Review

Madd Dawg's review because if you cannot tell I've pretty much given up on life

Medications and underlying medical conditions (even if controlled its at least a 2)

What makes someone a risk when it comes to ASA categories

Prior tracheal intubation (when, complications), previous anesthetic reactions, underlying metabolic disease (kidney, liver, blood), current medications/allergies

Other risk factors for surgeries

6+ months (unless they are going to die or something)

In general, after an MI we should try to postpone surgery for

Time sensitive procedure

A procedure in which you can delay for more than 1-6 weeks

Urgent procedure

A procedure in which cannot be delayed 6-24 hour

elective

Procedure that can be delayed up to 1 year

emergency

Surgeries which must be befored immediately

Visceral pain

Pain the is elicited by distention, inflammation, or ischemia and is described as dull, deep-seated and poorly localized

Parietal pain

Pain that is elicited by direct irritation of the peritoneum so it is easily localized

Adhesions (SBO)

A tensely distended abdomen with an old surgical scar is a red flag for

perforated ulcer

A scaphoid contracted abdomen is a red flag for

advanced bowel obstruction

Visible peristalsis is a red flag for

early paralytic ileus or mesenteric thrombosis

Soft doughy fullness is a red flag for

increased intra-abdominal pressure

An everted belly button is a red flag for

rugae (disappear with distention)

Characteristics of the stomach

Plicae Circulares, valvulae conniventes, Kerckring Folds (distinguish 2nd portion from the 1st portion of the duodenum), Ligament of treitz (determines upper from lower), ileocecal valve

Characteristics of the Small intestine

Haustra (helps make the distinction on imaging)

Characteristics of the Large Intestine

Small intestine (r/o ileus or obstruction)

Where should you NOT see air on plain abdominal films

Closed loop obstruction

A segment of bowel obstructed proximally and distally

Adhesions (then hernia, then tumor)

Most common cause of SBO

Cancer (then diverticular stricture, then volvulus)

Most common cause of LBO

Hold Metformin for 24 hours BEFORE and 24-48 after (increased risk of lactic acidosis)

Patient education measures for IV contrast

Barium sulfate (most common), Gastrografin (water soluble, iodine based - used for bowel perf)

Types of oral contrast

IV fluids baby

If we have a post op patient whose urine output is decreased, what we doing

A short term feeding tube that is placed post-pyloric into the duodenum (usually gravity fed)

Describe a Dobhoff tube

decompress the stomach (relieves N/V, if pre-op patient ate within 6 hours, ileus, obstruction)

What is the purpose of a NG or OG tube

basilar skull fracture, cribriform plate fracture

C/I for gastric tubes

esophageal/stomach injury, Hypokalemia (leads to metabolic alkalosis)

Complications of gastric tubes

PEG (percutaneous endoscopic gastrostomy), Percutaneous gastrostomy, Jejunostomy

Examples of long term feeding tubes

2nd post op day (helps maintain gut integrity, decrease pneumonia and sepsis)

When can enteral feeding start

X-rays (air in the soft tissues, displacement of the trachea, widening of the mediastinum, Pneumothorax), Esophagram with water soluble contrast (everybody!!), CT to localized, Thoracentesis (cloudy/purulent fluid with high amylase content)

Imaging studies for Boerhaave’s syndrome

Endoscopic U/S 🏆, Abdominal/Chest CT and PET (metastasis), bone scan

How do we stage carcinoma of the esophagus

ligate bleeding vessels, closure of the ulcer via pyloroplasty, Truncal Vagotomy with pyloroplasty (decreases ACh, decreases stomach acid production - good for high risk or refractory peeps)

Treatment plan for Gastric Ulcers

Omental (Graham) patch

Treatment plan for perforated ulcers

Elevated serum gastrin levels (make sure you stop the prazoles, tidines, and tums 1 week prior), Secretin provocative test (if borderline), Somatostatin receptor scintigraphy (localize - study of choice)

Diagnostics for ZES

continuous mucosal inflammation limited to the colon

Characteristics of UC

Noncaseating granulomas, Bear claw appearing ulcers, leads to fistulous connections

Characteristics of Crohn Disease

Hartmann Procedure (sigmoid resection + end colostomy - favored for perf), primary anastomosis with diversion, primary anastomosis without diversion

Surgical treatment plan for Diverticulitis

extensive phlegmon, abscess, fistula, obstruction, free perforation

Characteristics of Complicated Diverticulitis

Abx + bowel rest + percutaneous drainage (if big)

Treatment plan for Abscess related to diverticulitis

pneumaturia, abdominal pain, fecaluria, recurrent urinary tract infections, hematuria, urinary frequency

Signs of Colovesical Fistula (treat with elective surgical resection)

Passage of gas or stool through the vagina or presence of persistent foul smelling discharge

Signs of Colovaginal Fistula (speculum examination may reveal reveal a drainage site)

emergency surgery!

Free perforation of diverticulitis means…

CEA for Screening ONLY, colonoscopy with biopsy

Diagnostics for Colorectal cancer

Carcinoid Tumors

What is the most common endocrine tumors of the gastrointestinal system that presents with hot flashes, bronchospasms, and arrhythmias?

squamous cell cancers (SCC) that has rolled, everted edges often with central ulceration

Most malignant neoplasms of the anal margin are what type of cancer

Wide local excision (T1, early T2), Chemoradiations (best initial management strategies), Abdominoperineal resection (recurrent, residual, or bulky tumors)

Management of SCC of the anal margin

Abscess greater than 5 cm, recurrent, contains loculated segments separated by subcutaneous tissue

Which pilonidal diseases are best operated on? (Bascom procedure)

Incise and drainage

If a pilonidal abscess does not drain spontaneously, what is the game plan?

