Surgery Shelf Questions

What is the most common indication for intubation?
Altered mental status

When there is a need for an airway, but possible neck injury, what do you do?
Airway anyway! Make sure the spine is steady!

Most common reasons for shock in the trauma patient
Pericadial tamponade ( distended veins. CVP > 20)
Tension Pneumo ( tracheal deviation, loss of breath sounds)

Most common reasons for shock in the trauma patient
Cardiogenic shock
Vasomotor Shock

In a non trauma patient, shock + big distended neck veins mean what?
Cardiogenic Shock.

In a trauma patient, if the airway is blocked and intubation in needed, what do you do?
Cricithyroidectomy NOT tracheostomy

What is the downside to percutaneous ventilation?
It does not eliminate CO2. So in head trauma, it would increase the ICP

What is the first step to managing shock?
Stop the bleeding

In what instance, would you not stop the bleeding?
If it is wound directly to the heart.

What is the best way to control bleeding?
Direct pressure with a gloved finger. Not blind clamping or a tourniquet. Of course, use the latters if bleeding cannot be controlled.

Where can you place an IV line? with what? What kind of fluid? What rate?
In the periphery. Short, wide (16 gauge) needles. Percutaneous femoral vein catheters also work. Lactated ringers. 2 liters in the first 20 to 30 minutes.

In children, where is also another good place to put a central line?
Intraosseous, pretibial.

If a trauma patient in shock has big distended neck veins and no problems with breathing, what does he have and what is the next step?
Pericardial tamponade. DO NOT get a chest x-ray. Go straight to relieving the pressure. If wound to the heart, then best to go straight to the operating room.

First step of treating tension pneumo?
Needle into pleural space followed by chest tube.

How much blood do you need to lose to go into shock? What kind of bleeding does NOT cause shock and is often a trick questions?
1.5 liters

intracranial bleeding.

When do you treat skull fractures? When don’t you?
If they are a closed and asymptomatic, leave them alone.
If they are open, laceration can be cleaned and closed only if there is no depression or comminution.

What do you do with patients who have had a head injury and had LOC, however brief?
CT of head.

What are signs of a basal skull fractures?
Raccon eyes
Clear fluid from nose, ear
Ecchymosis behind the ear.

How do you manage acute epidural hematoma?
Emergency craniotomy

What has the worse prognosis? epidural or subdural hematoma? why?
Subdural. Generally, these are caused by massive trauma like a car accident and there is damage to the parenchyma.

In hematoma, if there is no symptoms or midline shift what is the management?
Control the ICP medically.

head elevation, hyperventilatoin, and avoidance of fluid overload.
THEN mannitol and furosemide.

For every 1 ml of blood loss, how much of do you replete? what about NG tube loss?
3 ml because 2/3 of fluid rapidly leaves the intravascular space.

NG tube = 1 ml for 1 ml

How do you calculate fluid requirements based on body weight?
First 10kg, 100 (ml/kg/hour)
next 10, 50
Beyond 20, 20 per kg

What is normal urine output?
.5-1 ml/kg/hr

When do you operate on a penetrating neck trauma?
When there is obvious signs of injury like an expanding hematoma or when their blood pressure is dropping, Spitting/Coughing up blood. The location of the wound does not matter is there are signs of unstable injury.

What is difficult about an injury to the upper part of the neck? How do you treat if they are stable?
Hard to get proximal distal control? Angiography is the better choice

How do you proceed if the injury is at the base of the neck?
Have to very careful in making preoperative diagnosis. Angiography, soluble contrast esophagram, esophagoscopy, bronchoscopy. Do this even if the patient is asymptomatic

How should asymptomatic patients with stab wounds to the upper and middle neck be treated?
Careful observation for 12 hours.

People who blunt neck trauma that is severe are at risk for what? what is good clue for it? How do we treat?
Spine injury
Neurologic symptoms are a good clue
Even if they don’t have symptoms, do a AP and lateral cervical view. Do a CT if you have high suspicion

Stab to the right back. Paralysis and loss of propioception distally on the right side. Loss of pain and propioception distally on the left side.
Brown – Sequard syndrome.

Burst fracture of the vertebral bodies. Loss of motor and and pain and temperature. Vibration still preserved
Anterior cord dysfunction.

Hyperextension of neck. Paralysis and burning in arms. Legs are ok
Central cord syndrome.

What is the best imaging for the spinal cord?

What do you give after a spinal cord injury to minimize permanent damage?

Do this immediately.

How do you treat a plain rib fracture? What do you NOT do? why not?
Local nerve block
Do NOT splint or bind because then they will hypoventilate and get pneumonia

How do you treat a plain pneumothorax in someone with stable vital signs?
Diagnose with Chest xray. you have time

Manage: chest tube to underwater seal and suction. Place it high in the chest.

How do you diagnose a hemothorax on physical exam?
Base has no breath sounds and is dull to percussion. Faint sounds heard at apex.

What determines the management of a hemothorax?
the amount of blood that comes out. It should be less than 600 ml in 6 hours.

Why must the blood be evacuated in a hemothorax?
You will get empyema

Major bleeding or prolonged bleeding from a hemothorax in indicative of what?
damage to a major vessel like an intercostal.

One single large air fluid level, and hyperressonance is generally indicative of what? in a trauma setting.

How do you manage a sucking chest wound?
Tape three sides of vaseline gauze.

What are the three things you worry about on blunt trauma to the chest?
Aortic transection
Abdominal injuries
Pulmonary contusion.

How do you proceed if you suspect an aortic transection?
Chest xray: If widened mediastinum, then spiral ct. If CT postive, then surgery. If CT negative, then, aortogram.

