Mgx of volvulus
flatus tube
endoscopic detorsion - flex sig or colonoscope
sx options
colectomy with primary anas or Hartmann or double barrel
also sigmoidopexy with mesenteric plication but high recurrence rate
cecal vol: right hemicolectomy
RF for DVT
think well’s criteria, Virchow’s triad
Blood stasis: immobility, long flight >6h, CHF, CVA in past 3/12
Endo damage: inflammation, trauma, surgery
Hypercoagulability: pregnancy, active cancer, HRT, OCP, tamoxifen, protein c/s deficiency, APS, hyperhomocystinuria, thrombophilia - anti protein c resistance, prothrombin gene mutation
prevention of DVT
- TED (Thromboembolic deterrent) stockings
- Intermittent pneumatic calf pumps
- Encourage early ambulation
- Pharmacological
1. Clexane (LMW heparin) [avoid in those with poor
renal function]
2.Unfractionated heparin
v.Surgical
1. IVC filter (in those with hx of recurrent DVT/PE, free
floating thrombus in duplex scan, anticoagulation
contraindicated]
Pneumothorax mgx
ABC
immediate needle thoracostomy (2IC, midclav)
followed by chest tube insertion in triangle of safety (midaxillary line, lateral border of pec major, upper border of 5th rib)
analgesia
Diagnosis of toxic megacolon
Jalan’s criteria
- radio evidence: >6cm colon
- 3 of (fever>38, HR>120, TW>10.5, anemia)
- 1 of (dehydration, AMS, elec abnormality, hypotension)
Mgx of toxic megacolon
Supportive: ICU, frequent blood/ serial AXR. correct electrolytes.
NBM. NG
IBD related: IV hydrocort > infliximab
C diff related: stop inciting abx. PO vancomycin 10d KIV +IV metronidazole
Immed sx if perf, massive hemorrhage, worsening
Mgx of Ogilvie syndrome
no obvious colonic cause. assoc with underlying dz/ recent sx
conservative mgx: serial abdo exam, bloods, AXR every 12 h for 2-3 days (if no high risk of perf, cecal>12cm, >6days)
if high risk:
neostigmine IV
or colonoscopic decompression
else sx: cecostomy or colectomy
Post op ileus mgx
supportive: nbm, drip&suck, wait, ambulate
oral gastrograffin (hyper osmotic)
prokinetics: metoclopramide, erythromycin
Intussusception mgx
children: air/barium enema, watch for reduction on fluoroscopy
adults: leadpoint - polyp. colonoscopy instead of barium enema
SAH
- findings on CT brain
- signs of raised ICP
hyperintense star shaped lesion in region of subsellar cisterns
6th n palsy, dilated pupils from uncal herniation, Cushing reflex- bradycardia, hypertension, altered breathing patterns
Wafarin
- MOA
- factors involved
- acute reversal
blocks vit K epoxide reductase (to change vitK to reduced form) to activate factors II, VII, IX, X - block reduction of vit K
vitK 10mg IV over 30min
+
FFP (15-30ml/kg) PR
Prothrombin complex conc (II, IX, X) 25-50 IU/kg
Pneumothorax sizing
American: Apex to cupola
- <3cm: small
- > 3cm: large
British thoracic society: inter pleural distance at lvl of hilum - <1cm: small - 1-2cm: moderate - >2cm: large
what is Kartagener?
triad of
bronchiectasis
situs inversus
chronic sinusitis
Cx of parenteral nutrition
Complications can be classified into that of line insertion and metabolic.
Acute – electrolyte imbalance, fluid overload, metabolic disturbances – hypo/hyper glycermia.
Line related – bleeding, infection, thombosis, pneumothorax, damage to surrounding structures.
Long term – inadequate nutrition, Cholecystitis, Bacterial translocation in the gut
Mgx of antiplt meds for surgery and procedures
determine reason for med: recent MI, CVA, stent?
in general stop 1-2w preop
- aspirin, clop: 7d
- dipyridamole: 10d
- ticlopidine: 14d
type of sx
- endoscopic: can continue DAPT
- cholecystectomy: can continue SAPT
Mgx of anti-coagulants for sx and procedures
depends on reason for med
- low risk of VTE (non valvular AF w no stroke, TIA or stroke with no AF > 3m ago): stop wafarin 5-7days pre op
- high risk: stop wafarin and bridge with clexane 1mg/kg/bd (stop 24h before sx) OR IV heparin (stop 6h before sx)
check INR 1 day pre op: if >1.5 discuss w surgeon
