Final study guide: New content

Question 1

Conus medullaris:
1) What is it?
2) S/Sxs?

Answer 1

1) Compression & dysfunction of T12-L2 region
2)Bladder & rectal sphincter paralysis
Impotence
Saddle anesthesia (S3-S5)
Leg muscle weakness

Question 2

What is the surgical Tx for both Conus medullaris and Cauda equina?

Answer 2

surgical decompression via laminectomy + subsequent discectomy

Question 3

Cauda equina:
1) What is it?
2) S/Sxs?

Answer 3

1) Compression & dysfunction of L1-L5 region
Not a true SCI
2) LBP accompanied by radicular pain
Weakness of plantar flexion with loss of ankle jerk
Bladder & rectal sphincter paralysis
Dermatomal sensory loss of corresponding nerve roots (saddle anesthesia S3-S5)

Question 4

Epidural hematoma (EDH) treatment?

Answer 4

1) Emergent surgical removal w/ standard craniotomy over EDH for hematoma evacuation
-EDH > 1 cm in depth
-Rapidly growing EDH on repeat imaging
2) Non-operative management: small volume EDH in stable patient

Question 5

Subdural hematoma:
1) What is it?
2) Cause?
3) Dx?

Answer 5

1) Bleeding under inner surface of dura
2) Usually due to traumatic rupture of bridging veins
3) CT head w/o contrast: Crescent shape may extend to entire hemisphere

Question 6

Subdural hematoma S/Sxs?

Answer 6

Coma (severe injury) or momentary LOC (lesser injury)
Headache, vomiting, anisocoria, dysphagia, cranial nerve palsies, nuchal rigidity, & ataxia
Usually present with progressively worsening mental status

Question 7

SDH Tx?

Answer 7

Typical candidates for surgical evacuation:
> 1 cm in thickness
Causing > 0.5 cm midline shift
Any accompanying neurological deficit
Operative approach: large craniotomy to evacuate hematoma
Large acute SDH: craniectomy with temporary removal of bone

Outcome: usually poor (mortality 50-90%; significant neuro deficits)

Question 8

Subarachnoid hematoma (hemorrhage)(SAH) treatment if traumatic?

Answer 8

non-op
Admit to ICU, constant hemodynamic & cardiac monitoring, stool softeners, bed rest, analgesia
Anticoagulation & antiplatelet agents discontinued
Pneumatic compression stockings to limit risk of DVT while immobile

Question 9

Subarachnoid hematoma (hemorrhage)(SAH) treatment if aneurysmal?

Answer 9

1) Surgical clipping
open brain surgery where a neurosurgeon places a small metal clip across the neck of an aneurysm to stop blood from entering it
2) Endovascular coiling
Soft platinum coils are inserted into the aneurysm sac, filling it so blood can no longer enter. Inserted via catheter through groin or wrist

Question 10

Intracranial pressure (ICP): Normal vs pathologic? Causes of pathologic?

Answer 10

Normal adult ICP < 15 mm Hg
Pathologic ICP > 20 mm Hg
Causes: tumor, bleeding, hydrocephalus, cerebral edema, increased cerebral blood flow

Question 11

S/Sx of increased ICP? What abt the triad?

Answer 11

AMS, headache, vomiting, papilledema on fundoscopic exam
Severely increased ICP may result in Cushing triad (HTN, bradycardia, respiratory irregularity)

Question 12

Cerebral contusion:
1) What is it? Is it common?
2) S/Sxs?

Answer 12

1) Non-space occupying lesion, localized
MC traumatic lesions, esp in the elderly
2) S&S: significant edema possible -> increased ICP and midline shift

Question 13

Cerebral contusion:
1) Dx?
2) Tx?

Answer 13

1) Perform neuro exam and standard concussion assessment
CT head w/o contrast
2) Usually conservative tx, no surgical intervention
If large + significant shift, ICP monitoring by neuro specialist
Normal ICP <10-15mmHg
ICP monitoring gold standard: intraventricular catheter connected to a standard pressure transducer

Question 14

Differentiate primary and secondary TBI

Answer 14

Primary: skull fractures, lacerations, & hemorrhages
Secondary: local inflammation, loss of regulation of CBF, cerebral edema, & global ischemia from increased ICP

Question 15

S/Sxs of TBI?

