Week 5 - General, Trauma, Neurosurgery, & Vascular Flashcards

Question

What is the pathophysiology of varicose veins?

Answer 1

Varicose veins (VV) are dilated, tortuous subcutaneous veins that permit reverse flow. They are most commonly found in the lower limb and may be primary, or secondary to deep venous pathology. The GSV system is most frequently affected with the SSV being involved in about 20% of cases. The aetiology of VV at a microscopic level is still disputed but the essential defect macroscopically is generally agreed to be the failure of venous valve closure resulting in the superficial veins becoming dilated, elongated and tortuous. The main factor contributing to the development and progression of varicose veins is sustained venous hypertension that increases the diameter of the superficial veins resulting in further valve incompetence.

Answer 2

If a large (> 5.5 cm) aneurysm is seen on ultrasound in a patient presenting with abdominal pain, refer the patient for treatment immediately.

Answer 3

A diabetic foot disease is any condition that results directly from peripheral artery disease or sensory neuropathy affecting the feet of people living with diabetes. Diabetic foot conditions can be acute or chronic complications of diabetes. The term "diabetic foot" refers to a range of foot complications that can arise in individuals with diabetes. Diabetes can cause damage to the nerves (diabetic neuropathy) and impair blood flow to the feet (peripheral arterial disease), leading to various foot problems. These problems can include ulcers, infections, deformities, and difficulties in wound healing. If left untreated or poorly managed, diabetic foot complications can progress and potentially lead to severe consequences, including amputation.

Answer 4

To evaluate the extent of carotid artery disease and its effects, imaging tests such as carotid ultrasound, CT angiography, or magnetic resonance angiography (MRA) may be performed. Depending on the severity of the disease and the individual's overall health, treatment options can include lifestyle modifications, medications to control risk factors (such as high blood pressure and cholesterol), antiplatelet therapy, and, in some cases, surgical interventions like carotid endarterectomy or carotid artery stenting.

Answer 5

**Underhydration** 1. Decreased tissue perfusion 2. Anastomotic Leak 3. Renal Failure 4. MODS **Over hydration** 1. Acidosis 2. Coagulopathy 3. Oedema

Answer 6

1. The kidneys cannot function without adequate perfusion 2. Renal perfusion depends on an adequate blood pressure 3. A surgical patient with a poor urine output usually requires more fluid 4. Absolute anuria is usually due to urinary tract obstruction. 5. Poor urine output in a surgical case is NOT due to frusemide deficiency.

Answer 7

1. What are normal losses? 2. What are normal intakes? 3. What is the metabolic response to injury? 4. What are the abnormal losses? 5. Which fluid to use? 6. How to monitor fluid therapy?

Answer 8

INTRA = potassium EXTRA = Na/Cl/Ca

Answer 9

1. ADH Secretion 2. Potassium from damaged tissues

Answer 10

**Sympathetic Outflow** 1. Venoconstriction 2. Increased myocardial contraction 3. Increased heart rate 4. Vasoconstriction vascular beds **Hormonal** 1. ADH Secretion: increases Water 2. Aldosterone: increases Sodium

Answer 11

**Abnormal Losses** 1. NasogastricTube 2. Increased insensible losses (200mls per degree) 3. Diarrhoea 4. Vomiting 5. Stoma 6. Fistula 7. Intra-operative Bleeding 8. Third Spacing

Answer 12

ECF that is not intravascular or interstitial (extravascular) Fluid accumulates in the lumen of the paralysed bowel (ileus)

Answer 13

**Is it like ECF?** 1. Fistula 2. Vomit 3. Diarrhoea 4. 3rd spacing **Is it predominantly water loss?** 1. Water deprivation 2. Fever

Answer 14

**ASK** - History taking **Examination** 1. PULSE 2. SKIN PERFUSION 3. CARDIO- RESPIRATORY 4. BP 5. TEMPERATURE 6. MUCOUS MEMBRANES 7. SKIN TURGOR 8. WEIGHT 9. URINE OUTPUT 10. OEDEMA 11. JVP

Answer 15

**Invasive Monitoring** 1. CVP 2. TOE 3. PiCCO = PiCCO is a cardiac output monitor that combines pulse contour analysis and transpulmonary thermodilution technique 4. SWAN-GANZ = Swan-Ganz catheterization (also called right heart catheterization or pulmonary artery catheterization) is the passing of a thin tube (catheter) into the right side of the heart and the arteries leading to the lungs. It is done to monitor the heart's function and blood flow and pressures in and around the heart.

