High Yield Surgery Shelf Review

PRE-OP EVALUATION
Contraindications to surgery
Absolute?
Diabetic Coma, DKA
Poor nutrition?
albumin <3, transferrin <200, weight loss <20%.
Severe liver failure?
bili >2, PT >16, ammonia > 150 or encephalopathy
Smoker?
stop smoking 8wks prior to surgery
If a CO2 retainer, go easy on the O2 in the post-op period. Can suppress respiratory drive.
Goldman Index: Who is at greatest risk for surgery
#1 = CHF
Check? EF. If <35%, no surg.
#2 = MI w/in 6mo (ischemic disease)
Check? EKG stress test cardiac cath revasc.
#3 = arrhythmia
#4 = Old (age >70)
#5 = Surgery is emergent
#6 = Aortic stenosis, poor medical condition, surg in chest/abd
Murmur of AS: Late systolic, crescendo-decrescendo murmur that radiates to carotids. with
squatting, with decr preload
Meds to stop
2 wks: Aspirin, NSAIDs, vit E
5 days: Warfarin drop INR to <1.5 (can use vit K)
! Take thyroid meds morning of surgery
If CKD on dialysis
Take morning dose of insulin if IDDM
Dialyze 24 hours pre- & post-op
Why check BUN/Cr? Increased risk of post-op bleeding 2/2
If BUN > 100: Uremic platelet dysfunction.
Coag panel: Normal platelets but prolonged bleeding time

VENT SETTINGS
Assist-control: set TV and rate but if pt takes a breath, vent gives the volume.
Pressure support: pt rules rate but a boost of pressure is given (8-20).
*Important for weaning.*
CPAP: pt must breathe on own but + pressure given all the time.
PEEP: pressure given at the end of cycle to keep alveoli open (5-20).
*Used in ARDS or CHF*
Best test to evaluate vent management? ABG
LowPaO2? increase FiO2
High PaO2? decrease FiO2
Low PaCO2 (pH is high)? Decr RR or TV
High PaCO2 (pH is low)? Incr rate or TV
TV is more efficient to change.

*Remember minute ventilation equation & dead space*

ACID-BASE DISORDERS
Respiratory: pH and PCO2 move in opposite directions
Metabolic: pH and PCO2 move in same direction
pH < 7.4 = acidotic.
High pCO2: Acute Respiratory Acidosis
High pCO2 and HCO3? Chronic
Low HCO3: Acute Metabolic Acidosis
Low HCO3 and pCO2? Chronic
Anion gap: (Na [Cl + HCO3])
Normal: 8-12
Anion-gap acidosis = MUDPILES (Methanol, Uremia, Diabetic ketoacidosis, Propylene glycol,
Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates)
Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV)
pH > 7.4 = alkalotic.
High HCO3: Acute Metabolic Alkalosis
High HCO3 and pCO2? Chronic
Low pCO2: Acute Respiratory Alkalosis
Low HCO3 and pCO2? Chronic
Decrease in serum K and ionized Ca
o Paresthesias, carpopedal spasm, and tetany.
Urine [Cl]
o [Cl] < 20: Vomiting/NG, antactids, diuretics
[Cl] > 20: Conns, Bartters, Gittlemans

TRAUMA
ABCDE: Airway, Breathing, Circulation, Dysfunction (neurological), Exposure (examine whole body)
AB: Airway, Breathing
Patient comes in unconscious or GCS </= 8: Intubate, Will Robinson! Intubate!
o Stung by a bee, developing stridor and tripod posturing: Intubate!
o Penetrating neck trauma, GCS = 15 BUT expanding mass/hematoma in lateral neck: Intubate!
Penetrating neck trauma, subcut. emphysema on palpation: Fiberoptic broncoscope/intubation
Huge facial trauma, blood obscuring/obliteration of oral/nasal airway: Cricothyroidotomy
Post-intubation: Check bilateral breath sounds
o If decr on left: Intubation of R mainstem bronchus
Pull back ET tube
Check pulse ox, keep at > 90%
Traumatic Aortic Injury

Hemothorax

Burns
American Burn Association Criteria for Referral to a Burn Center

Partial- or full-thickness burns of > 10% BSA in pts < 10 or > 50 y/o
Partial- or full-thickness burns of > 20% BSA in pts of other ages
Partial- or full-thickness burns involving face, hands, feet, genitalia, perineum, or skin over major joints
Full-thickness burns of > 5% BSA at any age
Significant electrical (incl. lightning) & chemical burns
Lesser burn injury in conjunction with inhalational injury, trauma, or preexisting medical condns
Patients requiring special social, emotional, or rehabilitation assistance (i.e., child or elder abuse)

