o Leriche Syndrome = bilateral hip/thigh/buttock claudication + impotence + symmetric

atrophy of bilateral lower extremities d/t chronic [atherosclerotic] ischemia

o Risk Factors = smoking

o Appendicitis = clinical diagnosis; CT or US only pursued if nonclassical presentation, equivocal

findings on initial assessment, or high likelihood for another differential
o MCL tear = blow to lateral knee; may see ecchymosis and joint tenderness on medial aspect
of knee; diagnosed clinically (laxity when abducting knee) or via MRI; managed via RICE
o Thyroidectomy = hypocalcemia d/t hypoparathyroidism
o Clinical Presentation = fatigue, anxiety, depression; QT prolongation, tetany, seizures when severe

o Gallstone Pancreatitis = if ALT >150, high chance pancreatitis d/t gallstones

o Peripheral artery aneurysms = pulsatile mass → compress adjacent structures {nerves, veins}
→ thrombosis + ischemia
o Association = abdominal aortic aneurysm
o Burn Injuries = SECURE THE AIRWAY if there are any signs of inhalation
o Stress Fractures = reduce weight bearing exercise for 4-6 weeks + Tylenol; podiatric shoe if
pain is severe; refer to orthopedic surgeon for fracture w/ ↑ risk for malunion (ie. anterior
tibial cortex; 5th metatarsal)
o Imaging = XR frequently normal

o Ruptured Ovarian Cyst = may initially present as acute abdomen d/t hemoperitoneum from
the bleeding
o Clinical Presentation: sudden-onset, severe, unilateral lower AP, immediately after strenuous activity
o Workup: pelvic US → pelvic free fluid; Laboratory Findings = ↓ hematocrit
o Treatment: surgery for hemodynamically unstable; Tylenol if unruptured

o Abdominal Aortic Aneurysm = severe back pain, syncope, hypotension

o Diameter >3 cm at renal artery level = aneurysm; true aneurysm involving all 3 layers
o Risk Factors = smoking, male, CAD
o Complications = rupture intro retroperitoneum → aortocaval fistula w/ IVC → venous congestion in
retroperitoneal structures (ie. bladder) → bladder rupture → gross hematuria
o Superior Mesenteric Artery Syndrome = intermittent intestinal obstruction (primarily
postprandial), where transverse [3rd] portion of duodenum is compressed between SMA &
aorta
o Etiology: recent weight loss; malnutrition; diminished mesenteric fat

o Peptic Ulcer Perforation = upper endoscopy may be considered after surgical repair, to
evaluate for cancer, H. pylori infection, and healing; if pneumoperitoneum not visible on
upright XR of chest + abdomen, can use CT + water-soluble contrast to find perforation
o Squamous Cell Carcinoma = most commonly the result of UV light exposure, but also
associated w/ chronically wounded [burn], scarred [radiotherapy, venous ulcers], or inflamed
[osteomyelitis] skin
o SCC 2/2 Burn Wound = Marjolin ulcer

o Prepatellar Bursitis = can become infected w/ S. aureus via penetrating trauma, repetitive
friction, or local cellulitis extension
o Workup: cell count + Gram stain
o Negative Gram stain: NSAIDs + activity modification
o Infectious treatment: drainage + ABx
o Gastric Outlet Obstruction = “succusion splash”
o Risk Factors = malignancy, PUD, Crohn disease, strictures d/t acid/caustic agents, gastric bezoars
o Diagnosis: upper endoscopy
o Treatment: surgical

o Blunt Abdominal Trauma = hepatic laceration, splenic laceration

o Hepatic laceration = hypotension, free intraperitoneal air, RUQ pain + bruising, referred shoulder pain

o Thoracic Aortic Aneurism = anterior spinal cord infarction is a potential complication

o Clinical Presentation: bilateral flaccid paralysis, loss of Pain/T sensation below level of injury, UMN signs
o Vibration/proprioception are spared

