DeVirgilio Flashcards

Question

Pancreatitis | Ranson criteria

Answer 1

Severe - APACHE 8+, Ranson 3+, organ failure, or pancreatic complications (necrosis, abscess, pseudocyst) ``` Ranson A. Admission - GA LAW Glucose >200 Age >55 LDH >350 AST> 250 WBC >16 ``` ``` B. After 48 hours - C. HOBBS Calcium <8 (due to saponification) Hct decreases 10% O Pa02 <60 BUN increases 5 Base deficit >$ Sequestration >6L ```

Answer 2

lower GI bleed: HDRAIN ``` Hemorrhoids Diverticulosis Radiation colitis Angiodysplasia Infections/ischemic/IBD Neoplasm/polyps ```

Answer 3

``` Fat Fecal impaction Fetus Flatus (ileus or obstruction) Fluid (ascites) ```

Answer 4

LBO A. MCC is left-sided colon cancer (R side is IDA), then diverticulitis, then volvulus B. Clinical - more pronounced distension, late onset vomiting, obstipation, decreased bowel sounds, feculent vomiting - IV fluids, foley - untwist sigmoid volvulus then sigmoidectomy if uncomplicated, go straight to resection if ischemic/perforated or a cecal volvulus (contrast enema can sometimes untwist volvulus)

Answer 5

NSAID ``` Neurologic deficit Spinal tenderness AMS Intoxicated Distracting injury ```

Answer 6

1. humeral head - axillary --> arm abduction 2. midshaft humerus - radial --> elbow, wrist extension 3. supracondylar - anterior interosseus (median) --> handgrip (no sensory problems) 4. distal radius - median --> thumb opposition 5. hip fracture - sciatic (peroneal) --> knee flexion 6. fibular head - fibular / peroneal --> foot drop, dorsiflexion, eversion

Answer 7

1. energy imparted to the wound 2. abx coverage - Grade I and II - Gram + --> 1st gen cephalosporin Grade III - ceph + aminoglycoside continue for 24 hours after wound closure if wound has dirt/soil - Clostridium --> PCN, Tetanus immunoglobulin (for dirty wounds, if <3 vaccine doses; don't give for clean wounds), tetanus toxoid vaccine (if last dose was >5 years ago for dirty or >10 for clean) 3. greatest risk hemorrhagic shock - pelvic fracture 4. crush injuries --> compartment syndrome, rhabdo, AKI

Answer 8

1. Froment sign - test of ulnar nerve, thumb adductor in which examiner can pull the paper from pt's hand - low ulnar lesion has severe ulnar claw 2. CTS - splinting wrist, injection of corticosteroids, then surgical (cutting of transverse carpal ligament) - unless there is thenar atrophy - indication for surgery 3. carpal tunnel - hypothyroidism 4. distinguishing prox from distal median nerve injury - palmar cutaneous branch of median nerve, runs above carpal tunnel --> spared in distal injury

Answer 9

1. CDH --> pulmonary hypoplasia --> high resistance in pulmonary arterial bed (pulmonary hypertension), does not reverse as it should when infant takes its first breath --> hypoxemia, acidosis, hypotension --> pulmonary vasoconstriction *directly correlated with survival - most commonly on left, posterolateral 2. Mgmt - intubate ASAP - place orogastric tube, take CXR --> tracheoesophageal fistula, CDH, choanal atresia 3. duodenal atresia - (double bubble sign on Xray) - down syndrome, cardiac defects, annular pancreas

Answer 10

Bilious vomiting - green or yellow, obstruction after ampulla of vater IVF, NGT A. stable --> Xray --> prox obstruction (min bowel gas) --> UGI contrast study to look for malrotation, if negative consider hernia, adhesions, Hirschsprung distal obstruction (lots of bowel loops) --> abdominal US to look for intussusception B. unstable --> Abx and OR for ex lap, suspect malrotation with midgut volvulus (failure of normal 270 rotation around SMA --> closed loop obstruction) *midgut volvulus most commonly has normal Xray findings

Answer 11

1. Clostridium septicum - associated with occult malignancies esp colon cancer 2. NSTI hard signs - hemodynamic instability, crepitus, bullae, skin necrosis - acute onset pain, swelling, erythema - clinical diagnosis --> needs surgical debridement and second look surgery

Answer 12