Rule of 9s

Start resuscitation with 1L LR bolus adults, 20 mL/kg for children

Parkland formula: 2-4mL/kg/%BSA burn (adults) children, 3-4mL/kg/%BSA
Give over 1st 8h, rest over next 16h
NO PO or IV abx; use topical tx
Painless, but doesnt penetrate eschar, var. gram-neg covg, can cause leukopenia: Silver sulfdiazine
Penetrates eschar, but hurts like hell, can cause acidosis via c. anhydrase inhib, poor Candida covg:
Mafenide acetate
Painless, but doesnt penetrate eschar, stains black, causes hypoK and hypoNa: Silver nitrate
Circumferential burns: Consider escharotomy (bedside, no anesthesia needed)
Inhalational burn: Singed nose hairs, wheezing, soot in mouth/nose
Low threshold for intubation
Pt w/confusion, HA, cherry-red skin: Check/monitor carboxyHb (pulse ox = worthless)
o Treatment: 100% O2 (hyperbaric if CO-Hb is )
Chemical burn: Irrigate > 30min prior to ER
Electrical burn: EKG first!
If LOC or abnormal EKG: 48 hours of telemetry
If urine dipstick + for blood but microscopic exam negative for RBCs: Myoglobinuria ATN
Check for hyperkalemia due to RBC lysis!

Chest Trauma
Inward mvmt of ribcage on inspiration: Flail chest > 3 consec. rib fx
o Tx: O2 and pain control
Acute SOB, confusion, petechial rash on chest/axilla/neck after long bone fx (esp. femur): Fat
embolism
Patient dies suddenly after removal of central line: Air embolism
o Suspect during: Lung trauma, vent use, major vascular surgery
Hypotensive/tachycardic/cool skin: Shock Hypovolemic, cardiac tamponade, tension pneumo
Flat neck veins and normal CVP: Hypovolemic
o Next step: 2 large-bore (14-16 gauge) periph. IV- 2L LR over 20min
o Follow with blood transfix
o Do not exceed CVP of 15mmHg
Muffled heart sounds, JVD, pulsus paradoxus: Pericardial tamponade
o Confirmation: FAST scan
o Treatment: Needle decompression, pericardial window or median sternotomy
Decr. unilateral BS w/ tracheal deviation AWAY: Tension pneumo
o Next step: Needle decompression, followed by 26-French chest tubeNOT CXR!
Types of Shock
Hypovolemic
Loss of circ. blood vol.
(hemorrhage, interstit. d/t bowel
obstr., excessive vom./diarrhea,
polyuria, burn)

Vasogenic
Decreased periph. vasc.
resistance sepsis (LPS) and
anaphylaxis (histamine)

Neurogenic
Vasogenic d/t spinal cord
injury/anesthesia, adrenal insuff.
(susp. in pts on steroids w/acute
stressors) acute loss of
sympathetic vascular tone

Cardio-compressive
Cardiac tamponade (pressure
preventing it fulfilling role as pump)

Cardiogenic
Failure of heart as pump, as in
arrhythmia or acute MI

Physical Exam

Swann-Ganz Catheter

Treatment

Hypotensive, tachycardic,
diaphoretic, cool, clammy
extremities

RAP/ Pulm. capill.WP

Systemic vasc. resist.
Cardiac output

Crystalloid resuscitation

Early: AMS, hypotn, warm/dry

extrem.
Late: Resembles hypovolemic

RAP/Pulm. capill.WP
Systemic vasc. resist.
Cardiac output (EF)

Hypotensive, bradycardic, warm,

dry extremities, absent reflexes and
flaccid tone.
Adrenal insuff.: hypoNa, hyperK

RAP/Pulm. capill.WP
Systemic vasc. resist.
Cardiac output

Fluid resuscitation (may

cause edema), tx
offending organism,
epinephrine/antihist.
Tx adrenal insuff w/
dexamethasone; taper over
several wks.

Hypotensive, tachycardic, JVD,

decreased HS, norm. BS, pulsus
paradoxus (10-pt PP drop w/inspir.)
SOB, clammy extrem., bilat.
rales/decr. BS, S3, pleural effusion,
ascites, periph. edema

FAST scan shows fluid in

pericardial space

Head Trauma
GLASGOW COMA SCALE (GCS): Classification of head injury
Severe:
8 or less
Moderate:
913
Mild:
14 or 15.ir

RAP/ Pulm. capill.WP

Systemic vasc. resist.
Cardiac output

Needle pericardiocentesis,
pericardial window,
sternotomy
Diuretics, raise HR to 60100, rhythm control;
vasopressors if necess.

