PsA, 4- complete occlusion, 5- transection
216
Ureter injury
prox- primary anastomosis middle- transUU distal- reimplant +/- psoas hitch
217
Access supraceliac aorta
mattox maneuver → divide left crus → supraceliac clamp
218
Indics for ED thorac
trauma with witnessed loss of vital but SOL | SOL = ECG activity, reflexes, GCS > 3
219
Tx Odontoid fx
1- upper D, stable, non-op 2- base of D, unstable, worst, +/- surg 3- c2 vert, usually no OR
220
tx Flank wound
HDS- CT w/ triple contrast (oral, IV, rectal) | HDUS- OR
221
Tx Urethral injury
Grade: 1/2- contusion/stretch, cath 3- part disruption, OR 4/5-complete disruption, cystostomy + OR
222
Tx Supra-renal aorta inj:
can’t resect (exposure); repair w/ (non-abs) polyprop; adj perfs connected/closed Close defect transversely to avoid stenosis; if stenotic → patch angioplasty
223
Tx DPGM injury
ABD approach, close w/ NAb
224
Thoracotomy access
Right thoracotomy- mid esophagus and DISTAL trachea | Left thoracotomy- distal esophagus, left mainstem
225
Tx congential DPGM hernia
prenatal dx on US; intubate (in delivery rm), NGT +/- ECMO → OR when stable
226
Hernia repairs
Lichtenstein: mesh recreates the floor; inferior → shelving edge; medial → PT; super → TA/conjoint tendon Bassilini: conjoint tendon to shelving edge recreates the floor Cooper’s/McVay: conjoint tendon to cooper’s lig; needs relaxing incision; use for fem hernia! Shouldice: 4-layer w/ 2 running sutures; no mesh; lowest recurrence
227
Superior epigastrics | Inferior epigastrics
SE: runs posterior to rectus but anterior to posterior rectus sheath; branch of int mammary IE: runs in pre perit space between transversalis fascia and parietal perit; branch of EI
228
Umbo ligs
round- umbo v. median- urachus medial- umbo a Omph/M- vitelline duct (Meckel’s)
229
Tx Umbo hernia in child
most close by 2 <3cm- primary repair >3cm- mesh; repair by 5
230
Tx SB fistula
⅓ close feed enterally unless high output (>500cc/day) Consider OR at 12w
231
Crohn’s stricture tx:
no surg hx- resct prior surg + <10 cm- Heineke 10-20 cm- Finney >20- S2S IsoP
232
Stricturoplasties - Heineke s’plasty: - Finney s’plasty: - Side2Side isoperistaltic s’plasty:
Heineke s’plasty: ideal for <10cm; open long and close transversely Finney s’plasty: ideal for > 10cm; structured segment folded on itself and common wall created Side2Side isoperistaltic s’plasty: > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together
233
Tx maltoma
triple therapy
234
Tx T cell SB lymphoma:
poor prog | tx w/ chemotherapy; surgery is palliative
235
FAP Tx
scope q1y at 10; scope= 100+ polyps 100% r/o CRC, especially peri-ampula offer ppx colectomy
236
Lynch S Tx
HNPCC scope q1y at 25 CRC by age 40
237
Tx Meckel's
base < 2 cm → diverticulectomy > 2 cm → seg resection do appe too
238
Tx Mucinous neoplasm of appendix
confined to appendix/unruptured→ appe only; otherwise → R hemi
239
Tx Primary thyroid lymphoma
chemo/XRT
240
Tx follicular thyroid ca
- if < 4cm, <45 yo, no distal dz, no fam hx → lobectomy - otherwise completion thyroidectomy - neck dissection: clinically positive nodes (rare), extrathyroid spread - RAI: >2cm, extrathyroid/vascular invasion, node +, anti-TG Ab, elevated TG
241
Thryoid nodes
Delphian nodes: w/in anterior suspensory ligament; connect L and R glands Rotter’s nodes: between pec major and pec minor Level VI: central compartment LNs
242
Tx Pap thyroid ca in perggo
postpone until 2T; if stable, post until after delivery; RAI is c/i
243
Tx Anaplastic thyroid ca
aggressive,undiff; mort ~ 100%; no tx; tx- XRT improves short-term survival +/- surg
244