If mediastinum not wide, then still spiral CT. If ct neg, then you can stop.

What is the real problem in flail chest? How do you treat?
Pulmonary contusion
Treatment is controversial
Fluid restriction, diuretics, colloid fluids
resipratory support!
IMPORTANT! If she is going to be put on any kind of positive pressure, she needs bilateral chest tubes because she could get a tension pneumothorax

How does pulmonary contusion present?
generally, respiratory distress, two days after a trauma and then her lungs white out on x-ray.

How do you manage a pulmonary contusion?
Fluid restriction, diuretics, respiratory support. Intubation, mech ventilation and PEEP.

What kind of injury causes a high risk for myocardial contusion?
Sternal fracture

How do you diagnose and treat myocardial contusion?
same way you treat an MI. ECG, troponins, control arrhythmias as they develop.

Don’t forget spiral ct looking for an aortic rupture.

What causes multiple fluid levels in the chest? How do you treat?
traumatic diaphragmatic rupture.
Always on the left.

NG tubecurling up into the left chest might be an added sign

Surgical repair

What three bones, if broken, indicate a massive injury? What are you worried about?
Sternum, first rib and scapula

Aortic injury

Surgical Repair, generally emergency repair

What three things causes thoracic subcutaneous emphysema?
ruptured esophagus (after an endoscopy)
tension pneumo (often more major things to worry about)
rupture of trachea or major bronchus

If a person is putting out a lot of air from this chest tube and his lung is not expanding, what do you suspect?
major bronchial injury

What does someone with an air embolis present like? give some examples.
sudden death after being hemodnamically stable.
Injured bronchus connecting with nearby injured pulmonary vein
Person pulling out central line. Supraclavicular node biopsy mishap

what is the picture of a fat embolism?
respitary distress
long bone fracture
petechial rashes in axillae and neck, fever and tachycardia.

Bilateral patchy infiltrates and platelet count in low.

What do you always do with a penetrating gunshot wound to the abdomen?
exploratory surgery

What is the prep for surgery for a penetrating gunshot wound?
Indwelling bladder catheter, large bore venous line for fluid administration, dose of broad spectrum antibiotics

What kind of repair do you do for trauma to the colon?
primary repair is ok.

USED TO BE always do a colostomy

What are the boundaries of the abdomen?
Belly begins at the nipple line. Chest does not end at the nipple line because the separation is a dome. SO you can have both abdominal and chest injuries.

What is the workup for a penetrating wound left midclavicular line, two inches below the nipple line?
Penetrating chest wound, and exploratory laparotomy

When do you do a ex-lap for stab wounds?
When it is clear that a peritoneal perforation took place

IE, short blade + fat woman = digital exploration of wound in the ER

Blunt trauma to the abdomen has what effect on organs? What are some signs?
Solid organs will bleed and hollow organs will spill their contents.
Tender abdomen with guarding and rebound in all quadrants
With bleeding, you will have low BP, elevated heart rate and low CVP.

If you know that your patient has massive bleeding and is in shock, how do you go about pinpointing where it is? In other words, what tests do you do to rule out bleeding in certain locations?
Shock comes on with 20-30% blood loss or about 1.5 liters.
First rule out external hemorrhage by examining the patient
Rule out incranial bleed because that much blood won’t fit in the head
Rule out neck by checking for hematoma
Rule out Chest with chest xray. >150 ml should be easy to spot in decubitus position
Rule out pelvic fracture and femoral fracture with physical exam and xrays
THE BELLY IS SILENT…..and deadly
Do a CT scan if patient is hemodynamically stable.
Otherwise: peritoneal lavage

What is the most likely organ to be damaged in blunt abdominal trauma? How do you manage?
If stable, observe with serial CT scans
If not, ex-lap

If you do find a ruptured spleen, what is the management? what if you definitely need to remove it?
Try to repair over removing it
If you definitely need to remove it, then give, pneumovac,Hemophilus B and meningococcus

Trauma patient in surgery receiving transfusions starts to ooze blood from all cut surfaces. what do you do?
transfuse fresh frozen plasma and platelets

During the course of an laporotomy a patient develops significant coagulopathy, a core temp < 34 and refractory acidosis
Stop surgery and close the abdomen with towel clips

In a multiple trauma patient in surgery, what risk do you run when you infuse a lot of fluids especially if there is an open abdomen?
Abdominal compartment syndrome. There is edema in the operative area so its hard to close the wound. Close the wound with abdominal mesh with formal closure later. OR with non absorbable plastic cover

Abdominal compartment syndrome that develops after surgery presents how?
Tense and distended abdomen around post op day 1. Hypoxia and renal failure

How do you treat a non expanding pelvic hematoma in a person with pelvic fracture when hemodynamically stable and when hemodynamically unstable?
IF hemodynamically stable, do nothing. Just make sure that there is no injury to the surrounding structures such as the rectum, bladder and vagina with physical exam and a foley.

If hemodynamically unstable, then sucks to be you. Laparotomy is not advised. External fixation may work OR arteriographic embolization

What is the hallmark of urologic injuries? What is the mangament?
Blood in the urine/foley
Surgical repair

Management for pelvic fracture with blood at the meatus? What other symptoms go along with posterior urethral injury?
most likely a bladder or a urethral fracture
start with a retrograde urethrogram
DO NOT put in a foley

scrotal hematoma, sensation that he wants to urinate but can’t. High riding prostate

What are signs of an anterior urethral injury?
Blood at the meatus and scrotal hematoma

What do you do if your patient has a pelvic fracture, no blood at the meatus, but there is resistance to foley insertion

And do a retrograde urethrogram

How do you assess a bladder injury when you see hematuria? what might prevent you from asessing the bladder properly?
retrograde cystogram

A bladder full of dye may hide a retroperitoneal trigone leak. Rupture at the dome, or extravasation, is pretty obvious.