Eyes 4, verbal 5, motor 6

Eye
Verbal
Motor

1
Does not open eyes
No sounds
No movements

GLASGOW COMA SCALE

2
3
Opens eyes to pain
Opens eyes to voice
Incomprehensible sounds
Inappropriate words
Decerebrate posturing
Decorticate posturing

4
Opens eyes spontaneously
Confused, disoriented
Withdraws from pain

Converses normally
Localizes pain

Obeys commands

Increased ICP: Hematoma, edema, tumor

Symptoms: Headache, vomiting, altered mental status
Treatment: Elev. head, hyperventil. to pCO2 28-32, diuresis (furosemide, mannitolwatch renal fxn)
Surgical: Burr hole, ventriculostomy
Neck Trauma
Penetrating trauma vs. GSW

Zone 3 = angle of mandible

Aortography and triple endoscopy
Zone 2 = Angle of mandiblecricoid
2D doppler +/- exploratory surgery
Zone 1 = cricoid
Aorto/angiography
Abdominal Trauma
Penetrating Abdominal Trauma: Do not pass go! Go directly to exploratory laparotomy.
GSW to abdomen: Ex-lap. (plus tetanus prophylaxis)
Stab wound w/unstable ptrebound tenderness & rigidity OR evisceration: Ex-lap. (plus tetanus
prophylaxis)
o Stab wound w/stable pt: FAST exam; diag. peritoneal lavage (DPL) if FAST is equivocal
Ex-lap if either are positive.
Blunt Abdominal Trauma: w/hypotn/tachycardia, Ex-lap.
If stable OR stable w/epigastric pain: Abdominal CT
Lower rib fx + abd. bleed: Spleen or liver lac.
Lower rib fx + hematuria: Kidney lac.

Kehr sign (mult. air/fluid levels) + viscera in thorax on CXR: Diaphragmatic rupt.
Handlebar sign: Pancreatic rupt.
Fluid found in retroperitoneum: Consider duodenal rupt.

Pelvic Trauma
If hypotensive, tachycardic: FAST and/or DPL to r/o bleeding in abd. cavity
Can exsanguinate into abdomen, pelvis, & thigh: Stop bleeding by fixing fxinternal fixn if stable, external
if not
Blood at urethral meatus and/or high-riding prostate: Consider urethral/bladder injury
o Test: Retrograde urethrogram (NOT FOLEY!)
If normal: Retrograde cystogram to evaluate bladder
o Check for extravasation of dye; 2 views (full/empty) to ID trigone injury
Extraperitoneal extravasation: Ex-lap and surgical repair
Intraperitoneal extravasation: Bed rest + foley
Orthopedics
XRs at 90 angles, including joints above and below
Fractures that go to the OR:
Depressed skull fx
Severely displaced or angulated fx
Open fx (w/in 6h)
Femoral neck or intertrochanteric fx (risk of necrosis)
Common fractures:
Shoulder pain s/p seizure/electrical shock: Post. shoulder dislocation
Arm ext. rotated/numbness over deltoid: Ant. shoulder dislocation
Old lady fell on outstretched hand (FOOSH) distal radius displaced: Colles fracture
Young person FOOSH, anatomic snuff box tenderness: Scaphoid (carpal navicular) fracture
o Initial XRs NEGATIVE unless displaced (surgery indic.); will show on XR 2-3wks. PI
I swear I just punched a wall: Metacarpal neck fracture (Boxers fracture)
o May need K wire
Clavicle: Most commonly broken between middle and distal 1/3s
o Need figure-of-8 device
Extremity extremely tender, numb, white, cold (pulse may or may not be attenuated): Compartment syndrome
Compartment pressure >30mmHg
Treatment: May require fasciotomy (through all fascial compartments)

Scaphoid fx

Depressed skull fx

Femoral neck fx
Intertrochanteric fx
Bone malig. in adults = mets from lung, prostate, breast
Colles fx

4-5 y/o w/ a painless limp: Avascular necrosis

o Adultssteroid use, s/p femoral head/neck fx
12-13 y/o w/knee or hip pain: SCFE
Most common primary bone malig. (us. peds): Osteosarcoma
o Distal femur, proximal tibia @ metaphysis, around the knee
o Codmans triangle (raised periosteum), sunburst appearance
Night pain, fever, elevated ESR: Ewing sarcoma
o Diaphysis of long bones
o Lytic bone lesions, onion skinning
o Neuroendocrine (small blue) tumor

