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 ½ 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: Conn’s, Bartter’s, Gittleman’s

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 cond’ns
 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 ½ over 1st 8h, rest over next 16h
NO PO or IV abx; use topical tx
 Painless, but doesn’t penetrate eschar, var. gram-neg cov’g, can cause leukopenia: Silver sulfdiazine
 Penetrates eschar, but hurts like hell, can cause acidosis via c. anhydrase inhib, poor Candida cov’g:
Mafenide acetate
 Painless, but doesn’t 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 tube—NOT CXR!

Types of Shock Physical Exam Swann-Ganz Catheter Treatment

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
Hypotensive, tachycardic,
diaphoretic, cool, clammy
extremities
Early: AMS, hypotn, warm/dry
extrem.
Late: Resembles hypovolemic
Hypotensive, bradycardic, warm,
dry extremities, absent reflexes and
flaccid tone.
Adrenal insuff.: hypoNa, hyperK
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
RAP/ Pulm. capill.WP↓
Systemic vasc. resist.↑
Cardiac output↓
RAP/Pulm. capill.WP ↓
Systemic vasc. resist.↓
Cardiac output↑ (EF↓)
RAP/Pulm. capill.WP ↓
Systemic vasc. resist.↓
Cardiac output↑
FAST scan shows fluid in
pericardial space
RAP/ Pulm. capill.WP↑
Systemic vasc. resist.↑
Cardiac output↓
Crystalloid resuscitation
Fluid resuscitation (may
cause edema), tx
offending organism,
epinephrine/antihist.
Tx adrenal insuff w/
dexamethasone; taper over
several wks.
Needle pericardiocentesis,
pericardial window,
sternotomy
Diuretics, raise HR to 60-
100, rhythm control;
vasopressors if necess.

Head Trauma
GLASGOW COMA SCALE (GCS): Classification of head injury
 Severe: 8 or less
 Moderate: 9–13
 Mild: 14 or 15.ir
Eyes 4, verbal 5, motor 6
GLASGOW COMA SCALE
1 2 3 4 5 6
 Eye Does not open eyes Opens eyes to pain Opens eyes to voice Opens eyes spontaneously
Verbal No sounds Incomprehensible sounds Inappropriate words Confused, disoriented Converses normally
Motor No movements Decerebrate posturing Decorticate posturing Withdraws from pain 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, mannitolwatch 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 mandiblecricoid
 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 ptrebound 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 fxinternal fix’n 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: Colle’s 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 (‘Boxer’s 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)

Colle’s fx
Depressed skull fx
Scaphoid fx

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

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

o Adultssteroid 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 Codman’s 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: MCthrough inguinal ring (lateral to epigastric vessels) in spermatocord
o R > L, more often congenital (patent proc. vaginalis)
 Direct inguinal: through Hasselbeck’s 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 rumblepeds: 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: Crohn’s
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: Crohn’s (give metronidazole)
o For Crohn’s, give metranidazole for ANY ulcer or abscess
 Granulomas on biopsy: Crohn’s
 Transmural inflammation: UC
 Smokers have lower risk: UC
o Smokers have higher risk for Crohn’s
 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 can’t be intubated
o Can’t 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 Don’t bx!
 Know hormone markers!
Testicular Torsion
 Acute pain and swelling w/ high riding testis
 STAT Doppler U/SNo flow (contrast w/ epididymitis)
 Can surgically salvage if <6hrs: Orchiopexy to BOTH testes