o Central Venous Catheter = internal jugular vein (US guided) or subclavian vein (anatomy)
o Complications = vein perforation, lung puncture [PTX], myocardial perforation → cardiac tamponade
o Diagnose = proper placement is proximal to the angle between trachea & right mainstem bronchus, as
seen on CXR; do not administer drugs until placement is confirmed
o Compartment Syndrome = tissue compartment pressure >30 mmHg
o Principles: in high-risk pt (ie. recently revascularized limb), diagnosis can be made on clinical grounds →
send to OR for fasciotomy
o Etiology:
1. Direct trauma
2. Prolonged compression of extremity
3. After revascularization of an acutely ischemic limb
o Clinical Presentation: excruciating pain worsened w/ passive ROM, does not respond to narcotics;
paresthesia d/t sensory nerve ischemia; rapidly increasing & intense swelling of region
o Diagnosis: measurement of compartment pressures
o Treatment: fasciotomy
o Sphincter of Oddi Dysfunction
o Etiology: postcholecystectomy syndrome
o Pathophysiology: inflammatory process (ie. surgery, pancreatitis) → dyskinesia + stenosis of SOD →
obstruction of flow through SOD → retention of bile [comes from the liver!]
o Clinical Presentation: recurrent, episodic RUQ or epigastric pain
o Opioid analgesics worsen SOD symptoms
o Laboratory Findings: ↑ aminotransferase & ↑ alkaline phosphatase
o Workup: initially US, which shows dilated CBD in the absence of any stones
o Diagnosis: SOD manometry
o Treatment: sphincterotomy
o If a pt had an ex-lap after abdominal trauma! = assume he had a splenectomy! And whatever
else a splenectomy implies! = encapsulated organisms, reactive thrombocytosis (↑ platelets)
o Elderly Patients = pts with multiple comorbidities and risk factors prior to surgery, need a full
cardiac workup before being given anesthesia + invasive procedure
o Check for heart failure before bolusing in an elderly pt
o Surgery may only be delayed up to 72 hours during workup

o Septic Shock = IV Fluids + Cx + ABx → then vasopressors → then hydrocortisone

o Syringomyelia = CSF drainage from central canal of SC is disrupted → fluid filled cavity
o May develop months to years after initial injury
o Etiology = Arnold-Chiari malformation, prior traumatic spinal cord injuries

o Barium enema = useless

o Clavicular Fracture:
o Principles: ALL pts should have neurovascular examination; a bruit over clavicle could indicate injury
to subclavian artery & requires angiogram to evaluate
o Treatment:
o Middle third – brace, rest, ice + physical therapy
o Distal third – open reduction + internal fixation
o Postoperative Fever o Postoperative Complications
o Atelectasis – 2nd-5th postop night
o Principles: pain and changes in lung
compliance → impaired cough & shallow
breathing
o Shallow breathing = limit alveoli
recruitment
o Weak cough = airway mucus plugging
o Etiology: airway obstruction d/t retained
airway secretions, airway tissue edema,
residual anesthetic effects, ↓ lung
compliance, postoperative pain, medications
that inhibit deep breathing
o Presentation: hypoxemia → respiratory
alkalosis, hypocapnia
o Prevention: ISS
o Atelectasis
o Etiology: airway
obstruction d/t retained
airway secretions,
airway tissue edema,
residual anesthetic
effects, ↓ lung
compliance,
postoperative pain,
medications that inhibit
deep breathing
o Presentation:
hypoxemia →
respiratory alkalosis,
hypocapnia
NECROTIZING
o Principles: polymicrobial
o Common in diabetic pts

o Clinical Presentation:
1. Pain, edema, erythema spreading beyond surgical site
2. Systemic signs such as fever, hypotension, tachycardia
3. Paresthesia or anesthesia at edges of wound

4. Purulent, cloud-gray discharge

5. Subcutaneous gas or crepitus

o Management: ABx + urgent surgical debridement

o Adequate hydration
o Tight glycemic control
FEVER
PAIN
ERYTHEMA
SWELLING
HYPOTENSION
epidermidis
o Clinical Presentation: pts with a recent history of skin infection → fever, abdominal pain
radiating to groin; back pain, limp; anorexia, weight loss
o Deep abdominal palpation required to elicit posterior tenderness
o Psoas sign = abdominal pain w/ hip extension

o Pathophysiology:
o Hematologic seeding from distant infections
o Direct extension of intraabdominal infection
o ie. diverticulitis, vertebral osteomyelitis