If a MVC patient has multiple injuries, abdominal injuries, but no pelvic fracture, normal retrograde cystogram and a foley full of blood, what do you suspect is injured? What do you need to diagnose? How do you manage?
the kidneys
CT scan
Surgery only if renal pedicle is evulsed or if the patient is exsanguinating. Ok if it just smashed

High speed collision with rib fracture and abdominal contusions. No hematuria with foley. normal retrograde cystogram. renal injuries that don’t require surgeries. ^ weeks later, acute shortness of breath and a flank bruit.. What is it? How do you manage?
Traumatic AV shunt at the site at the renal pedicle and subsequent heart failure

Management for trauma related microhematuria. What do you worry about if there is microhematuria with no trauma? What about microhematuria in children?

Cancer of kidney, bladder or urethra

Check for congenital abnormalities. Sonogram (Better) or intravenous pyelogram

What is the issue with a scrotal hematoma in a child? How do you tell if they have one? What is the management if ruptured?
Whether there is a testicular rupture

Large penile shaft hematoma What really happened?
Woman on top during sexual intercourse

Rupture of the tunica albuginea/ corpus cavernosa

Urologic emergency. Prompt surgical repair needed

Gunshot wound to the thigh, anterolateral entrance to posterolateral embedded. What is the management?
Unlikely to rupture vessels

Give a tetanus shot and clean the wound. leave the bullet where it is

Gunshot wound to the thigh, anterolmedial entrance to posterolateral exit. What is the management?
Even though no signs of vessel injury, its is still possible given the anatomy. Do a doppler study

Gunshot wound to the thigh, anterolmedial entrance to posterolateral exit. What is the management?

Gunshot wound to the thigh, anterolmedial entrance to posterolateral exit. Spreading hematoma in the upper inner thigh. What is the management?
Do a surgical exploration. Arteriogram if it will determine where you cut. Like base of the neck for thoracic outlet syndrome.

Shot in arm, medial to lateral. Large hematoma in the inner aspect, no distal pulses, radial nerve palsy and shattered humerus? What is the sequence that you fix things?
Fracture stabilization, the vascular repair the nerve repair.

May need to do a fasciotomy because of the delay in repairing blood vessel

Hit with high velocity bullet. what is the shape of the destruction? what do you do?
Shape is cone shape. Small entry large exit. Surgical debridement of tissue

Crush injury to entire hand, forearm and lower arm. Bruised and battered, but normal pulses and no broken bone. What are the risks, what is the management?
risks: Hyperkalemia. Myoglobinuria leading to acute renal failure. Delayed swelling that might lead to compartment syndrome

Plenty of fluids, osmotic diuretics and alkalinization of the kidneys.
Fasciotomy of the compartment syndrome.

Spilled draino on arm . First step?
Irrigate with water for 30 min. then ER

Electrical burns to the thigh. entrance and exit close to each other. What are you worried about? how do you manage?
electrical wounds are always much bigger than they appear
Need surgical debridement
Possible myoglobinemia leading to renal failure: Fluid, mannitol, alkanization of the urine

Rule out posterior dislocation of the shoulder, compression fractures of vertebral bodies, development of cataracts and demyelination syndromes

rescued from burning building. Burns around mouth and nose. Soot inside mouth. What are the two major issues? How do you diagnose and treat each?
Carbon monoxide poisoning: Determine blood levels and put on 100% oxygen

Respiratory burns: Bronchoscopy. Degree of damage done by monitoring blood gases.

respiratory support for both

third degree burns from lighter fluid. Burns are dry, white, leathery and circumferential all around arms and forearms. What is the main problem?
Circumferential burns will cut off circulation as massive edema forms underneath because they will not expand

What do second degree burns look like? What do third degree burns look like in kids? How about adults? How do you treat second degree burns?
2: Moist, have blisters and really painful to the touch

3: in kids: deep bright red. In adults: white leathery analgesic

Silver sulfadiazene cream

What is the rule of 9s?
Used to calculate body surface that is burned
9 for head,
9 for each arm
9 for each side of leg ( 2 9s per leg)
Four 9s for torso

If 3rd burns are over 20%, Fluid administration should be started at what rate?
Ringer lactate with no dextrose at 1

What is the parkland formula? what do you use it for?
4 ml of ringer lactate per kg of body weight, per percentage of burned area (up to 50%) + 2L of 5% dextrose for maitenence. First half in first 8 hours. Second half in next 16 hours.

Second day: half the calculated amount plus colloids.

Third day: Hold fluids because there should bea brisk diuresis

What is the expected urine output for regular burns? What about electrical burns?
Reg burns: .5-1 ml per kilogram per hour
Electrical Burns: 1-2 ml per hour

How do you calculate surface area for babies?
head – 2 9s
Both legs – 3 9s
arms – 9 each
Torso – 4 nines.