- surgical (artery/vein) - medications (anticoags) - inherited eg vW, hemophilia - liver failure (Reduced clotting factors) --> FFP - renal failure (uremia impairs platelet function) --> desmopressin and dialysis - DIC TRALI - blood transfusion related acute lung injury - leading cause of fatalities, non-cardiogenic pulm edema - donor Ab attack recipient WBCs --> complex aggregates in lung vasculature --> inflammation --> pulmonary edema - requires fluid resuscitation, pressors ARDS: - b/l fluffy white infiltrates on CXR - normal PCWP < 18 (means its not cardiac) - Pa02 / Fi02 < 200 transfusion rxns A. febrile nonhemolytic - min to hours, due to cytokines, give tylenol B. acute hemolytic - within 24 hrs, due to ABO mismatch --> fever, low BP, flank pain, hemoglobinuria, jaundice C. allergic - due to plasma in donor blood, give antihistamine (diphenhydramine) D. anaphylactic - IgA deficiency, give epi

Answer 13

normal urine output = 50-100 mL / hour oliguria = <0.5-1 ml/kg/hour OR <400-500 mL in 24 hours first make sure foley is not clogged, flush it then review all meds and dose adjust renally excreted drugs, then fluid challenge (500 mL bolus NS in 30 min) --> urine output will increase if oliguria is due to hypovolemia if not: - put in central line --> CVP (nl 8-12) will help assess volume status - if oliguric after normal CVP is reached --> consider postrenal and and intrinsic renal etiologies oliguria normal in the first 24 hours postop due to increased aldosterone and ADH

Answer 14

1A. Cardiogenic - acute cardiac event eg MI, LVF, arrhythmia S3 gallop, JVD, crackles + cool extremities elevated PCWP >18 tx - reduce preload and afterload, pressors on POD3 can be due to third spacing, IVF goes back to vasculature and overwhelms the heart B. Non-cardiogenic - PNA, ARDS, pulm contusion, fat emboli due to increased permeability 2/2 cytokine signaling / inflammation; wide A-a gradient tx - ventilatory support 2. PE -- start heparin, do CTa, b/l leg doppler + V/Q scan respiratory alkalosis, hypoxemia, and increased A-a gradient EKG - sinus tach, S1Q3T(inverted)3 - due to RV strain normal CXR usually can be low-risk, submassive (RV strain), massive (hypotension)

Answer 15

1. Shock - PCWP ~ LAP A. Hypovolemic (trauma, burn) - low PCWP, low CO, high SVR B. Cardiogenic (MI, HF, arrhythmia) - high PCWP, low CO, high SVR C. Obstructive (tamponade, tension pneumo, PE) - decreased preload D. Distributive - low PCWP, low SVR i. neurogenic - dry skin, low CO ii. sepsis, anaphylaxis - warm skin, high CO 2A. Neurogenic shock - SNS outflow through spinal cord disrupted --> vasodilation, bradycardia, hypotension B. Spinal shock - temporary syndrome with flaccid paralysis below level of injury with loss of all reflexes, urinary and rectal tone

Answer 16

1. chest, abdomen, pelvis, long bones, external 2. Tachycardic (100+) - 750-1.5L blood loss Hypotensive (SBP < 90) - 1.5-2L blood loss 3. Pulsating mass - AV fistula, aneurysm, pseudo-aneurysm (full thickness injury that is temporarily tamponaded by surrounding soft tissue, pulsating is due to blood being pumped into cavity) 4. narrow PP = <30 mmHg --> compromised stroke volume *worry when diastolic p starts rising DDx - pericardial tamponade, hypovolemic shock, cardiogenic shock

Answer 17

Neck injury A. Hard signs --> expanding hematoma, shock, hematemesis, neuro deficit, airway compromise --> OR stat B. soft signs --> subQ air, dysphagia, chest tube air leak C. Mgmt ``` Zone 3 (above mandible) penetrating - aortagram, triple endoscopy stab - observe ``` ``` Zone 2 (mandible to cricoid) penetrating - doppler maybe surgery stab - observe ``` ``` Zone 3 (below cricoid) penetrating eg GSW - aortogram, esophogram, bronchoscopy ``` blunt --> do lateral or CT cervical spine

Answer 18

Lethal: 1. airway obstruction - stridor, gurgling, hematoma 2. tension pneumo - tracheal shift away, unilateral absent breath sounds + JVD + hypotension + dyspnea + tachypnea 3. open pneumo - open injury 4. massive hemothorax - total whiteout of lung field 5. flail chest - 2+ fracture sites in 2+ consecutive ribs 6. cardiac tamponade - beck's triad (JVD, hypotension, muffled heart sounds) Hidden: 1. Blunt aortic injury - deceleration injury, trachea deviates right 2. esophageal injury - penetrating injury, subQ air 3. tracheobronchial injury 4. diaphragmatic rupture - on L side, see bowel in chest 5. blunt cardiac injury 6. pulmonary contusion (lungs white out on CXR)

Answer 19