o Risk Factors:
o HIV, IV drug abuse, diabetes, Crohn’s disease

o Diagnosis: abdominal/pelvis CT
o Treatment: PCI drainage + Cx for ABx therapy
o Principles: possible complication of cardiac surgery d/t intraoperative wound contamination
o Occurs in 5% of sternotomies; presents within 14 days postoperatively
o May also be d/t retropharyngeal abscess 2/2 penetrating trauma → abscess can drain into superior
mediastinum or carotid vein sheath→ acute necrotizing mediastinitis
o Clinical Presentation: fever, tachycardia, chest pain, leukocytosis, sternal wound drainage or
purulent discharge
o Imaging:
o CXR = widened mediastinum

o Diagnosis: clinical; confirmed during correctional drainage procedure

o Treatment: surgical drainage, debridement + closure; prolonged ABx course
o Differentials:
o Postpericardiotomy Syndrome = fever, leukocytosis, tachycardia, chest pain; autoimmune & occurs
after pericardium incision (not performed in a CABG); treat with NSAIDs
o Principles: penile fracture
implies muscular damage; if
concurrent urethral damage
is suspected, perform
urethrogram
o Indications:
o Blood at meatus
o Hematuria
o Dysuria
o Urinary Retention
o Indications:
o Hemodynamic instability
o Peritonitis – rebound tenderness, guarding
o Evisceration
o Blood from nasogastric tube or on rectal exam
S T A B L E
o Principles: massive internal hemorrhage
o Hypovolemic Shock = body will attempt to maintain CO + organ perfusion
o SNS → peripheral vasocontraction (↑ SVR) [cold extremities] + ↑HR [tachycardia] → LV to ↑EF [~75%]
o RECALL = LV is ↓ in size d/t low filling volume
o Eventual circulatory collapse if no intervention

o Clinical Presentation: hypotension, tachycardia, cold extremities, ↓ JVP [flat neck veins]
o Contraindications:
o Positive Pressure Ventilation = acute increase in intrathoracic pressure
o In the setting of ↓ CVP (ie. d/t hypovolemic shock), PPV endotracheal ventilation → acute ↑ in intrathoracic
pressure → collapse venous capacitance vessels [IVC] → acute loss RV preload + loss of CO + cardiac arrest
o Clinical Presentation = flat neck veins, altered mental status, bruising

o Differentials:
o Cardiac tamponade = diastolic collapse + ↑RV filling pressure…+Beck’s triad
o Pulmonary embolism = RV dilation (backflow from lungs) + JVD
o Cardiogenic shock d/t myocardial contusion = dilated LV + JVD
o Imaging:
1. CXR
2. Hemodynamically stable = CT chest w/ contrast
3. Hemodynamically unstable = TEE (can be rapidly performed)
o Aortic rupture = most pts die in the field
o Profound hypotension if survived
o Pts who survive, suffer the injury distal to L subclavian artery (which contains the hematoma within
the mediastinum) → presents as HTN aka pseudocoarctation syndrome
o Aortic injury = incomplete/contained aortic rupture
o Clinical Presentation: anxiety, tachycardia, HTN
o Imaging:
o CXR = mediastinal widening, large L-sided hemothorax; deviation of mediastinum to the right; depression of L
mainstem bronchus; disruption of normal aortic contour
o Treatment: anti-hypertensives if needed + surgical repair

o Imaging: CXR
o Diagnosis = confirm findings via CT + angiography
o Imaging: CXR
o Hemothorax = blunting of costophrenic angle; partial to complete opacification of a lung filed
o Clinical Presentation = ↓ breath sounds, dullness to percussion + contralateral tracheal deviation
o Pulmonary contusion = opacities (patchy, irregular alveolar infiltrates) d/t hemorrhage in involved
lung segments; symptoms develop in under 24 hours [ARDS develops in 48 hours after trauma]
o Treatment: pain control + oxygen + chest physiotherapy