Answer 15

Basilar skull fracture
Raccoon eyes: periorbital ecchymosis
Battle sign: retro-auricular (mastoid) ecchymosis
Hemotympanum
CSF rhinorrhea/otorrhea
*Suspect EDH with temporal bone basilar skull fracture

Question 16

Imaging for TBI?

Answer 16

STAT noncontrast CT head for all mod-severe TBI pts
Concern for vasc injury?
CTA = convenient and quick
Conventional Angiography = gold standard

Question 17

Glasgow coma scale?

Answer 17

13 – 15 : minor brain injury
9 – 12 : moderate brain injury
3 – 8 : severe brain injury

Question 18

Descr basic mgmt of severe brain injury

Answer 18

Initial resuscitation
Primary neurologic survey
Immediate surgical management (if necessary)
Management of cerebral edema & increased ICP

Question 19

Descr the parameters for TBI pts

Answer 19

Blood pressure (avoid SBP < 90)
Oxygenation (avoid hypoxia; PaO2 < 60, sat < 90%)
DVT prophylaxis (ICD)
ICP monitoring (GCS 3-8 & abnormal CT findings)
ICP targets (target < 20)
Feeding (fed by post-injury day 7)
Seizure prophylaxis (valproate or phenytoin)

Question 20

Descr Tx of fractures of skull

Answer 20

1) Open fractures: usually require surgical management
2) Closed fractures: managed medically or surgically
3) Depressed fractures greater than width of bone: usually repaired operatively
4) Basilar fractures:
ALL admitted for observation
generally managed conservatively
Surgery for intracranial hemorrhage (EDH)

Question 21

Descr Tx of Penetrating injury & GSWs of the head

Answer 21

Causes focal injury and penetrates skull & brain
Emergent craniotomy may be performed
debris removal, debridement
Contaminated foreign objects = increased risk of infection/meningitis
Broad-spectrum abx
*Up to 90% fatality rate with head GSW

Question 22

How do you Tx Increased intracranial pressure (ICP)/hypertension in TBIs?

Answer 22

Optimization of cerebral venous outflow, CSF drainage, seizure prevention, hyperosmolar therapy, hyperventilation, barbiturate coma, control fever
Surgical decompressive craniectomy:
Maximal aggressive measure
Associated with decreased ICP
Last resort when maximal medical tx fails to control ICP

Question 23

[Hypertrophic] Pyloric stenosis:
1) Is it common?
2) Risk factors?

Answer 23

1) MC cause of gastric outlet obstruction in infants
2) RF: male (80%), first-born, Caucasians

Question 24

[Hypertrophic] Pyloric stenosis: S/Sxs?

Answer 24

1) Infant (2-8 weeks, peak onset 3-5 weeks) previously feeding well -> progressive feeding intolerance & nonbilious forceful (“projectile”) postprandial emesis
2) Palpable mass (“olive”) in epigastric or RUQ
3) Poor feeding, signs of dehydration, electrolyte abnormalities (hypochloremic hypokalemic metabolic acidosis)

Question 25

[Hypertrophic] Pyloric stenosis: Dx?

Answer 25

1) Abd u/s = most sensitive and specific imaging test to confirm dx Pyloric muscle thickness > 3 mm & pyloric channel length >15 mm Lack of gastric emptying 2) If U/S not available/equivocal -> upper GI study (XR + barium)

Question 26

[Hypertrophic] Pyloric stenosis: Tx?

Answer 26

1) Considered medical emergency (not surgical emergency) -Surgery postponed until dehydration, electrolyte derangement, & metabolic acidosis corrected 2) Definitive management is surgical: Open or laparoscopic pyloromyotomy -Complete division of hypertrophied muscle from prepyloric antrum to pyloroduodenal junction using single longitudinal incision -Should visualize circular fibers of stomach wall & independent movement of both halves of pylorus

Question 27

[Hypertrophic] Pyloric stenosis: 1) Mc cause of persistent Sxs? 2) Significant technical risk? 3) Post op?

Answer 27

1) Incomplete myotomy 2) Mucosal perforation 3) Feeding resumed upon recovery from anesthesia in most pts Postop regurgitation common

Question 28

Chronic otitis media: 1) Dx? 2) Indications for surgery?