After fluid resuscitation, what is proper management and supportive care for regular burns? deep burns? Burns near eyes?
Tetanus prophylaxis
Suitable cleaning and topical agents
silver sulfadiazine is essential for reg burns

Mafenide acetate – ONLY for areas of deep burn cause it hurts and can cause acidosis

Eyes – triple antibiotic ointment

IV pain meds. Graft to areas that did not undergo regeneration after 2-3 weeks.
Day or two of ng suction and then nutritional support ( high calorie and high nitrogen)

What is management for small third degree burns?
Early excision and grafting

Treatment for provoked dog bite
Watch the dog for rabies
Tetanus prophylaxis and standard wound care

Bitten by a wild coyote that is captured
Kill it and check the brain. Wait for vaccination

Bitten by wild bat that flies away
rabies prophylaxis immediately
Immunization plus vaccine

What does a rattle snake look like?
Elliptical eyes, pits behind nostrils, big fangs and rattlers on the tail.

Even if a venomous snake bites you what is the chance that you got envenomated? What will the wound look liek if you were envenomated? What is the treatment for envenomation? What about in kids?

local edema, ecchymotic discoloration, painful and tender to palpation

Blood drawn for type and cross, coag studies and renal and liver function. Antivenin – 5-20 vials. Surcial excision and fasciotomy in severe cases.

Same process and treatment in kids. Same dosage of antivenom regardless of size. Antivenom dosage in based on amount of venom injected.

What is the managment for non envenomated snake bites?
Observation for 12 hours. Standard wound care, without tetanus prophylaxis

Stung by bee. Wheezing, hypotensive and itchy rash. How do you treat?
Epi! and removal of stingers carefully

What is the antidote for black widow spider bites? What are the symptoms?
IV calcium gluconate and muscle relaxants

nausea and vomiting and severe generalized muscle cramps

What does a brown recluse spider bite look like? How do you treat?
1 cm in diameter, necrotic center, with surrounding halo of erythema

Dabsone. Local excision and skin grafting after one week when full damage is known

Human bite management?
Surgical exploration by an ortho surgeon.

Newborn with a easily displaced hip. What is it and how do you treat?
Developmental dysplasia of the hip
Abduction splinting with Pavlik harness

What is legg-Perthes disease? What does it present like?
Avascular necrosis of the capital femoral epiphysis.

Decreased hip motion, knee pain on same side. Antalgic gait

Unclear treatment

What is a bad hip in teenagers generally due to? External rotation of the leg upon flexion
Slipped capital femoral epiphysis

Surgery to pin the femoral head in place

Toddler with flu, then two days later, cant walk and won’t move hip. Elevated ESR. Diagnosis and treatment?
Septic hip
Aspirated under general anesthesia to confirm diagnosis
Then open arthrotomy

Child with febrile illness but not history of trauma had persistent localized pain in a bone. Diagnosis and treamtn?
Acute hematogenous osteomyelitis

Bone scan and then antibiotics

What is genu varum? Up till what age is it common?
Bow legged ness. Common till age 3. After that it is blount disease: Medial proximal tibial growth plate.

What is osgood schlatter disease?
Osteochondrosis of the tibial tubercle

What does club foot look like? How do you treat?
Both feet are turned inward. Adducted forefoot, planter flexion of the ankle, inversion of the foot and internal rotation of the tibia.

Series of plaster casts

How do you manage scoliosis? Until when does it progress?
Monitor with serial xrays. Progresses until skeletal maturity in reached. Pulmonary function could be limited if there is a large deformity

In general, how do you treat broken bones in kids?
reasonable alignment and immobilization

Supracondylar fracture of the humerus, distal fragment is displaced posteriorly. What do you worry about?
Can produce vasculature or nerve injruies or both and end with witha Volkmann contracture. Watch for compartment syndrome

appropriate casting and traction

What do you do if the growth is displaced from the metaphyses? What if its in two pieces?
1. Closed reduction
2. Open reduction and internal fixation

What is the most common primary malignant bone tumor?
Second most common? Describe on xray. What is the age range affected? What do you do?
Osteogenic sarcoma: Seen around the knee. Large tumor breaking through the cortex into the adjacent soft tissues and exhibiting a “sunburst” pattern

Ewing sarcoma: Persistant pain deep in the diaphysis. Large fusiform bone tumor pushing the cortex out and producing periosteal onion skinning.


In adults, fractures for trivial reasons, indicate what?
Bone tumor, generally metastatic.

Women, breast
Men, Lung

What imaging do you use if you suspect multiple myeloma? What makes you suspect it in the first place?
Multiple lytic lesion + anemia


bence jones proteins on serum electrophoresis

Treat with chemo

Large soft tissue tumor in thigh. What is the imaging technique?
Soft tissue sarcoma


What are the rules from ordering x-rays to evaluate a fracture?
get xrays 90 degrees to each other and include the joints above and below. Check bnes in the line of force

How do you treat a broken clavicle?
Treat it with a figure 8 device for 4-6 weeks

Axillary nerve damage happens with what type of shoulder disclocation?
AP and lateral xrays
Redice it

What xrays do you order for posterior dislocation of the shoulder?
Axillary or scapular

What is a colles fracture? How do you manage?
Dorsally displaced, dorsally angulated fracture of the distal radiaus and small non displaced fracture of the ulnar stylus, dinner fork

close reduction and lang arm cast

Hit on raised arm. What is the name of the fracture and how do you treat?
Monteggia fracture. diaphyseal fracture of the proximal ulna and anterior dislocation of the radial head

Close reduction of radial head and open reduction and internal fixation of the ulnar fracture.

Fracture of the distal third of the radius and dorsal dislocation of the distal radiolunar joint.
Galeazzi fracture.

Open reduction and fixation of the radius and casting of the forearm in supination.

