Dr High Yield Surgery

Trauma

• GSW: automatic ex-lap

• Blunt abdominal trauma: guarding, rigidity, rebound tenderness, peritonitis = ex-lap

  • Hypotension but no signs of peritonitis = FAST exam

• Hemodynamically stable = CT of abdomen

• Cardiac tamponade: Beck triad

  • Two IV bore lines for fluid resuscitation and potential blood transfusion, to ensure adequate volume replacement and stabilize the patient.

  • Pericardiocentesis

• Tension pneumothorax: tracheal deviation

  • If you see tracheal deviation, needle thoracostomy followed by chest tube

  • If there is no tracheal deviation, chest tube can be done first

• Head trauma w/ unconscious period: CT head w/o contrast

  • Alert and oriented with negative CT = discharge

• Epidural hematoma = emergency craniotomy

• Increased ICP = mannitol, hyperventilation, increased HOB

• Hemothorax = OR intervention if greater than 1.5L of blood loss

  • This is sign of intercostal artery injury

• Pulmonary contusion: 1 day later, white out lung on CXR; treat conservatively

• Myocardial contusion: Trauma to sternum; get EKG/troponins, associated with sternal fractures

• Transection of aorta: high falls and MVCs with rapid deceleration, widened mediastinum on CXR, assoc with fracture of 1st rib, scapula, and sternum; get CT angiogram

• Bladder injury: Retrograde cystogram

  • If leakage into peritoneum, this is intraperitoneal bladder injury; it gets surgery and closed with suprapubic cystotomy tube

  • Extraperitoneal bladderinjury: it gets Foley catheter

• Renal injury: associated with 11th and 12th rib fracture

  • Gross hematuria = get CT

    • Self-limiting, leave alone

• Urethral injury: Blood at the meatus, potentially scrotal hematoma, inability to void, high riding prostate

  • Get retrograde urethrogram, do NOT use Foley

• Hard signs of extremity injury: Pulsatile bleeding, Expanding hematoma, Bone exposure, Ischemia of affected limb, Significant dysfunction or loss of motor/sensory function

  • These all suck; if you see any of these, they go immediately to the OR

  • On the other hand, if none of these are present, get Doppler

• SCFE: look for “ice-cream cone sign” and an obese patient; other symptoms to watch out for are hip pain, limited range of motion, and the patient often presents with a limp.

  • Surgical pinning is what is done for this

• Legg-Calves-Perthes disease: idiopathic avascular necrosis of the hip, seen in kids 6-10 and on the skinnier side; other symptoms to look out for are hip pain, groin pain, and limited mobility, typically resulting in a limp that worsens with activity.

  • Treatment is supportive

• Tibial stress fracture: gets cast and repeat X-ray

• DeQuervain tenosynovitis: inflammation of extensor pollicis

  • Have the patient put their thumb in their wrist and deviate to ulnar side; if painful, give them a steroid injection

• Cauda equina syndrome: get immediate MRI

• Marjolin ulcer: a rare and aggressive form of skin SCC that arises in chronic wounds or scars, requiring excisional biopsy and often associated with poor prognosis.

• Gout with CKD = intra-articular steroids

Pre-Op and Post-Op

• Patients with recent MI must wait 6 months before getting another surgery

• Need to get smokers to stop 2 months before surgery

• IVC filters are only done if anticoagulants fail or they cannot be used due to increased risk of bleeding

• Confused and disoriented = immediate O2 supplementation

• Post-op low urinary output = bladder scan

  • No urine in bladder = get IV fluids

  • Urine in bladder = get Foley

• Paralytic ileus = distension of small intestine and colon

  • Ogilvie syndrome = distension of colon but normal small intestine; gets colonoscopy suction

• Wound dehiscence: salmon-pink coloration

  • They will need to be resent to the OR

• Wound evisceration: bowel straight out into the air, needs to also go straight to OR

• Wound infection: gets abx

GI

• Dysphagia: first thing is barium swallow

  • If alarm symptoms like weight loss and anemia, they get endoscopy first

• Iron deficiency anemia in elderly: they get colonoscopy

• Mallory Weiss tear: gets endoscopy

  • Active bleeding = ablation

• Esophageal perforation: gets surgery

• H. pylori causes gastric adenocarcinoma and MALT lymphoma

  • To treat MALT lymphoma, treat H. pylori

• SBO: first thing is abdominal X-ray

  • Treat with NPO and NG decompression

  • If failure: go to surgery

• C difficile colitis gets oral vancomycin

• Acute mesenteric ischemia: physical exam tenderness ≠ subjective tenderness

  • Get CT angiogram

• Pyogenic liver abscess: gets percutaneous drainage

• When RUQ ultrasound is negative for gallstones, pericholecystic fluid, and thickening of wall, next is HIDA scan

• Choledocholithasis: treated with ERCP

  • If left untreated, ascending cholangitis

• Signs of gallstone pancreatitis:

  • Severe abdominal pain, usually in the epigastric or LUQ region

  • Nausea and vomiting

  • Elevated serum amylase and lipase levels

  • Possible fever and jaundice

  • If these signs are present, get RUQ ultrasound, NOT CT

• Pancreatic pseudocyst: getting full early, vague abdominal pain

  • If less than 6 cm, leave it alone

  • If greater than 6 cm: drain

• Bowel rest regimen for SBO, pancreatitis, volvulus, diverticulitis

• Umbilical hernia: leave it alone until age 5

• Acalculous cholecystitis gets cholecystostomy tube

• Congenital diaphragmatic hernia: intubate, then surgery

• Intussusception: in kids, pain is colicky and may present with a "currant jelly" stool.

  • They get air enema

• Midgut volvulus pain is constant and they will need barium enema

Cardiopulmonary

• Vascular ring: congenital, inspiratory wheezing, hyperextension will relieve

• Tracheomalacia: supine worsens, prone

• Valve replacement: indicated in severe aortic stenosis or regurgitation, often resulting in improved hemodynamics and symptomatic relief.

• CABG: LAD will be 70%+ occluded

• CXR reveals new lung nodule

  • Get previous X-ray

  • If not available, get CT

  • FEV1 must be 800+ mL to proceed to surgery

• AAA greater than 5 cm get percutaneous stenting

• ABI <0.4 get stent and aspirin

• Aortic dissection: get CT angioplasty

  • MRI or TTE if renal disease

Ophthalmology

• Strabismus in babies: treat with surgery if the condition persists beyond age 2, or if it causes significant amblyopia.

• Strabismus in adults: get them glasses

• Acute angle glaucoma: severe eye pain, halos, dilated and fixed pupil

  • Get laser beams, pilocarpine, timolol

• Orbital cellulitis: infection around the eye

  • They get emergency CT

Neurology

• First sign of stroke: CT w/o contrast

  • Hemorrhage: control HTN with CCB

• Acromegaly/gigantism: check IGF-1 first

• MRI of brain for brain tumors

Urology

• Septic kidney stones get percutaneous nephrostomy

• Epididymitis: in younger people, ceftriaxone and azithromycin; older people, fluroquinolones

• Posterior urethral valve (remember it’s in kids): VCUG, temporary catheterization, then surgical intervention to relieve obstruction