Answer 28

1) CT before surgery to r/o cholesteatoma 2) Failure of medical therapy (otorrhea continues after 3 weeks of medical tx) & persistent TM perforation

Question 29

Chronic otitis media: Descr the 2 surgery options

Answer 29

1) Tympanoplasty: MC eradicate disease & reconstruct hearing mechanism +/- TM grafting 2) Tympanomastoidectomy: Tympanoplasty with mastoidectomy for CSOM (chronic suppurative OM) with cholesteatoma Surgical resection of cholesteatoma with reconstruction of ossicles & tympanic membrane to restore functional hearing

Question 30

Indications for tonsillectomy and/or adenoidectomy include?

Answer 30

1) Obstruction and recurrent infections 2) Infectious indications: Recurrent or chronic tonsillitis, pharyngitis, or tonsillopharyngitis

Question 31

Benefits of tonsillectomy +/- adenoidectomy for children with recurrent throat infections depends on frequency & severity of previous documented episodes; what are some causes of these?

Answer 31

Common causes: group A β-hemolytic streptococcal species, anaerobes, Haemophilus influenzae, and viruses

Question 32

Define severe tonsil infections

Answer 32

≥ 7 episodes in one year, ≥ 5 episodes in each of two years, or ≥ 3 episodes in each of three years Surgery vs watchful waiting with treatment Decision made on case-by-case basis

Question 33

What should you do for mild/moderate tonsil infection cases?

Answer 33

Recurrent episodes less frequent or severe = Symptomatic care & antimicrobial tx Exceptions: recurrent & complicated group A strep pharyngitis

Question 34

Gastroschisis: 1) What is it? 2) Is it common? 3) S/Sxs?

Answer 34

1) Defect lateral to umbilicus with variable evisceration of viscera without sac 2) Twice as common as omphalocele 3) > 70% premature; liver usually NEVER present in defect almost always right-sided Eviscerated bowel often inflamed & edematous may have thick & matted membrane (“peel”) Ongoing protein losses

Question 35

Gastroschisis Tx?

Answer 35

Urgent closure needed due to exposed viscera 1) Small defects: primary closure 2) Moderate-large defects: staged closure using silo reduction (~5-7 days) Most infants require TPN due to prolonged post-op ileus (>2 wks) Long-term outcome = good

Question 36

Wilm’s tumor: 1) Is it common? 2) What is it?

Answer 36

1) MC primary renal malignancy in childhood - Peak incidence age 2-3 2) Tumor consists of embryonic tissue, muscle fibers, cartilage, bone

Question 37

Wilm's tumor S/Sxs?

Answer 37

Left > right kidney Most present with asymptomatic abdominal mass Abdominal mass usually large, firm, smooth, & usually doesn’t cross midline May have abd pain, hematuria, malaise, weakness, anorexia, weight loss, fever, HTN

Question 38

Wilm's tumor Dx?

Answer 38

U/S initial study of choice CT abdomen & chest to r/o metastasis Calcifications on x-ray more rare than neuroblastoma Labs: CMP, CBC, coags, UA

Question 39

Wilm's tumor Tx?

Answer 39

1) Surgery to completely excise tumor (nephroureterectomy) & stage usually possible without preop tx Staging based on surgical eval prior to chemo Chemo typical postop 2) 5-yr survival >85%

Question 40

Renal transplant: 1) Indications? 2) Absolute contraindications?

Answer 40

1) Advanced CKD documented by a GFR or creatinine clearance ≤ 20 mL/min or once dialysis has been initiated 2) Active infections, active malignancy, active substance abuse, reversible kidney failure, uncontrolled psychiatric disease, documented active & ongoing treatment nonadherence, significantly shortened life expectancy

Question 41

Renal transplant survival rates?

Answer 41

HLA identical living-related: 1-year >95% 5-year >90% 10-year >65% Deceased donor: 1-year >88% 5-year >66%

Question 42

Indications for EN?

Answer 42

dysphagia Inability to take PO nutrition (head/neck cancer, facial trauma) Hypermetabolism w/ inability to take adequate oral nutrition Mechanical ventilation Severe malnutrition

Question 43

When should you use nasal/ oral EN?

Answer 43

Oral & nasal routes for short-term (6-8 weeks)

Question 44

Can you use EN postop?

Answer 44

Early EN in post-op period (12-72 hr) may be beneficial & advance as tolerated

Question 45

Descr refeeding syndrome

Answer 45

May occur when initiating TPN in severe malnutrition Results in profound hypophosphatemia Hypokalemia & hypomagnesemia may also occur Slowly increase rate over several days