How do you treat scaphoid fracture?
Thumb spica cast if there is no evidence of fracture on xray

open reduction and internal fixation on xrays shwos dispaced and angulated fracture

How do you treat metacarpal fractures?
Mild: closed reduction and ulnar gutter split for the mild ones
Kirchner wire or plate fixation for the bad ones

What are you worried about with a displaced femoral neck fracture?
Compromise of the blood supply. Better to put a metal prosthesis in

Intertrochanteric fracture in an old person
less concern about avascular necrosis

Open reduction and pinning. worry about DVT and anticoagulate

Closed fracture of femoral shaft
intramedullary rod fixation

Medial collateral ligament injury is tested with what? LCL? How do you treat both?
Hinge cast if isolated tear
Surgery if multiple tears

ACL tears are treated with what?
immobilization and rehabilitation
Athletes need arthroscopic reconstruction


Meniscal tear present how?
Pain, swelling, click, with extension

After a long march, guy get pain in the tibia? what is it and how do you treat?
stress fracture

won’t initially show up on xray

cast and repeat xray in two weeks: will show up then

Tib/Fib shaft fracture. Treatment?
Reduced and cast. Intramedullary nailing for the other ones

What are two places with the highest incidences of compartment syndrome?
Forearm and lower leg.

How do you treat achilles tear?
casting in equianas position

Can normal pulses be present with compartment syndrome?

If there is pain after putting on a cast, what do you do?
take off the cast

Can be too tight, or rubbed off skin, etc

How soon after the trauma must open fractures be treated?
6 hours

How do you treat gas gangrene?
IV penicillin, surgical debridement of dead tissue and then hyperbaric chamber

Fractures of the humeral shaft affect which nerve leading to which deformities?
radial nerve, wrist extension

What are you worried about in posterior dislocation of the knee?
popliteal artery rupture

integrity of pulses, arteriogram and prompt reduction

How do you treat carpal tunnel?
Splints and anti inflammatories?

Girl wakes up with middle finger acutely flexed. Can only unflex it with the other hand with a painful snap? What is it and how do you treat?
trigger finger

steroids first then surgery if needed

What is de quervain tenosyntovitis? How do you treat?
Inflammation of the tendons of the wrist

Splints and antiinflammatories

Dupuytren’s contracture
Can’textend fingers. palmar fascial nodules

What is a felon abscess?
Closed space infectionsof fingertip pulp. Like a compartment syndrome. needs to be drained

How do you treat a severed digit?
wash with sterile saline, wrap in saline moistened gauze, place in plastic bag and then place the bag on ice.

How do treat lumbar disc herniation?
MRI for diagnosis

Lightinigng through big toe: L4-L5 or L5-S1 if through little toe
bed rest. Surgery only if worsens OR sphincteric defecits

How does ankylosing spondylitis present?
young man. progressively worse pain and stiffness. Morning stiffness and pain that is worse at rest, but improves with acitivity

anti- inflammatories to treat

What is the management of ischemic ulcers?
Doppler looking for pressure gradient. Arteriogram. Revascularization may be possible and then the ulcer may heal.

Venous stasis ulcer present how? Managed how?
skin around in thick and unhealing. Frequent episodes of cellulities and varicose veins

Unna bot, support stockings. Varicose vein surgery

Chronic irritation sites on the skin develop into what?
Squamous cell carcinoma

Marjolin ulcer: Wide local therapy needed

How do you treat plantar fascitis?
Symptomatic treatment until it resolves spontaneously

What is a morton neuroma?
Inflammation of the common digital nerve
wearing pointy shoes
excision if conservative treatment fails

An ejection fraction of .35 give what perioperative risk of mi?

Before you do surgery on someone with JVD you should….
you have to treat the heart failure with Ca-channel blockers, digitalis and diuretics

MI within how many months gives you the greatest risk? how long should you wait?


Before you do surgery on someone for AAA who has severe angina, you should….
Do a coronary revasculariztion.

Surgery in smokers with COPD requires what screening?
Evaluate FEV1 cause the problem in with ventilation

Cessation of smoking for 8 weeks and respiratory therapy. Physical therapy, expectorants, incentive spirometry and humidified air.

what hepatic risk factors increase mortality for surgery by 40%?
Bilirubin above 2
albumin below 3
prothrombin above 16

3 things: 85%
4 thing: 100%

what hepatic risk factors increase mortality for surgery by 80%?
bili over 4
Albumin under 2
Ammonia above 150

What are signs of severe nutritional depletion?
20% body weight loss in two months
Low serum albumin
Anergy to antigens injected
transferrin level of 200mg/dl

Are people in DKA surgical candidates?

How do you treat malignant hyperthermia?
IV dantrolene
100% o2
correction of acidosis
cooling blankets

Fever, 45 min after procedure, means?
3x cultures and IV antibiotics

high fever PO day one. What if patient doesn’t comply with therapy? what can happen?


What are the 4 Ws and what is the time frame?
Wind – day 1
Water – UTI – Day 3
Walking – Thrombophebitis – Day 5
Wound – infections – Day 7
Wonder Drugs –

Patient who had abd surg. Spikes fever on the tenth day. What is it?

Periopertaive Mi happen when?
In the first 3 days

7 days after hip surgery, old man develops pleuritic chest pain and shortness of breath.

Don’t think PE if venous pressure is low. Pulm angioography, VQ scan, or spiral CT

Therapy with heparin. Put in IVC Filter if he has PEs on heprain.

A drunk man aspirates durign intubation. What do you do?
Lavage and removal of particulate matter, bronchodilators, and resp support

If there is a tension pneumo during abd surgery what do you do?
Cut the diagphragm

Place chest tube later.