Answer 16

**Is the patient?** Euvolaemic Hypovolaemic Hypervolaemic **Aims of Fluid Prescription** 1. Maintenance 2. Replacement 3. Resuscitation

Answer 17

**Colloids** 1. Gelofusine 2. Haemaccel 3. 5% Human albumin 4. Hetastarch Rapidly Expand the Intravascular volume as they contain large molecules which stop fluid leaving blood vessels. May interfere with cross-matching and coagulation.

Answer 18

**Oliguria** - “Passage of less than 400mls in a day” - <0.5ml/kg/hr - Oliguria is common after surgery. - Prerenal causes predominate for postoperative oliguria. - Intravenous fluid challenges treat most oliguria after surgery. - Do not overlook retention, urinary catheter obstruction, SIADH, and abdominal compartment syndrome in the postoperative patient.

Answer 19

**5. Investigate the possible causes:** - Obtain laboratory tests, including serum electrolytes, renal function (creatinine, blood urea nitrogen), urine analysis, and urine output measurements. - Consider imaging studies, such as renal ultrasound or Doppler studies, to evaluate for obstructive uropathy or renal blood flow abnormalities. **6. Consider reversible causes and interventions:** - Ensure adequate intravascular volume by administering intravenous fluids cautiously. - Address any identified electrolyte imbalances or acid-base disturbances. - Identify and treat any potential urinary obstruction, such as bladder distention or urinary retention. - Evaluate and manage medications that may contribute to renal dysfunction or oliguria. **7. Involve a nephrologist or critical care specialist:** - If the patient remains oliguric despite appropriate interventions or if there are concerns for severe AKI or renal failure, consult a specialist for further evaluation and management.

Answer 20

**Composition of body fluid compartments** Adult body weight 60% water - 75% as neonate - 50% at 80 yrs Of this 60% - 40% intracellular fluid - 20% extracellular fluid - 15% interstitial fluid - 5% plasma **Circulating Blood Volume** (plasma +cells) = 7mls/kg=5000mls

Answer 21

**BLOOD LOSS NEED FLUID IN IV SPACE** 1. **BLOOD** - will stay in the intravascular space 2. **COLLOID** - Will stay in the intravascular space due to high oncotic pressure, Draws water from intracellular and interstitial compartments. 3. **0.9% SALINE** - Goes intravascular then passes out into INTERSTITIAL (Extravascular) COMPARTMENT, Water will move from intracellular to interstitial compartment.

Answer 22

**Hyperchloraemic Metabolic Acidosis** - Normal saline has high Chloride but is Missing K, Ca, Glucose, Mg, Bicarbonate. - Recommendations: Hartmann’s or Ringer’s less risk of hyperchloraemic acidosis. (Unless hypochloraemic)

Answer 23

**5% Dextrose** - Goes intravascular - Glucose removed - Water then redistributes - Not nutritive 170Kcal/l **Hypertonic Saline** - Volume expander - 1ml HTS 7mls water drawn into EC space - Lasts 15 minutes due to equilibrium between IV and EV space - May decrease ICP and ICH

Answer 24

= None - just monitor

Answer 25

1. Don’t do unnecessary bloods 2. Repeat her bloods (from the arm without the drip) - likely just an error Remember if the result is not what you were expecting, repeat it!

Answer 26

1. Blocked catheter 2. Retention

Answer 27

British Consensus Guidelines on Intravenous Fluid Therapy For Adult Surgical Patients.