o Tracheobronchial perforation = PTX that does not resolve with chest tube; subcutaneous
emphysema & pneumomediastinum
o Treatment: operative repair
o Myocardial contusion = LV dysfunction after crush injury
o Clinical Presentation: arrhythmias, ventricular/septal/valvular injuries, free wall rupture, tamponade
o NS infusion will rapidly raise PCWP, but barely increase systemic blood pressure
o Pathognomonic = ↑ or high PCWP at baseline
o Workup: echocardiogram
o Imaging: CXR
o Diaphragmatic rupture = herniation of abdominal contents into thorax
o More common on L side, as R is protected by liver; may have a delayed presentation up to 2 months
o Pts have respiratory distress/SOB + mediastinal contents shifted to opposite side; pain referred to shoulder
o Workup: NG tube lands in pulmonary cavity on CXR
o Diagnosis: CT chest
o Complications: bowel strangulation
o Treatment: surgical repair + ex lap
o Duodenal Hematoma = common in children, who have thin abdominal wall muscles, less adipose,
more pliable ribs
o Pathophysiology = blood collects between submucosal & muscular layers
o Clinical Presentation = initial pain of trauma; clinical deterioration as hematoma expands → epigastric pain,
N/V, colicky pain after meals d/t failure to pass gastric contents beyond obstructing hematoma
o Diagnosis = CT abdomen
o Treatment = NG tube + TPN; otherwise self-resolving
T PTX -
1. 5th intercostal
space
midaxillary line
2. F/u w/ tube
thoracostomy
o Principles:
o Complication of iatrogenic procedures – central venous line; trauma
o Life-threatening condition

o Pathophysiology:
o Air within pleural space from the inside of the lung
o Displaces mediastinal structures → compromised cardiopulmonary function
o Injured tissue essentially forms 1 way valve for air to enter pleural space, without escape mechanism

o Clinical Presentation:
o Rapid-onset SOB
o Tachycardia
o Tachypnea
o Hypotension
o Distension of neck veins 2/2 superior vena cava compression

o Contraindications:
o PEEP
o Principles: prevention of
atelectasis + pneumonia
o Significant pain may lead to
conscious hypoventilation
o Pain management is paramount

o Management:
o Extensive fractures managed in-
patient = epidural infusion
o Intercostal nerve blocks carry risk of
iatrogenic PTX
o Less extensive fractures = NSAIDs
(ketorolac, ibuprofen) + opioids
o Although opioids may cause central
respiratory depression, still better
than nothing
o PPV Principles:
1. Respiratory failure often occurs d/t pulmonary contusion +
accumulation of edema/blood in alveoli
2. Intubation w/ PPV is now required
3. Corrects the paradoxical motion of flail segment by
replacing [default] negative intrapleural pressure w/ positive
intrapleural pressure → forcing lung segment to move
outward with rest of rib cage during inspiration
4. Complications: lung puncture against any rib fracture
segments → PTX
o Prophylaxis = bilateral external chest tubes
o Clinical Presentation: costovertebral angle pain, hematuria
o Renal contusions, laceration, vascular injuries (ie. renal artery dissection)

o Workup in Stable Patient:

1. Focused GU physical examination
2. UA
3. Abdomen + Pelvis CT w/ contrast
4. Plain XR - look for fractures
5. US – testicular injury
6. Retrograde cystogram – bladder rupture
Retrograde urethrogram – urethral injury
 Urethral injury = pt will have gross hematuria, difficulty urinating/urinary retention, blood at meatus, perineal/scrotal
hematoma, high-riding prostate
 Extraperitoneal bladder injury = contusion or rupture of neck, anterior wall, anterolateral wall of bladder → localized
pain from extravasation of urine into adjacent tissues, gross hematuria, pelvic fracture, urinary retention; no
chemical peritonitis
 Intraperitoneal bladder injury = rupture of bladder dome → intraperitoneal urine leakage → chemical abdominal
peritonitis = diffuse abdominal tenderness, guarding, rebound; may irritate diaphragm
o Workup in Unstable Patient:
1. IV pyelography
2. Surgical evaluation
o Clinical Presentation: hemodynamically stable, weakness & ↓ pain sensation in both legs;
lower anterior abdominal discomfort
o Workup in Stable Patient:
1. Focused neurological examination
2. Bladder catheterization – assess for urinary retention + acute distension of full bladder
3. Spinal imaging
Absent pulses
Cool extremities o HARD SIGNS
o Distal ischemia = absent
pulses, cool extremities
o Principles: ratio of ankle SBP/brachial SBP
o Confirmation of PAD