Disorientation after surgery ; what is the most lethal reason? Name some other things it can be?
hypoxia – > take blood gases

uremia, hyponatremia, hypernatremia, ammonium, hyperglycia, DT, or meds

How do you treat ARDS?
PEEP Positive end expiratory pressure

How do you treat DT?
Alcohol or Ativan

How can water intoxication present?
Low Na concentration

confused, lethargic, severe headache, grand mal seizure, and coma

Very careful use of hypertonic saline

How do you treat surgery induced DI?
1/3 or 1/4 normal saline

Portocaval shunts in corrhotic patients can cause what?
Ammonium intoxication.

Overt liver failure suspected if there is hypokalemia alkalosis and high cardiac output-low peripheral resistance

What is Fena in renal failrue?

Post op patient has low urine output, Bp is ok. What is going on?
Kidneys are being perfused, but either dehydrated or in renal failure

Look at urine sodium to tell

What is the difference between someone who lost 5L of water during surgery and someone who lost 5L being lost in the desert?
In the latter case, the brain has had time to get used to the hyponatremia, so you have to correct it slowly.

Why do you have to careful with the K concentration during DKA?
with severe acidosis, the K comes out of the cells when the H ions go in. When you correct the acidosis, the K goes back into the cells. Also K is lost in the urine during acidosis. SO, when you correct the acidosis, you can see a huge drop in K

“in and out of shock” means what for the kidneys?
Low perfusion

What are some ways to reduce K in the body?
Kayexelate – binding resin
Calcium gluconate
Insulin with glucose

Shock produces what kind of acids?

How do you treat metabolic acidosis?
Bicarb or bicard precursors like lactate or acetate but in some cases it can cause alkalosis if the therapy is continued beyond therapeutic levels
Fluid resuscitation may be a better idea.

Excessive vomting leads to what acid base disorder? How do you treat?
hyperchloremia, hypokalemic, metabolic alkalosis

rehydration with normal saline and a lot of KCL (10meq/h)

What is the management of Gerd?
Normal antacids, but should also consider an endoscopy and biopsies to assess the extent of esophagitis

What is the management for barrett’s?
medical management
fundoplicaiton in symtpoms worsen
Dysplastic changes require resection

What is the pre- work up for a nissen?
confirm reflux: ph monitoring
confirm that motility is okay: manometry
Confirm severity of the esophagitis: endoscopy and biopsies
Confirm that gastric emptying is not a problem: isotope gastric empyting study

Barium swallow for anatomy

How do you manage mallory weiss tear?
endoscopy to ascertain the diagnosis. Bleeding is generally self limiting, but photocoagulation can be done

How do you manage Boerhaave?
Gastrograffin swallow to confirm

Emergency surgical repair

How do you manage suspected gastric cancer?
endoscopy, then biopsies. then CT

how do you treat mechanical intestinal obstruction such as with adhesion? What if your patient starts to develop fever, leukocytosis, abdominal tenderness and rebound tendernes
NG sution, IV fluids and careful observation

probably a strangulated obstruction
Emergency surgery

How do you diagnose carcinoid syndrome?
24 urinary collection for 5-hydroxy-indolacetic acid

How is appendicitis diagnosed?
mostly clinically, CT scan if necessary

If you suspect colon cancer what do you do?
Colonoscopy and biopsies

Give blood transfusions if they are anemia and eventually surgical resection

What are some complications of UC?
Toxic megacolon – needs surgery

How do you manage C.diff
Stop clinda
DO NOT give anti diarrheals
Metronidazole or Oral Vanc

What are the characteristics of external and internal hemorrhoids?
Internal hemorrhoids bleed but do not hurt
External hemorrhids

What is the proper things to do when someone with known hemorroids reports a bleed?
Do a proctosigmoidoscopy to make sure there’s no cancer

What is the first step to deal with any sort of perianal bleeding or abscess or fistualr?
rule out cancer

What is the first step for any sort of GI bleed? what is the exception?
Scoping to identify area of bleeding. Start with upper Gi scope. then check for hemorhoids. then you can do a tagged red cell study

Don’t scope if you suspect inflammation or friability. you can perf.

7 year old boy has a large bloody bowel movement. What can it be?

Diagnose with technitium

How do you treat an acute abdomen?
exploratory lap

What examples of peritonitis do you not need immediate surgery?
cirrhotic with ascites
child with nephrosis and ascites

What presentation clues you into perforated duodenal ulcer?
Acute abdomen plus perforated viscous. air under diaphragm.

How do you manage acute pancreatitis?
Diagnose with urinary amylase or lipase. CT if unclear diagnosis

Management: NPO, NG suction, IV fluids

How do you treat acute cholycystis?
Medical management to cool down the process and then surgery

How do you diagnose diverticulitis? How do you manage?
CT scan

NPO and antibiotics for the acute attack. Resection for recurrent disease

what is a “parrot’s beaK” on xray?
Volvulos or the sigmoid

AFP is a marker for what? what about CEA?
Colon cancer

How do you treat primary hepatoma?
Resection if you can get all of it

How do you treat metastases to the liver?
If only one met, then resect, provided its surgically possible and the primary is slow growing

Long term use of birth control pills can lead to what regarding the liver?
hepatic Adenoma which can then rupture.

What is so special about amebic abscess?
they don’t have to be drained. (from mexico, tenderness over liver, mild jaundice and elevated alkphos)

Treat with metronidazole

Can’t grow amoeba from pus

How do you manage hepatocellular jaundice?
Get serologies to confirm

Total bili will be high. Alk phos will be slightly high and transaminases will be very high

How do you manage obstructive jaundice?
Sonogram, look for dilated intrahepatic ducts and possibly extra hepatic ducts. Follow up with ERCP

Alkphos will be 6 times the upper limit of normal

Silent obstructive jaundice indicated what? what additional finding worsens the prognosis?
Gallbladder carcinoma, distended gallbladder is bad because when stones are involved, Gb is thick and pliable

What procedure is indicated for cholangiocarcinoma?

