Emma Holliday Review —IM, Psychiatry, Pediatrics, Surgery

Absoulte contrindications to surgery

diabetic coma and DKA

Other contraindications to surgery

poor nutrition -

------albumin < 3,,

------transferrin < 200

------weight loss of total body < 20%

Lever failure - High bili, Pt > 16 ammonia > 150

SMoker - stop 6-8 wks prior

Meds to stop prior to surgery

aspirin

NSAIDS

vit E ( 2 weeks)

If have CKD what do you do 24 hrs proior to surgery

diayllsis 24 hours prior

What post surgical complication would you worry about with the BUN > 100

Platlet dysfunction and bleeding

What would the labs show for uremia induced platlet dysfunction

Normal platlets but prolonged bleeding time

SIMV

You get a set TV. therfore if the patient starts the breath they get the full volume

PVRC

Pt determines the rate but a boost of pressure is given for each breath

CPAP

Pt must breath on their own but prssure is given all the time

PEEP

- pressure delivered at the end of the cycle to help th avelooi open VERY important top help in ARDS

What would you change on a vent if : PaCO2 is Hihg and pH is low

increase Rate or TV

What would you change on a vent if : Paco2 is low and Ph is high

decrease rate OR TV

IF Hco2 is low and pCO2 is low

what is the cuase and what do you check next

Metabolic acidosis

next check anion gap - ( Na- [cl+ hco3])

Causes of metabolic acidosis With a HIgh anion gap

M-methanol

U- uremia

D- DKA

P-propylene gylcol

I-iron, isoniazid

-L - lactic acidosis

E- etholnol

S- Siacylic acid

Causes of metabolic acidosis With a normall anion gap

diarrhea, diuretics RTA I< II, IV

If HCO3 is high and PCO2 is high and cl- in the urine is < 20

Vomiting/NG tube antacids, diuretics

If HCO3 is high and PCO2 is high and cl- in the urine is > 20

Conns Bartters Gittlemans

then you have low sodium when do you use 3% Na iv

when the patient is symptomatic with seizures or sodium is below 110

complication of correctio of hyponatermia too quickly

Centeral pontine myoliinolysis

If you ahve an increase in total body sodium what do you replace with and what is a complication

replace with D5 or hypoteonic fluid

risk of cerebral brain edema

Numbness chvostek, or troussaeus sign or Prolonged Qt interval

Decrease Ca2+

Bone pain, kidney stones, Abdominal discomfort from constipation, Depression anexity trouble sleeping anorexiaOR shortened QT

Increased Ca2+

Paraylsis, Ileus, ST depression U waves

Cause and Treatment ?

Cause decrease K and treatment Give K max 40 mEq/hr

Peaked T waves ( generalized) prolonged PR and QRS waves

Cause?

Treatment?

Cause - give Ca gluconate then insulin + glucose and kayexalate albuterol and sodium bicarb..... last resort is diaylsis

Maintenacne IVF equation

$: 2;1

0-10 kg - 4ml/kg/hr

10-20 - 2 ml/kg/hr

all above 20kg: 1ml/kg/hr

Complication of TPN

Acalculus cholecystitis hyperglycemia liver dysfuxn, zinc def. lyte prob

If someone hasa circumferential burn

consider escharotmy

If someone has signed nose hairs wheezing and soot in mouth

Bad intubation - low threshold

Patient with confusion and cherry red skin

CO - best test is carboxy hb - DONT use pulse Ox

HYPER-Clotting. In the elderly

CAcner especiially pancreatic

Hyper- Clotting and Edema Htn and foamy pee

nephrotic syndrom

HYPER- Clotting in a young person with a + Family hx

factor V leiden

If you have AtIII def what medicatio will not work on the clots

heparin

HYper- clotting and a young women with a PMH of spontenous abortions

Lupus anticoagulant

Post Op HYper Clotting decrease in Plt

HIT - if heparin was given w/in 5-14 days

How do you treat HIT

leparudin and agatroban

Bleeding problem with an isolated decrease in Pltss

ITP

Normal PLts but increase in bleeding time and Ptt

von willibrands disease

Low Plts, Increase PT, PTT BT Low Fibrinogen, high D dimer and schistocytes

DIC!!! caused by Gram - sepsis carcinomatosis and OB stuff.

RULE of 9 for burns Adults Vs children

Adults- 9 for each Arm, 9 for the head, 18 front, 18 back, 1 genitals, 18 for each leg

Babies- 18 for the head, 0 for each arm, 18 front and 18 back and 1 genitals and 14 legs

Parkland forumla adults and babies

and how fast do you give the voluem

adults : KG %BSA 3-4

Kids : Kg %BSA 2-4

- this gives you a value in Ml and you give 1/2 over the 1st 8 hrs and rest over the next 16hrs

How do you abx to Burn patients

TOPICAL !!!!

Silver sulfadiazine

Doesnt penetrate eschar and can cause leukopenia

Mafenide

Penetrates eschar but hurts like helpp

silver nitrate

Doesnt penetrate Eschar and causes hypoK and HypoNa

Chemical burn 1st step

irrigate > 30 min

Electrical burn

1st test and then amangement

1st test: Get and EKG to check for arrthymias

managment: check for myogliobinuria and ATN

Check K levels from cell lysis

Monitor limb temperature for compartment syndrome

- criteria - 5 P and pressure > 30mmhg

When a smoker is coming out of anesthetics do you want to keep their pulse ox at 100

No because smokers and Co2 retainers need the low oxygen for the respiratory drive

Goldmans risk what is the MOST important Risk

CHF- check EF < 35% NO SURGERY for you

Goldmans risk what is the Second MOST important Risk

MI w/in 6 mon

EKG-> stress test--> cardiac cath --> revasc.