HERNIAS

Umbilical: Peds close spontaneously by age 2

o In adults: 2/2 obesity, ascites or pregnancy
Indirect inguinal: MCthrough inguinal ring (lateral to epigastric vessels) in spermatocord
o R > L, more often congenital (patent proc. vaginalis)
Direct inguinal: through Hasselbecks triangle (medial to epigastrics), more often acq. weakness
Femoral: More common in women
Treatment: Emergent surgical repair if incarcerated (to avoid strangulation)
o Elective if reducible

CARDIAC MURMURS

Systolic ejection murmur (SEM) cresc/decresc, louder w/squatting, softer w/valsalva + parvus et
tardus: Aortic stenosis
SEM louder w/valsalva, softer w/squatting or handgrip: Hypertrophic cardiomyopathy
Late systolic murmur w/click; louder w/valsalva and handgrip, softer w/squatting: Mitral prolapse
Holosystolic murmur radiates to axilla: Mitral regurgitation
Holosystolic murmur w/late diastolic rumblepeds: VSD
Continuous machine-like murmur: PDA
Wide, fixed splitting in S2: ASD
Rumbling diastolic murmur w/opening snap, LAE and A-fib: Mitral stenosis
Blowing diastolic murmur w/widened pulse pressure: Aortic regurgitation

INFLAMMATORY BOWEL DISEASE

Involves terminal ileum: Crohns

o Mimics appendicitis, Fe deficiency
Continuous involving rectum: UC
o Rarely, ileal backwash, but never higher
Incr. risk for Primary Sclerosing Cholangitis: UC
o PSC leads to higher risk of cholangioCA
Highest risk of colon cancer: UC (another reason for colectomy)
Fistulae likely: Crohns (give metronidazole)
o For Crohns, give metranidazole for ANY ulcer or abscess
Granulomas on biopsy: Crohns
Transmural inflammation: UC
Smokers have lower risk: UC
o Smokers have higher risk for Crohns
Associated w/ p-ANCA: UC
Treatment = ASA, sulfasalzine to maintain remission
o Corticosteroids to induce remission
o Azathioprine, 6MP and methotrexate for severe dz

TRANSPLANT
Hyperacute Rejection
Vascular thrombosis in minutes
Caused by preformed antibodies
Acute Rejection
Organ dysfunction (incr. GGT or Cr depending on organ) in 5days/3mos
o Due to T-lymphocytes

o Tx w/steroid bolus and antilymphocyte agent (Muromonab, anti-CD3)

Technical problems common in liver:
o 1st, US check for biliary obstruction
o Then check for thrombosis by Doppler
Cardiac sxs come late periodic ventricular bx
Chronic Rejection
Occurs after years
Due to T-lymphocytes
Untreatable need re-transplantation

ANESTHESIA
Local
Lidocaine, etc.: Give with epi to prevent systemic absorption
numb tongue, seizures, hypotension, bradycardia, arrhythmias
NO epi: Fingers, nose, penis, toes
Spinal/subarachnoid
Bupivicaine, etc.: Pts who cant be intubated
o Cant give if incr ICP or hypotensive
Epidural (local + opioid): If high block, blocks cardiac SNS/phrenic nerve
General
Meperidine: Norperidine metabolite can lower seizure threshold, esp. in pts w/renal failure
Succinylcholine: Can cause malignant hyperthermia, hyperK (do not use in burn or crush victims)
Rocuronium, etc.: Sometimes allergic rxn in asthmatics
Halothane, etc.: Can cause malignant hyperthermia (tx w/dantrolene Na), liver toxicity

UROLOGY
BPH: Anticholinergics worsen foley for acute urinary retention
Medical tx 1st : Tamsulosin or finasteride
Surgical tx: TURP (hyponatremia, retro-ejac)
Prostate Cancer
Nodules on DRE or elevated/rising PSA: Transrectal ultrasound and bx.
Bone scan looks for blastic lesions.
Tx w/surgery, radiation, leuprolide or flutamide
Kidney Stones
CT is best test
Stone <5mm: Hydrate and let pass
>5mm: Shockwave lithotripsy
>2cm: Surgical removal
Scrotal Mass
Transilluminate (cystic = hydrocele/hernia; solid = tumor)

U/S & excision

o Dont bx!
Know hormone markers!
Testicular Torsion
Acute pain and swelling w/ high riding testis
STAT Doppler U/SNo flow (contrast w/ epididymitis)
Can surgically salvage if <6hrs: Orchiopexy to BOTH testes