Also may want to get brushings for cytology

What signs point to ampullary carcinoma?
Slowly bleeding into GI Tract along with obstructive jaundice

How is acute ascending cholangitis different from acute cholecystitis?
the former will have more severe symptoms and liver enzymes will be elevated. WBC count will bemuch higher

How do you manage acute ascending cholangitis?
IV antibiotics plus emergency decompression of the biliary tract. ERCP can do the latter, but PTC works also

What is ranson’s criteria?
Age in years > 55 years
White blood cell count > 16000 cells/mm3
Blood glucose > 10 mmol/L (> 200 mg/dL)
Serum AST > 250 IU/L
Serum LDH > 350 IU/L

After 48 hours:
Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10%
Oxygen (hypoxemia PO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L

How do you manage hemorrhagic panc?
drain the panc abscesses. CT scan

Acute pancreatitis and damage to the pancreas can lead to what? How do you manage it?
Pancreatic pseudocysts

CT scan probably the best choice. Watch for 6 weeks and then drain if not gone.

Chronic panc is defined by what?
Panc Calcifications
diabetes, steatorrhea

Stop alcohol intake. replace panc enzymes, ERCP for further testing of anatomy

When do you not treat a hernia with surgery?
umbilical hernias in babies under 2

All other hernias, elective surgery if stable. Immediate surgery if strangulated.

18 year old woman with a firm, rubbery mass in the left breast that moves easily with palpation. What is it and how do you manage?

Sonogram or FNA. Mammogram is no good cause breast tissue is too dense. excision in optional after diagnosis is confirmed. Reassurance is not the answer

14 year old with firm movable rubbery mass in her left breast that was first noticed 1 year ago and has grown 6 cm since then. What is it and how do you manage?
Giant juvenile Fibroadenoma

at 14 cancer is very unlikely, don’t need to FNA or sonogram. Excise to prevent cosmetic deformity

Describe what cystosarcoma phyllodes feels like on palpation. what is the concern with it?
Firm, rubbery, completely movable

Can turn into malignant sarcoma

needs a margin free resection

10 year history of tenderness in both breast related to menses. Multiple lumps come and go. Firm, Round, 1-cm mass not gone away in 8 weeks. What is it and how do you manage?
palpable cyst in fibrocystic disease

Start with mammogram to look for other non-palpable lesions. Aspirate the fluid. If bloody, send to cytology. If mass does not go away or recurs, needs biopsy.

On and off bloody discharge from the nipple for months. No palpable masses. What is it and how do you manage?
Intraductal pappilloma most likely.
Mammogram is best if you suspect cancer that is not palpable. Even if mammo is negative, may want to resect the pappiloma. for symptoms releif

Lactating mother has cracks in the nipple and fluctuating, red, hot, tender mass. Fever and Leukcytosis. What is it and how do you manage?
Abscess. ONly lactating breasts are entitled to develop abscesses. Anyone else, cancer until proved otherwise.

Incision and drainage.

49 year old woman has a firm 2 cm mass in the right breast, present for 3 months. What is it and how do you manage?
Could be anything. Mammography guided multiple core biopsies

How is a diagnosis of possible breast cancer treated in a pregnant woman?
Same as a non pregnant woman.

Do not need to terminate the pregnancy

60 yo woman with 4cm hard mass in the right breast. Ill defined borders, movable from the chest but not movable within the breast. The skin overlying the mass in retracted and has orange peel appearance. What is it and how do you manage?
Classic presentation of breast cancer. Mammographically guided core biopsies.

Other presentations: Retracted nipple, Red swollen breast, not tender, not hot, no fever or leukocytosis

Eczemoid lesion in the areola. Won’t go away with lotion.

42 year old with trauma to the breast noticed a lump deep in the tissue. what is it?
Cancer until proven otherwise. Biospy

What is a breast tumor excised by lumpectomy?
When its far away from the nipple. and small.

but do an axillary biopsy. With sentinal lymph node. radiation therapy afterwards

Otherwise Modified radical mastectomy with sentinal lymph node biopsy. No radiation needed when the whole breast is removed

What is the most common breast cancer? what is unique about the other ones, esp lobular and inflammatory?
infiltrating ductal caricinoma.

Lobular has a higher incidence bilaterally, but not enough to warrant a mastectomy

Inflammatory has terrible prognosis

all the others have a little better prognosis than infiltrating ductal

If you have one lesion of DCIS what is the treatment?
if confined to one quadrant, no need from axillary sampling. Lumpectomy and radiation is enough.

Simple total mastectomy if multicentric

What don’t you do in the treatment of breast cancer in pregnant women?
No radiation therapy and no chemotherapy during first trimester

If you have a giant fungating ulcerated mass occupying the entire right breast what do you do?
Tissue diagnosis with core biopsy.

This is inoperable and incurable, most likely. Palliation can be offered.

Chemo is first line of treatment. Maybe the tumor will shrink and become operable.

How do you determine what chemotherapy to give to breast cancer patients?
Look at receptor sensitivity and then look at age.

Estrogen and Progesterone receptor positive patients, will be given either tamoxifen or Anastrozole

Severe headache in breast cancer T3 N2 M0
Brain mets until proved otherwise.