1. Burns First degree - superficial (epidermis) - dry, red painful Second degree - partial thickness - warm, blistered superficial = painful while deep = painless Third degree - full thickness (epidermis + dermis) - painless, leathery, do not blanch severity = total body surface area of 2nd or 3rd degree burns 2. alkali worse than acidic bc they penetrate tissues deeper acidic --> coagulation necrosis alkali --> liquefactive necrosis electrical --> do EKG, monitor *if pt has myglobinuria - check K+ due to rhabdo 3. use LR bc use of NS will lead to hyperchloremic metabolic acidosis watch for hyponatremia, hyperkalemia Parkland =4 * weight in kg * TBSA 4. Topical abx - silver sulfadiazeine - standard, causes leukopenia - silver nitrate - causes hypoK and hypo Na - mafenide - for deep burns bc penetrates eschar, hurts like hell - triple abx - for eyes

Answer 20

1A. Acute gastritis - erosive, superficial inflammation of lining of stomach due to NSAIDs, alcohol, steroids, uremia B. Chronic gastritis - non-erosive inflmmation of mucosa - fundus dominant - pernicious anemia - antral dominant (most common) - H pylori 2. Variceal bleed - abx ppx, somatostatin (octreotide) endoscopic band ligation propanolol to prevent future GI bleeds 3A. intestinal - well-differentiated, decreasing incidence as H pylori decreases, due to environmental factors B. diffuse - infiltrative, generalized hypertrophy and leads to linitis plastica

Answer 21

1. LR - hypotonic to plasma (Na = 130), physiologic K and Cl; can lead to metabolic alkalosis NS - hypertonic to plasma (Na = 154), low pH and high Cl load can cause metabolic acidosis 2. maintenance = 1/2NS + 20KCl (if peeing) rate per day = 1500 mL + [(kg - 20kg) x 20 ml/kg/day] e.g. for 60 kg --> 1500+ (40x20) = 2300 ml/day 3A. Hypernatremia - every 3 meq/L above 140 --> 1 L water lost - replete with D5 1/2NS - if acute --> use more diluted fluid eg D5 or D51/3NS B. Hyponatremia - - increased volume (CHF, nephrotic cirrhosis) - fluid restrict, diuretics, hypertonic saline IF <110 or sympomatic - nl volume e.g. SIADH --> fluid restriction - decreased volume e.g. pt losing GI fluids and forced to retain water --> isotonic fluids 4A. Hypokalemia - IV K at 10 meq/hr, monitor renal fx B. Alkalosis - KCl bw 5-10 mEq/hr

Answer 22

1. Contraindications to surgery - absolute - DKA - poor nutrition - albumin < 3, transferrin < 200, weight loss < 20%; do enteral feedings - liver - PT > 16, ammonia >15, bili > 2 - smoker - stop 8 weeks before surgery 2. predictors of periop mortality - CHF --> check EF if <35% --> no surgery - MI (in last 6 mos) *surrogate for cardiovascular status* --> do EKG --> stress test --> Cath lab for reperfusion (stent, CABG) - arrhythmia - age > 70 - aortic stenosis - CKD - worry if BUN > 100 bc of uremic platelet dysfunction --> normal platelets but risk of bleeding 3. Meds to stop - aspirin, NSAIDs, Vit E (2 weeks preop) - warfarin (5 days) - INR <1.5 - metformin - risk of lactic acidosis

Answer 23

1. Assist control - Set tidal volume and respiratory rate but if patient takes breath, vent gives volume 2. Pressure support - patient controls rate but vent gives some tidal volume; important for weaning 3. CPAP - patient has sufficient respiratory drive but continuous positive pressure so alveoli stay open 4. PEEP - used in ARDS or CHF, positive pressure at end of exhalation If... 1. Pa02 too low --> increase Fi02 2. PaC02 too low (pH high) --> decreased RR or TV (TV is better bc you're not dead space ventilating as with RR)

Answer 24

1. Pneumothorax - tension - absent breath sounds, tracheal deviation away, JVD (think tension or tamponade), subQ emphysema; one-way valve due to lung injury --> needle in midclavicular 2nd intercostal space, then chest tube - open - sucking chest wound --> leads to tension - small spontaneous - 100% 02, avoid PEEP 2. Hemothorax - absent breath sounds, dullness to percussion - chest tube --> if >1.5L immediately or >600 mL in 6 hours --> go to OR for VATS 3. Flail chest - 2+ fractures in 2+ consecutive ribs - give 02 and nerve block for pain control *NOT opiates (decrease RR) - underlying pulm contusion (whiteout on CXR) --> give diuretics bc sensitive to fluid overload

Answer 25

Normally I&D abscesses 1. do NOT do that for lung abscesses - tx with abx, IV clinda or PCN - surgery if abscess > 6 cm, abx fail, or empyema 2. Liver abscesses caused by Entamoeba histolyica - give metronidazole * bacterial liver abscesses (ecoli, bacteroides, enterococcus) -- drain and IV abx

DeVirgilio Flashcards

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