Metformin important prior to surgery

YOU must stop because of lactitic acidosis

What is more effective for your patient to increase Rate or Volume ?

By increasing rate you are not increasing the amount of I2 to the aveoli

by increasing TV you are increasing the effective oxygenation

Low sodium but signs of fluid retention

CHF, nephrotic cirrotic

DEcrease volume and decrease sodium

diureticcs or vomiting and free water

NOrmal volume but decrease in NA

SIADH ! addisons and hypothyroidism

When do you use hypotonic saline 5%

patient is symptomatic with seizures or sodium less then 110

Maintenacne IVF for daily requirments

up to 10Kg - 100ml/kg/day

NExt 10 -> 50ml/kg/day

All above 20 -> 20ml/kg/day

1st degree burn what layer of skin

epidermis

Why dont you give IV or PO antibiotics to a burn victom

it breeds resisitance

If yo have low sodium what do you want to check

the serum osmolarity because high glucose makes the plasma look too dilute

What kills you in rhado!

The hyperkalemia

Patient is unconscious

INTUBATE

If a guy is stabbed in the neck and there is subcutenous stridor then what to do

Use fibrooptic broncoscope to secure the airway

when do yo immeadatly brind a patietn to the OR

Upput is greater then 1500 ml when the tube is first placed or greater then 200ml/hr in the first 4 hours

If patient was inward mvmt of the right ribcage upon inspiration

FAIL chest > 3 consec rib fractures

Fail chest treatment

o2 and pain control ( NERVE BLOCK) - do not give morphine because it decreases repiratory drive

A patient is confused petechial rash in hte chest and axilla and neck with Acute SOB post Car accident multiple bone injuries

Fat embolism - mcc after long bone fracture s

A patient dies suddenly dies after a centeral line

AIR embolism

Causes of air embolism

lung trauma ( too much TV) , vent use, during heart vessel surgery

If the neck veins are flat and the CVP is normal what type of shock

Hypovolemic/ hemorraghic

After hypovolemic shock has been indentified whats the next best step

2 large bore iv-2L NS or LR over 20 min followed by the blood

If muffled heart sounds, Disteneded JVD, electracal alternas on EKG Pulsus paradoxus

pericardial tamponade

What test to confrim pericardial tamponade

FAST scan

Treatmetn for Pericardial tamponade

needle decompression pericardial window or median sternotomy

IF decrease breath sounds on one side tracheal deviation away from the collapsed lung

Tension pneumothorax

You do not need to confrim - simply place the need and then a chest tube

NO CXR nessisary

NEurogenic shock physical findings

Bradycardia, warm dry extremities

NO relfexs or flaccid muscle tone.

CAN HAVE hyponatermia and Hypokalemia d/t adrenal insufficency - give dexamethasone

Neurogenic shock swan ganz catheter pressures

Increase CO

Systemic Vascular rsistance - decreases SVR

PCWP- Decrease

Vasogenic physical exam

AMS!, Warm Dry extremities ( early)

LATE APPEARSlike hypovolemic shock

Vasogenic swan ganz catheter pressures

PCWP decrease

SVR decrease

CO increase

Cuase of neurogenic shock

loss of sympathetic input there for dilatation of the vascular tone.

Physical presentation of cardiocompressive shock

hypotensive tackycardiac JVD decreased heart sounds normal breath sounds Pulsus paradoxcus

Cardiogenic shock physical exam

SOB ( pulmoary edema) clammy extremities rales b/l S3 pleural eddusion and decrease breath sounds ascities and peripheral edema

Cardiogenic pressure readings

PCWP - increase ( back up of blood)

SVR increase

CO decrease

Physical exam for hypovolemic shock

Hypotensive tackycardiac diaphoretic cool clammy extremites

Lung pressures

PCWP decrease

SVR increase

CO decrease

Increased ICP

Heachache, projectile vomiting and AMS ! also papilledema ( visual cahnges

What are the besd side treatments for increase ICP

Elevate HOB, Hyperventilate to ppCO2 28- 32

give mannitol watch renal failure

Surgical managmnt for head trauma and bleeding

Ventriculostomy - or BUrr hole

Zone 3 of the neck

ABOVE The angle of the mandible

WORK up for damage of zone 3 of the neck

AOrtography and triple endoscopy to make sure the trachea nd esophagus are still patetn

zone 2 neck location

Angle of the mandible to the cricoid

ZOne 2 work up for neck trauma

2d Doppler (vessels) and +/- exploraoty surgery

zone 1 location

below the cricoid

work up for zone 1 damage

angiography

IF Gun shot wound to the abdomen where for you go

OR immeadatly + tetnus prophaylaxis

If stab wound and patient is unstable with rebound tenderness and rigidy or evisceration

OR immeadatly + tetnus prophalaxis

If blunt ab trauma pt with hypotension/tachycardia

OR ex lap

If stab wound to the abdomen but patient is stable

FAST exam

DPL ( diagnositc peritoneal lavage ) if FAST is equivocal

EX lap if EITHER are postive

BAT + unstable vitals

OR immeadatly

BAT + hemodynamically stable next best step

CT Of the abdominal