Tx med thyroid ca
TOTAL thyroidectomy AND bilateral L VI dissect → complete lateral if +
245
Tx of Thyroiditis: Hashimoto’s thyroiditis De Quervain's/Subacute thyroiditis Reidel’s thyroiditis
Hashimoto’s thyroiditis: AI/lymphocytic; tx- LT4, surg if compression sxs De Quervain's/Subacute thyroiditis: tx- NSAID +/- steroids Reidel’s thyroiditis: tx- steroids, surg if compression
246
Sonograph FNA recs
cystic- no bx isoech/hyperech- FNA if > 2cm hypoech (high sus)- FNA if > 1cm
247
Tx MEN2A
tx pheo 1st w/ adrenalectomy! → then resect T/PT
248
Tx Parathyroid ca
en block resection + XRT (not chemo)
249
Pheo w/up:
plasma or urine metanephrine (se) → 24-urine metanephrine (sp) → CT +/- MIBG (multi-focal)
250
Tx MEN1
tx hyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) → asses other lesions
251
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene MEN2: RET gene, receptor TK protein, proto-oncogene
252
Hyperaldo w/up:
CT → unilateral → lap adrenal; CT → negative or bilateral → bilat venous sample
253
Indic for retroperitoneal adrenalectomy:
multiple previous ab surgeries, bilateral lesions
254
Cryptorchidism tx
wait until 6m old | if no resolution- elective orchiopexy to decrease r/o torsion, infertility, ca
255
Tx choeldochoal cyst
``` 1- fusiform, excise/REY 2- divertic, excise 3- ampulla, transduo 4- extra/intra, REY 5- intra, trx ```
256
Tx Biliary atresia
REY portoenterostomy (Kasai) → liver trx
257
Neuroblastoma
S1-2 (low risk) → surg alone | S3+ → surg + chemo/XRT
258
Hirschsprung surgeries - Duhamel - Soave - Swenson
Duhamel: agang stump in place/gang colon pulled behind; neo-rectum; less dissection/stricture Soave: pull-through; “reverse alte”; remove M/SM; pull bowel within an aganglionic cuff; least dissection Swenson: original; aganglionic segment resected to sigmoid colon; oblique anastomosis- colon x rectum.
259
Tx Thyroglossal duct cyst
excise cyst, duct + mid hyoid
260
Tx ASD
surg if sxs or asx < 5 yo; surg before school
261
Tx PDA
to close- indomethacin; to open- PGE1
262
Tx Trx of great vessels:
1st give PGE1 → ballon atrial septostomy
263
Tx SqCC Lip
WLE w/ 3cm margin | radical neck dissection if palp nodes
264
Tx SDH
nonop- HDS, <10 mm, <5 mm shift | evac- > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
265
Tx afib
stable- BB/CCB, amio if HF unstable- SYNCHRONIZED cardioversion consider acoag after 48h
266
Tx Aspergillosis
MC fungal infxn in IC aspergilloma- resect inv aspergillosis- voriconazole
267
Px and Tx Histoplasmosis
px- ohio river valley | tx- itraconazole → ampho B
268
MOA of antifungals: Micafungin Azoles Amphotericin
Micafungin: echinocandin; inhibit glucan x linking Azoles: ergosterol synth inhibitor Amphotericin: binds ergosterol and inhibits
269
Tx Soft tissue sarcoma
resect w/ 1-2 cm marg neoadj- rhabdomyosarcoma, Ewing sarc, high grade > 10 cm adj XRT- > 5cm, high grade, recurrence, close marg adj chemo- never
270
Tx of seminoma
surveillance or chemo/XRT
271
NNT
1/ARR | ARR = control rate - event rate
272
RRR
(control rate - event rate)/(control rate)
273
Cohort:
prosepective; exposed vs. non-exposed | RR- [a/a+b]/[c/c+d]
274
Case control
retrospective; diseased vs. non-diseased | OR- (a/b)/(c/d)
275
Type 1 error | Type 2 error
Type 1: false positive (a) | Type 2: false negative (b)
276
Periop Warfarin
stop 5 days before | indics to bridge: mech valve, h/o TE event, afib only if CHAD/VASC 5-6
277
Periop NOAC
stop 2 days before elective surgery
278
Tx keloid
Z plasty + steroids + silicone sheets

zAbsite Final 2019 (5 decks)

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