Surgery COMAT

Dr HY Surgery Notes

What to do for gunshot would below the nipple?

Immediate exploratory laparotomy (ex-lap)

What to do for blunt abdominal trauma with guarding, rigidity, rebound tenderness, or peritonitis?

Immediate exploratory laparotomy (ex-lap)

What to do for blunt abdominal trauma with hypotension and no signs of peritonitis?

Perform FAST exam

• RUQ (right upper quadrant / Morrison’s pouch)

  • Checks for fluid between the liver and right kidney.

• LUQ (left upper quadrant / splenorenal recess)

  • Checks for fluid between the spleen and left kidney.

• Pelvis (suprapubic / pouch of Douglas)

  • Checks for free fluid behind the bladder (rectouterine/rectovesical pouch).

• Pericardial (subxiphoid view of the heart)

  • Looks for pericardial effusion (tamponade)

What to do for Hemodynamically stable blunt abdominal trauma

CT abdomen

what to do for stable stab wound to abdomen

CT abdomen

What to do for Unstable stab wound for the abdomen or with peritonitis?

exploratory laparotomy

What is used to diagnose Cardiac Tamponade?

Beck’s Triad

what is Beck’s Triad?

hypotension

JVD

muffled heart sounds

how is Cardiac Tamponade differentiated from Tension Pneumothorax?

absence of respiratory distress

• tension pneumothorax has respiratory distress and tracheal deviation

What do you use for Cardiac Tamponade in trauma?

two large bore IV line (16 gauge)

Diagnosis of cardiac tamponade is clinical, what do you do if unsure?

FAST or Echo

Tx for Cardiac Tamponade

Pericardiocentesis

Tx for tension pneumothorax

needle thoracentesis followed by chest tube

Tx for non-tension pneumothorax

chest tube

Unconscious period after head trauma - what test to get?

Head CT w/out contrast

• negative Ct and alert/oriented pt can go home

convex aka lens shaped (lemon) hematoma

Epidural Hematoma

Epidural Hematoma Tx

emergency craniotomy

Describe pt alertness/orientation w/ epidural hematoma

lucid interval - initial loss of consciousness, temporary recovery, then deteriorate

Tx for increased ICP

elevate head, hyperventilate, administer mannitol

when to intervene for hemothorax?

> 1.5 L of blood or > 200 mL/hour for 4 hours

Blunt chest trauma complications

pulmonary contusion, myocardial contusion, aortic transection

What does pulmonary contusion look like on Chest Xray?

white outline after a day - treat supportively

Myocardial contusion (trauma to sternum) Dx:

EKG and troponin

• associated with sternal fractures

Aortic transection DX

• associated w/ high falls, MVAs

CT angioplasty; chest x ray, widened mediastinum

• associated w/ fractures of first rib/scapula/sternum

DX for bladder injuries:

retrograde cystogram

Tx for Intraperitoneal bladder injury (leakage into peritoneum)

surgical

Tx for Extraperitoneal bladder injury (below peritoneum)

Foley catheter

Pt presents with gross hematuria + rib fracture - what is diagnosis?

Renal injury associated with lower rib fractures (11th and 12th ribs)

Renal injury from rib fracture Dx

CT - usually self resolving

Key signs of urethral injury

blood at meatus, scrotal hematoma, inability to void, high riding prostate

Urethral injury Dx

retrograde urethrogram, avoid Foley catheter to prevent worsening injury

what is the major concern with extremity injuries?

Arterial injury

How do you differentiate extremity injuries?

soft signs (absence of hard signs) and hard signs (expanding hematoma or pulsatile bleeding

What to do if hard signs present in extremity injuries?

immediate OR

soft signs - doppler next

Kid presents with malformation of of acetabulum, clunking sound, and asymmetric gluteal folds….what is it?

Developmental dysplasia of the hip

dx Developmental dysplasia of the hip

ultrasound

Tx Developmental dysplasia of the hip

pavlik harness

Obese kid around 11……hip issue….what is it?

slipped capital femoral epiphysis

dx slipped capital femoral epiphysis

x-ray

tx slipped capital femoral epiphysis

surgical pinning

what to do if child has genu varum or genu valgum?

reassure unless age criteria

• varum = normal until age 3

• valgum = normal until age 8

Skinny kid around 6 years old presents with hip issue….what is it?