Answer 28

**Pre-Operative** 1. Don’t withhold fluids for more than 2 hours 2. CHO rich drink 3-4 hrs pre-op 3. No need for routine bowel prep

Answer 29

The metabolic response to injury, also known as the systemic inflammatory response, can have significant effects on fluid balance in the body.

Answer 30

- Metabolic acidosis is a condition characterized by a decrease in blood pH and bicarbonate (HCO3-) levels, resulting in an excess of acid in the body. - In some cases, correction of the underlying condition may be sufficient to restore acid-base balance. In more severe cases, additional interventions such as IV bicarbonate or renal replacement therapy (e.g., hemodialysis) may be required to correct the acidosis.

Answer 31

- Metabolic alkalosis is a condition characterized by an elevation in blood pH and bicarbonate (HCO3-) levels, resulting in an excess of base in the body. - Treatment may involve discontinuing or adjusting medications, correcting fluid and electrolyte imbalances, and providing supportive care. In some cases, administration of IV fluids with chloride or acetazolamide (a carbonic anhydrase inhibitor) may be used to promote renal excretion of bicarbonate and restore acid-base balance.

Answer 32

Respiratory acidosis is a condition characterized by an increase in carbon dioxide (CO2) levels and a decrease in blood pH due to impaired ventilation.

Answer 33

**Disk protrusion**: protrusion of the vertebral disk nucleus pulposus through the annulus fibrosus **Disk herniation** (disk extrusion or disk prolapse): complete extrusion of the nucleus pulposus through a tear in the annulus fibrosus **Disk sequestration**: extrusion of the nucleus pulposus and separation of a fragment of the disk **Spondylosis**: a broad term used to describe degenerative changes of the spine that may result in irritation and/or damage of the adjacent nerve roots or spinal cord

Answer 34

- As dermatomal territories often overlap (except in autonomous sensory zones) and muscles are often supplied by several myotomes, sensory and motor deficits may be absent or minimal if a single spinal root is compressed.

Answer 35

- Cervical nerve roots C1-C7 run superior to the named vertebrae - eg. If disk C4-5 is herniated then the C4 nerve root gets compressed. - Lumbar nerve roots run inferior to the named vertebrae so an L4-5 disc herniation would cause L5 nerve compression. - Herniated lumbosacral disks commonly cause radiculopathy below the level of the herniated disk (e.g., L4–L5 disk herniation results in L5 radiculopathy). However, a far lateral disk herniation can cause radiculopathy above the level of the disk (e.g., L4–L5 far lateral disk herniation resulting in L4 radiculopathy).

Answer 36

**Symptoms of Cervical radiculopathy** 1. Neck pain commonly associated with radiculopathy 2. Can manifest with difficulty with fine motor skills 3. Can be accompanied by headache and/or shoulder pain

Answer 37

**Provocative maneuvers** 1. **Hoffmann reflex:** A positive result suggests cervical myelopathy. 2. **Neck compression test** (Spurling maneuver): screens for cervical radiculopathy - Tilt and rotate the neck toward the affected side while applying downward pressure (axial loading) to the head. The test is positive if it produces pain and/or paresthesia that radiates to the motor or sensory area of the affected nerve root.

Answer 38

**Lumbosacral radiculopathy - Symptoms** 1. Low back pain (lumbago) commonly associated with radiculopathy 2. Pain characteristically worsens with lumbar flexion (e.g., on sitting). 3. Worsening of low back pain with lumbar flexion (e.g., on sitting) is suggestive of lumbar disk herniation, while improvement of pain with lumbar flexion is suggestive of lumbar spinal stenosis.

Answer 39

Child at risk of abuse/suspected non-accidental injury Behavioural/Psychiatric: - very distressed, risk of self-harm - acutely psychotic or thought disordered - situational crisis, deliberate self-harm - agitated / withdrawn - potentially aggressive

Week 5 - General, Trauma, Neurosurgery, & Vascular Flashcards

(90 cards)