CT scan of the brain and high dose steroids and radiation

What is the most sensitive test for bone metastases?
Bone scan

What are worrisome characteristics of patients with thyroid nodules?
young, male, single nodule, history of radiation to the neck, solid mass on sonogram and cold nodule on scan. Reserve surgical excision for selected cases. Best answer is FNA and cytology.

What is next step for FNA reads that are indeterminate for a thyroid?

What is the management for a “hot” adenoma?
Confirm hyperthyroidism with free T3 or TSH. Radioactive iodine scan to confirm source of excessive hormone. Surgery after beta blocking.

What are most cases of hypercalcemia caused by?
Metastatic cancer

What is the second biggest cause of cancer? How do you manage?
Parathyroid adenoma

Sestamibi scan and then surgery to follow

How do you manage suspected cushings?
Overnight dose dexamethasone suppression.
Suppress at low dose: normal
If not suppressed at low dose, check 24 cortisol is high and then do high dose.
If suppressed at high dose, MRI of pituitary.
If not suppressed at high dose, CT or MRI of Adrenals

How do you treat a gastrinoma?
Measure serum gastrin to confirm. CT scan with contrast of the pancreas and surgery to remove it

How do you treat insulinoma?
CT scan and then surgery.

How do you treat Nesidioblastosis?
95% pancreatectomy

Babies get it. high insulin, low c-peptide

What does glucagonoma present like?
Severe, migratory necrolytic dermatitis. unresponsive to herbs and unguents. Thin, mild stomatitis and mild DM

How do you treat glucagonoma?
CT scan looking for tumor in pancreas and then surg.

If inoperable, somatostatin for symptomatic relief and streptozocin

How do you differentiate between adrenal hyperplasia and adrenal adenoma?
Hyperplasia has appropriate response to postural changes

What is the management of suspected pheo?
24 urine metaneprine or vanillylmandelic acid. CT of adrenals. Surgery with alpha blocker prep first!

What is the workup for suspected coartaction of the aorta?
Chest x-ray to look for rib scalloping.
Fancy spiral CT or MRi angiogram. and ultimately surgery.

How do you treat, fibromuscular dysplasia?
Because these are generally in young women, her HTN must be cured. Angiographic balloon dilatation with stenting is the first choice.

What is the treatment for a tracheoesophageal fistula?
Rule out Vacterl. then surgery

What is the treatment for an imperforate anus?
Rule out Vactrl

Look for fistulas nearby to determine level of the blind pouch

That will determine if you need to do the surgery right away

What will a congenital diaphragmatic hernia present like?
Newborn will be tachypnic, cyanotic and grunting. Bowel sounds will be heard on the chest. Hypoxia and acidosis

What is the management of congenital diaphragmatic hernia?
Wait 36-48 hours to give the hypoplastic lung some time to mature and the baby switches over from fetal circulation.

in the meantime, endotracheal intubation, low pressure hyperventilation, sedation and NG suction.

How do you manage gastroschisis?
Look out for atresias
put the bowel back in. May need to slowly do it with a silicon silo.

Vascular access for IV nutrition.

How do you manage omphalocele?
Look out for multiple defects
Put the bowel back in.

What does extrophy of the bladder look like?
A moist medallion of mucous between pubis and umbilicus that is bathed in urine.

How long do you have to repair a extrophy of the bladder before its too late?
48 hours

If a baby is vomiting green stuff, name three things it can be? What is the treatment?
Duodenal atresia, malrotation, annular pancreas
surgery if complete blockage. However, these kids will have other congenital abnormalities, look for them first.

How do you diagnose Malrotation?
Contrast enema: safer
Upper GI study: more reliable

What does intestinal atresia present like? What is it caused by?
Green vomit
No meconium passed
Abdominal distension, multiple air fluid levels and distended loops of bowel.

Caused by vascular accident in utero

Premature baby, feeding intolerance, distension, dropping platelet count. Treated with indomethacin for PDA. What is it and how do you treat?
necrotizing enterocolitis

Stop feeding, broad spectrum ABX, IV fluids and nutrition.

Surgical intervention if: abdominal wall erythema, air in the portal vein or pneumopertoneum

3 day old full term, brought in because of feeding intolerance and bilious vomiting. Multiple dilated loops of bowel and ground glass appearance in lower abd. Mom has CF. What is it and how do you treat?
Meconium ileus

Gastrografin enema. Surgery if unsuccesful

3 week with trouble feeding. Not growing. Bilious vomit and brought in for eval. X-ray shows double bubble and normal looking gas pattern. What is it and how do you treat?

Diagnostic studies

How do you treat a pyloric stenosis?
check lytes, this can can hyperkalemic, hyperchloremic metabolic alkalosis. Correct, lyte disturbance, rehydrate and do ramstedt pylorotomy.

8 week old with persistent progressively increasing jaundice. Elevated bili. 2/3 is direct bili. Negative sweat test. no Hepatitis. What is it and how do you treat?
Biliary atresia.

HIDA after one week of phenobarbital.

2 month old in because of chronic constipation. Abd distension. gas in dilated loops of bowel. Rectal exam followed by explosive stool and flatus. What is it and how do you treat?

Barium enema to visualize. Full thickness biopsy needed to confirm.

9 month old with episode of colicky pain that makes him double up and squat. Lasts for about 1 min. Lage vague mass on right side of the abdomen and “empty” RLQ. Currant jelly stools. What is it and how do you treat?

Barium enema or air anema.

7 year old boy passes large bloody bowel movement. What is it and how do you treat?

Radioisotope scan. gastric muscos in the lower abdomen.

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