o Interpretation:
o <0.9 = abnormal → occlusive PAD → segmental ankle-brachial index + pulse volume recording to localize
o 0.91 – 1.30 = normal
o >1.30 = calcified & uncompressible vessels; additional vascular studies should be pursued → check pulse
volume recording
o Intervention:
o If diagnosis in question +/- intervention planned = vessel angiography
o In any blunt trauma, always evaluate for urethral, kidney, or bladder injury:
o Urethral = retrograde urethrogram; check for high-riding prostate = digital rectal exam
o Renal = A/P CT with IV contrast
o Bladder = retrograde cystogram

o Hypotension in supine position implies blood loss of 1.5-2 L

o Rapid deceleration injuries can lead to descending aortic transection, which can be
fatal → screen via CXR
o In a trauma setting, preferred entry for central line is femoral access
o When giving a bolus, picking a solution with lower sodium is risking: hyponatremia →
cerebral edema
o If pt vitals do not respond to the 2 L challenge, prepare resuscitation with packed RBCs
o Supracondylar Fracture of Humerus
o Principles: most common fracture in pediatric population
o Pathophysiology: fall on outstretched hand; area is thin/weak d/t physiologic remodeling in childhood
o Complications: cubitus varum deformity; compartment syndrome
o Brachial artery injury = impingement may occur; always check distal pulses before + after reduction
o Medan nerve injury = motor & sensory function should be checked
o Treatment: pain control + casting
o Displaced fractures → consult ortho

o Trochanteric Bursitis
o Definition: inflammation of bursa surrounding gluteus medius insertion on femur trochanter
o Pathophysiology: frictional forces, overuse, trauma, joint crystals
o Clinical Presentation: hip pain with direct pressure, or on external rotation (outside edge of hip)
o Principles:
o Anatomic Snuffbox = pain in dorsoradial
wrist bound by extensor pollicus longus &
abductor pollicus longus + extensor pollicus
brevis
o ↑risk of osteonecrosis, as bloody supply
can be disrupted by fracture
o Management:
1. Wrist XR
2. CT or MRI – if XR is inconclusive, or can
just repeat XR in 7-10 days
3. Displaced Fracture = surgery + pins
4. Nondisplaced Fracture = cast
o Requires f/u XR to monitor for osteonecrosis
Brachial artery
MENINGIOMA
o Definition: benign, primary brain tumor arising from
meningothelial cells
o Commonly in middle-age to elderly women

o Clinical Presentation: headache, seizure, focal

weakness, numbness
o Workup:
o CT head w/ no contrast = calcified, hyperdense, round
mass
o MRI = extra-axial well-circumscribed or round
homogenous enhanced dural-based mass
o Treatment: surgical resection
o Management:
o Small/asymptomatic = close observation + serial CT scans q6-8 hours
o Symptomatic = neurosurgical hematoma evacuation

o Miscellaneous:
o Cerebral angiography = cerebral aneurysms, AV malformations
o IV corticosteroids = control ICH d/t abscess or tumor
o IV mannitol = osmotic diuretic to ↓ brain volume, when ↑ intracranial pressure

o Disease Course:
1. Brief loss of consciousness → lucid interval
2. Hematoma expands
3. ↑ ICP → impaired consciousness, HA, N/V
4. Uncal herniation = ipsilateral CN III palsy & hemiparesis
 HERNIATION
o Principles:
o Epidural hematoma can rapidly expand → compress temporal lobe + ↑ ICP
o Innermost part of temporal lobe = uncus → herniates through tentorum & compresses ipsilateral CN
III + PCA + contralateral cerebral peduncle
o Clinical Presentation:
o ↑ ICP = hypertension + bradycardia + respiratory depression [Cushing’s reflex]
o Compression of contralateral crus cerebri against tentorial edge → ipsilateral hemiparesis
o Compression of ipsilateral CN III → ipsilateral mydriasis + strabismus
o Compression of ipsilateral PCA → homonymous hemianopsia
o Compression of reticular formation → altered consciousness, coma
o Principles: result of traumatic acceleration/deceleration shearing forces → diffuse damage of
axons in the brain; angular injury
o Clinical Presentation: coma
o Imaging:
o CT head = diffuse small bleeds at grey-white matter junction