Indirect inguinal hernia

Congenital hernia from patent processus vaginalis that is the most common hernia in BOTH sexes

Direct inguinal hernia

A hernia through Hesselbach’s triangle that is due to a weakened floor of the inguinal canal

Dilated veins of the scrotum, Isolated to the left, related to decreased fertility

Characteristics of varicocele

Cancers (referral for U/S and surgery)

A solid mass on the testicle is _____________ until proven otherwise

Urgent U/S with doppler and surgical eval (pexy if viable, orchiectomy if not)

18 y/o male presents to the ED for xtreme 10/10 testicular pain that started after a basketball game. He also reports N/V. What is your workup and treatment?

U/S!!

What is the imaging of choice for anything gallbladder related?

diet advanced as tolerated, ID and treat underlying

Treatment for mild edematous pancreatitis

elective laparoscopic cholecystectomy and IOC (after inflammation has subsided)

Treatment for mild biliary pancreatitis

ERCP with maybe endoscopic sphincterotomy (ES) for stone extraction

treatment for severe acute pancreatitis and evidence of cholangitis

a direct blow to the epigastrium

Hx findings for pancreatic trauma

Strep Pneumoniae, H. Flu, Meningococcus

Post splenectomy vaccines

tender mass within the abdominal wall on palpation, Pain increases when sitting up (Fothergill Sign)

How do you diagnose rectus sheath hematoma

Appendectomy (which we already did so slay!!)

If the appendix comes back from pathology as carcinoid but is under 2 cm, what is the plan?

Cellulitis (staph or strep) around the nipple in lactating women

Presentation of Acute Mastitis

Complete CBE, Culture, Sensitivity

Workup for Acute Mastitis

Abx, localized moist heat, continue to drain the breast (breast feed or pump)

Treatment plan for Acute Mastitis

raised tender mass near the nipple, Systemic symptoms (fever, chills, ect)

Presentation of a breast abscess

Stop nursing, Admit and IV abx, Drain if needed

Treatment for breast abscess

additional imaging needed (bad scan)

What does 0 mean in BI-RADS

Consider at 4

In BI-RADS when do we need to start biopsing

Coagulation (must debride), Stasis (initially viable), Hyperemia (vasodilation, typically viable)

What are the zones of burns

Second Degree (blisters)

What type of burn extends through the epidermis and into the papillary dermis

Superficial partial

What type of second degree burn heals within 2-3 weeks without scarring or functional impairment

Deep Partial

What type of second degree burn extends into the reticular layer of the dermis and typically heal in 3-8 weeks with severe contraction, scarring, and loss of function

Third Degree (DOES NOT BLANCH)

What type of burn extends into the subcutaneous tissue and is typically white/black, dry and painless

Excision and grafting, YOU MUST REMOVE THE ESCHAR

Treatment plan for 3rd degree burns

Escharotomy (bi-valve the chest)

Treatment of circumferential burns (presents with pain out of proportion)

Profound hypermetabolism (worse during the 1st week), Catabolism

Complications of burns

(4 x burn surface area x body weight in Kg)/2

What is the Parkland Formula?

30-50 mL/hour

Target urine output for burn peeps

Electrical current injury, electrothermal burns (arching current), flame burns

Types of Electrical Injury

150+ Volts

Industrial/lightening voltage

Admits to burn units, Continuous cardiac monitoring, aggressive fluid resuscitation and monitoring electrolytes, serial evaluation of extremities

Treatment for Electrical Injury

Elevate HOB, Elevate extremity injury to reduce swelling/bleeding, Secure the airway, Ensure adequate ventilation

Brainstem Herniation Treatment plan

Vasoconstriction → lowers ICP (may decrease CPP to the point of ischemia)

Hyperventilation produces

Normal respiration is 35-45; Hyperventilation 25-35

Capnography to monitor end tidal CO2

Primary Survey, Manage airway (intubate at 8, prevent hypoxia), Aggressive BP control (SBP 90+), Hyperventilate only with brainstem herniation, Prevent hypoglycemia, manage ICP

TBI Game plan

Consciousness

Subjective experience of environment and self - that is made up of arousal and awareness

Arousal response

What defines the level of consciousness

Awareness

What defines the content of consciousness

Alert

Awake and immediately responsive to all stimuli

Stupor

Less alert but stills responds to stimulation

Obtunded

Appears asleep but still responds to noxious stimuli

Vegetative

arousal without awareness

Comatose

Appears asleep and does not respond to stimuli

Acute Respiratory Distress Syndrome (ARDS)

A non-cardiogenic pulmonary edema that does not respond to diuretics (inflammation not fluid overload)

Increased PEEP, Increases functional residual capacity, prone ventilation

Treatment plan for ARDS

Monitor ABGs, R/O MI/PE

You are rounding on your hip replacement surgical patient when the patient notes they have been feeling short of breath and you note some confusion. On physical exam you spot some petechiae. What is your game plan?

External fixation or ORIF Early

How can you prevent a fat embolus?

Clindamycin, Cephalosporins, FQs

Most common cause of C.Diff (Suspect in 3+ loose stools in 24 hours)

Oral Vanc or Metro, Fecal transplant, Subtotal colectomy

Treatment plan for C. Diff