Legg-Calve Perthes disease - idiopathic avascular necrosis of hip

Tx: Legg-Calve Perthes disease

supportively

athletic kid w/ tibial tuberosity inflammation with micro-fractures

Osgood Schlatter disease

Tx Osgood Schlatter disease

conservative treatment

Pt w/ point tenderness over shin, normal x-ray initially…..diagnosis?

tibial stress fracture

Tx for tibial stress fracture

cast and non-weight bearing, repeat x-ray in few weeks

what is compartment syndrome associated with?

fractures, supracondylar fractures, and revascularization procedures

What are the 6 P’s of compartment syndrome?

Pain

Pallor

Pulselessness

Paresthesia

Paralysis

Poikilothermia

• excruciating pain with passive movement is key sign

Tx of compartment syndrome

fasciotomy

what to do if pt is in cast and has pain under cast?

remove cast immediately…..assess for compartment syndrome

Inflammation due to repetitive thumb movements (using phone)

De Quervain’s tenosynovitis

Dx De Quervain’s tenosynovitis

Finkelstein’s test - pain on ulnar deviation of thumb

Tx De Quervain’s tenosynovitis

steroid injections

What is game keeper’s thumb?

ulnar collateral ligament tear

Tx for game keeper’s thumb

casting

what is mallet finger?

extensor tendon injury

Tx for mallet finger

splinting

What is Jersey Finger?

flexor tendon injury

Tx Jersey finger

surgically

Cauda Equina Syndrome

disc herniation affecting lower motor neurons, presenting with urinary/bowel incontinence, saddle anesthesia, and possible paralysis

Cauda Equina Syndrome Dx + Tx

Emergency MRI and surgical intervention required

What is a chronic non healing wound that can progress to squamous cell carcinoma requiring biopsy?

Marjolin Ulcer

Acute Gout Tx

indomethacin or colchicine

• indomethacin contraindicated in kidney disease; instead use intra-articular steroids

Chronic Gout Tx

allopurinol or probenecid

Dx of Acute Gout

fluid aspiration will show negatively birefringent, needle shaped crystals

Meniscus Injury

popping sound, catching or clicking while extending knee

ACL injury

immediate swelling

• dx: anterior drawer sign

Surgical Contraindications

• ejection fraction <35% or DKA

• Wait 6 months after MI

• stop smoking 2 months before surgery to improve wound healing

Hyperthermia syndrome w/ anesthesia

Malignant Hyperthermia

Malignant Hyperthermia Tx

Dantrolene

Hyperthermia syndrome following antipsychotic use

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome Tx

Dantrolene

Hyperthermia syndromes following antidepressant use

Serotonin Syndrome

Serotonin Syndrome Tx

benzodiazepines or cyproheptadine

PE/DVT management - what do you use if anticoagulants are contraindicated or ineffective?

IVC filter

Post surgical management: first step for confused/disoriented patient

oxygen supplementation

Post surgical management: low urine output

bladder scan

Tx: IV fluids if no urine; insert foley if neurogenic bladder

Post surgical management: paralytic ileus

negative bowel sounds, no flatus, distension worsened by hypokalemia

Ogilvie syndrome

paralytic ileus of colon

Tx of Ogilvie Syndrome

colonoscopy suction

Wound Complication: Dehiscence

fascia tearing, salmon pink color

Wound Complication: Dehiscence Tx

cover wound, bind abdomen, prepare for OR

Wound Complication: Evisceration

bowel exposed

Wound Complication: Evisceration Tx

cover with saline dressings, immediate OR

Wound Complication: Wound Infection

erythema, pain, fever, leukocytosis

Wound Complication: wound infection Tx

open wound, irrigate, antibiotics, heal open

Enterocutaneous fistula - green intestinal contents- Tx:

electrolyte replacement and fluids

Dysphagia workup: first step

Barium swallow

Dysphagia Workup: Dysphagia w/ alarm symptoms (anemia, weight loss)

endoscopy

iron deficiency anemia in older patients - next step

colonoscopy to r/o colon cancer

Mallory Weiss Tear

mucosal tear at LES

Mallory Weiss Tear Dx

endoscopy

Boerhaave syndrome

transmural perforation, pneumomediastinum

Boerhaave syndrome Dx and Tx

Dx: Gastrografin swallow

Tx: surgical

What type of cancer can H. Pylori cause?

gastric adenocarcinoma and MALT lymphoma

treatment for MALT lymphoma

eradication of H. Pylori

Causes of Small Bowel Obstruction

hernia, adhesions

Symptoms of Small Bowel Obstructions

nausea, vomiting, abdominal pain, distention, obstipation

Small Bowel Obstruction Initial Treatment

NG suction, NPO, IV fluids