o Prognosis: fatal
Peripheral nerve injury
CXR AIRWAY

CT
Bronchoscopy

Bronch
Embolization
Resection
Rectal sparing!
-d/t collateral
circulation
o Management:
1. IVF + NPO + optimize hemodynamics (but limit pressors) + broad-spectrum ABx + anti-coagulation
w/ heparin & tPA + IV papaverine (vasodilator)
2. If peritonitis = directly to OR
3. SMA thrombosis (~60%) = PCI or surgical revascularization
4. SMA embolism = embolectomy
5. Non-occlusive = address underlying cause (ie. A-fib)
6. Mesenteric venous thrombosis = 3 months of (heparin → warfarin)
o Etiology: trauma, injury, ulcer, typhoid fever
o Bowel obstruction, colon cancer, Crohn’s disease, diverticulitis, appendicitis

o Management:
1. (If pt on warfarin = warfarin reversal via FFP)
2. NG tube + IVF + Abx
3. Emergency laparotomy
o Principles: mature, walled-off pancreatic fluid collections [w/o necrosis or solid debris],
surrounded by thick, fibrous capsule containing enzyme-rich fluid, tissue
o May leak amylase-rich fluid into circulation → ↑ serum amylase
o Pt will have a history of pancreatitis

o Clinical Presentation: abdominal distension, N/V

o Imaging:
o Abdominal CT = well-circumscribed, encapsulated fluid in the pancreatic bed

o Complications: spontaneous infection, duodenal or biliary obstruction, pseudoaneurysm,

pancreatic ascites, pleural effusion
o Management:
o Asymptomatic = expectant management + NPO
o Symptomatic {including pseudoaneurysm} = endoscopic drainage
o Pseudoaneurysm usually embolized prior to drainage
o Infected = ABx
o Gallstone Ileus
o Definition: mechanical small bowel obstruction
o Pathophysiology: gallstone passes from biliary-enteric fistula → small bowel
o As stone advances, may cause intermittent “tumbling” obstruction w/ diffuse AP, V → eventually lodge in
ileum (narrowest section of small bowel)
o Risk Factors: cholecystitis predisposes to fistulas; common in middle-aged women
o Clinical Presentation: N/V; abdominal distension; inability to pass gas or stool; hypovolemia
o Hyperactive bowel sounds
o Workup:
o Abdominal upright series = dilated loops of small bowel
o Abdominal CT = gallbladder wall thickening; pneumobilia, obstructing stone
o Treatment:
o Surgical stone removal
o Cholecystectomy
o Ileus
o Definition: functional deficit in bowel motility
w/o physical obstruction
o Clinical Presentation: N/V, abdominal
distension, failure to pass flatus or stool
(obstipation), hypoactive bowel sounds
o Course: may follow abdominal surgical
procedures, however, persistence beyond 3-5
days → prolonged postoperative ileus
o Etiology:
o Recent surgery – ↑ splanchnic nerve sympathetic
tone
o Retroperitoneal/abdominal hemorrhage or
inflammation
o Intestinal ischemia
o Electrolyte abnormalities
o Medication induced – postoperative opiate use
o Prevention: epidural anesthesia preference,
minimally invasive surgery, liberal IV fluids
o Diagnosis: clinical
o XR = dilated loops of small + large bowel w/ no
clear transition point
o Treatment: IVF + NGT + NPO + chewing gum
o Small Bowel Obstruction
o Definition: mechanical bowel obstruction,
presenting long after surgery (weeks to years
later)
o Bowel function does/did return after surgery
o Pathophysiology: adhesions; hernias; ovarian CA
o Clinical Presentation: hyperactive bowel sounds
→ eventual dysmotility →bowel sounds
diminished ; peristaltic waves on abdominal wall
o Distended, tympanitic abdomen
o Obstipation
o Diagnosis:
o XR = dilated loops of mainly small bowel; very clear
transition point; air-fluid leveling
o Partial obstruction = some air in colon
o Complete obstruction = abrupt transition point;
no air in colon
o Management: IV fluids + NG tube + bladder cath
o Complicated SBO: ↑ risk of ischemia, strangulation,
necrosis → ex-lap
o Features: changes in pain, fever, hemodynamic
instability [hypotension, tachycardia], guarding,
leukocytosis, metabolic acidosis
o Complications: necrosis → bowel perforation
o Ileus o Small Bowel Obstruction
o Ogilvie Syndrome [colonic pseudo-obstruction] – marked
colonic distention w/o mechanical cause can lead to
perforation
o Etiology: debilitated, elderly long-term hospitalized patients;
often postoperative; electrolyte imbalances
o Clinical Presentation: N/V, abdominal distension

o Imaging: dilated colon; no anatomic

obstruction
o Treatment: may decompress with neostigmine or colonoscopy

o Differential:
o Sigmoid Colon Torsion = dilated colon [no haustra d/t distension]
appears as inverted U-shape
o Risk Factors = elderly
o Chronic constipation → chronic dysmotility → torsion of sigmoid
colon around mesentery
APPENDICEAL ABSCESS
o Principles:
o Pts with delayed presentation, with extended duration of symptoms (>5 days) → rupture →
contained abscess
o Clinical Presentation: fever, leukocytosis
o Psoas signs, obturator signs, rectal exam more indicative at this stage
o Psoas sign may indicate presence of abscess posterior to appendix area, next to psoas muscle

o Diagnosis: CT abdomen
o Management: complication rate is ↑ if immediate surgery is performed in contained abscess
o IV ABx + NPO + PCI drainage
o “Interval appendectomy” = appendectomy 6-8 weeks after
o Definition: colonic diverticular inflammation
o Clinical Presentation: LLQ pain, fever, leukocytosis
o Imaging: CT scan

o Classification:
o Complicated (25%) – hospitalization + IV ABx
o Elevated Risk = elderly, immunosuppressed, high fever, severe leukocytosis
o Features = abscess, perforation, obstruction, fistula
o Abscess Management:
o Fluid <3 cm = IV ABx + observation
o Fluid >3 cm = CT guided percutaneous drainage
 Worsening symptoms → surgical drainage + debridement
 Recurrent attacks, peritonitis, obstruction, diffuse fistulation → bowel resection
o Uncomplicated (75%) – bowel rest, oral ABx, observation
o Classification:
o Initial – blood at beginning of voiding
o Total – blood during entire voiding
o Terminal – blood at end of voiding+ clots
o Locations = prostate, bladder neck, trigone, urethra

o Workup
o Terminal = bleeding from bladder is always concerning → cystoscopy

o Differentials:
o Glomerular disease = will have RBC casts on UA; no clots
o Urethritis/urethral injury = initial hematuria presentation
o Mechanism of Action: depolarizing neuromuscular blocker
o Binds postsynaptic ACh receptors → trigger influx of Na+ ions & efflux of K+ ions → depolarization →
temporary paralysis ensues
o Delays repolarization of skeletal muscle membrane

o Principles: used in RSI as it has rapid onset (45-60 secs) & offset (6-10 mins)
o Complications: cardiac arrhythmia d/t electrolyte [hyperkalemia] derangement
o Scenario: pt experiences severe crush injury → ↑ risk for hyperkalemia d/t rhabdomyolysis +
upregulation of postsynaptic ACh receptors → massive efflux of K+ after succinylcholine
administration
o Inciting Conditions → Upregulation of Postsynaptic ACh Receptors: skeletal muscle injury, burn
injury, disused muscle atrophy, denervation (ie. Guillain-Barre syndrome, critical illness
polyneuropathy)
o Prevention: non-depolarizing neuromuscular blocking agents (ie. vecuronium, rocuronium); do not
affect postsynaptic ligand-gated ion channels
o Etiology: ↓ PTH secretion
o Post-surgical – most common; can occur during total thyroidectomy & sub-total parathyroidectomy [-3.5
glands d/t parathyroid hyperplasia]; symptom onset is more rapid + severe
o Autoimmune – most common non-surgical cause
o Congenital – DiGeorge
o Defective sensor on parathyroid gland
o Infiltrative destruction - hemochromatosis, Wilson disease, neck irradiation

o Clinical Presentation:
oPerioral numbness
o Muscle cramps
o Tetany
o Carpopedal spasms
o Seizures
o QT prolongation

o Management: calcium + vitamin D

o Calcium levels must be monitored: calcium x phosphorus >55 → deposition in basal ganglia [calcification]
 INSUFFICIENCY
o Pathophysiology:
1. Lower extremity venous valvular incompetence → pooling of venous blood + ↑ pressures [venous
hypertension] in post-capillary venules → loss of fluid, plasma proteins, erythrocytes into tissue
o Erythrocyte extravasation → hemosiderin deposition + classic coloration of stasis dermatitis
o Inflammation of venules & capillaries + fibrin deposition + platelet aggregation → microvesicular disease →
ulceration
o Clinical Presentation: unilateral LE edema that worsens while standing, and improves with elevation
o Stasis dermatitis = medial leg, below knee
o Xerosis – dry skin
o Lipodermatosclerosis – stasis dermatitis will eventually lead to fat necrosis → permanent skin sclerosis
o Ulcerations
o Principles: disruption of skin barrier → avascular, immunologically poor, protein-rich substrate
for growth and proliferation of bacteria & fungus
o Immediately after burn = G+ organisms (S. aureus) from hair follicles & sweat glands dominate
o 5 days after burn = G- organisms (P. aeruginosa) or fungi (Candida)
o Larger burns (>20% surface area) are at high risk for infection

o Clinical Presentation of Burn Wound Infection:

o Early sign = 1) change in skin appearance: partial-thickness injury → full-thickness injury; 2) loss of a
viable skin graft
o Burn Wound Sepsis
o Systemic Findings:
o Temperature <36.5 C [97.7 F] or >39 C [102.2 F]
o Progressive tachycardia - >90/min
o Progressive tachypnea - >30/min
o Refractory hypotension – SBP <90 mmHg
o Clinical Presentation: oliguria, unexplained hyperglycemia, thrombocytopenia, AMS
o Diagnosis: quantitative wound culture + biopsy for histopathology (determine tissue invasion depth)
o Treatment: empiric, broad-spectrum IV ABx + MRSA coverage &/or Pseudomonas coverage
o Local wound care + debridement
o Piperacillin/tazobactam + vancomycin +/- aminoglycoside

o Compartment Syndrome
o Pathophysiology = full-thickness (3rd degree) burns → eschar → restricts venous & lymphatic
drainage → acute compartment syndrome
o Treatment: excise the eschar
+ pain meds
Rapid weight loss
Promotes gallstone
formation d/t excess bile
acids
Gallstones
Prophylaxis: ursodeoxycholic
acid or prophylactic
cholecystectomy
o Principles:
o Reducible hernia = contents can be pushed back through the defect into the peritoneal cavity
o Incarcerated hernia = contents are stuck in the hernia sac
o Strangulated hernia = a subset of incarcerated hernia with compromised blow flow to the bowel may
lead to ischemic bowel (look for SIRS [fever, tachycardia, tachypnea, leukocytosis])
o Classification:
o Ventral or incisional hernia = at the site of a previous surgery
o Femoral hernias:
o Rare, more common in multiparous women, and highly prone to incarceration/strangulation
o Posterior and inferior to the inguinal ligament and medial to the femoral vein
o Indirect inguinal hernia:
o Most common hernia in men, women, and children
o Congenital (patent processus vaginalis), lateral to inferior epigastric vessels, and through the deep and
superficial ring
o Direct inguinal hernia:
o More common in older men
o Acquired weakness in Hesselbach’s triangle, medial to inferior epigastric vessels, and only through the
superficial ring
o Management:
o Asymptomatic hernias can be observed
o Exception: femoral hernias, inguinal hernias in infancy (wait until preemie is out of the ICU)
o Indirect hernia (most common) = open the sac (anteriorly), reduce any contents, and perform a high
ligation (at the internal ring) of the hernia sac
o Direct hernia (older men) = do not open sac (no patent processus vaginalis), and reinforce floor with
mesh (Lichtenstein) repair
o Femoral hernia (women) = high incarceration risk
o Incarcerated hernia = attempt reduction, otherwise repair semi-electively
o Strangulated hernia = urgent surgery
o Umbilical hernia in children = repair if persists > age 5, defect > 2 cm, and progressive enlargement
after age 2
o Complications:
o Persistent pain from nerve injury is common
o Recurrence
o Testicular ischemia: swollen painful testicle following surgery