Professional Documents
Culture Documents
If patient is conscious and fully normal, normal voice, does not need airway
Patient with hematoma but normal voice, still needs an airway because of the
expanding hematoma. Use laryngoscope, with anesthesia
Pt with subcute air (emphesyma) needs an airway, means injury to trachea or
major bronchus. Cant put a tube blindly, might lead to perforation etc...
Fibrotic bronchoscope (with visualization) so we can advance beyond injury.
Pt is uncons, but breathing spontaneously, but makes noise/gurgles when he
breaths. So indication for airway. Also trauma pt who is uncons needs airway
even if he is breathing spontaneously.
Pt unable to move ext, then became unconscious. First thing we do is take
care of airway, but we know he has cervical spine injury so we cant
hyperextend neck. Use fiberobtic through endotracheal tube.
Patient alert, with facial fractures drowing in his own blood normal
anatomic pathways not available, so we go through the neck. Do
cricothyroidotomy, or percutaneous tracheostomy.
Breathing
Trauma Patient in shock
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Is chest involved?
o If chest is not involved, then we know the patient is in schock because
he is bleeding
When Chest is involved
o Are neck veins distended, or CVP high?
No = patient is bleeding
Yes = either pericardial tamponade or pneumothorax
Is it hard to breathe?
o YES = pneumothorax
o NO = pericardial tamponade
Must stop bleeding and replace bleeding
o If patient is in ER, and we know where he is bleeding, then stop the
bleeding first.
Pt in shock, shot in abdomen - near emerg surg center, take him to OR for
laparotomy
If you see the bleeding, stop it with direct pressure, and start IV fluids.
MVA spont breathing, JVD not distended, hypotensive.
o We know shock is from bleeding
o Patient gets intubated.
o If we dont know where he is bleeding from, first start fluid
resuscitation. 2-3 large iv bores.
If you think its pericardial tamponade but not sure, do ultrasound.
o Treatment for pericardial tamponade
Pericardiocentesis, tube or window, or mediostenotomy.
Head Trauma
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Neck Trauma
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Gunshot wounds:
o Patient has wound to neck, spitting/coughing blood, expanding
hematoma near area of thyroid cartilage.
o Indications for surgical exploration
Gunshots wounds between mandible and above cricoid cartilage
(middle of neck)
Spitting/coughing blood means injury to larynx/pharynx
Expanding hematoma
o Exceptions
Patient with gunshot wound above the mandible
Needs angiogram/angiographic assessment of vascular
tree and embolization
Patient with gunshot above clavicle but below cricoid
Angiogram, esophagogram, bronchoscopy
Blunt trauma to neck
o Stable, lacerations to face, tenderness in posterior neck midline
Think cervical spine/spinal cord injury
If theres pain, even if neuro is normal we need CT scan
Hemisection
o Loss of pain/temp on one side, paralysis and loss of vibration/propiro
on the other distal to lesion
Anterior cord syndrome (anterior spinal artery)
o Loss of pain/temp, paralysis on both sides, and preservation of
vibratory/position. (dcml posterior)
Central cord syndrome
o Hyperextension of neck
o Upper extremity issues but lower ext spared.
Need to do MRI for any of these
Steroids as soon as diagnosis made
Chest Trauma
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Blunt trauma and penetrating is the same in chest due to broken ribs that
leads to penetration
Rib fracture Rx topical anesthetic so they can breath normal
Tension pneumo dont do CXR, normal pneumo do XRAy, then chest tube in
upper part of chest
Hemothorax bleeding usually stops on its own, have to get rid of blood
with chest tube in bottom part of chest
o Once we see drain only drains a little bit we know were doing good and
bleeding has stopped
o In the case that drain recovers a ton of bleeding, that means systemic
vessel usually intercostal, means bleeding not stopping, so we need
surgical intervention thoracotomy.
Flail chest chest tubes, diuretics, fluid restriction. Follow with CXR and EKG
she might have contusions lung/heart also in cases of deceleration injuries.
o May even eventually lead to aortic dissection (slowly)
o If CXR shows wide mediastinum do spiral CT if they match, do surgery.
If they dont match then we do arteriogram
Diaphgragmatic rupture
o Bowel sounds in chest, multiple air levels in chest, more common in
left.
o Gastric tube goes up into chest
Thoracic subcutaneous emphesyma
Caused by:
Transection of esophagus during endoscopy
Tension pneumothorax (patient will be in shock)
Transactional injury to trachea need to do fiberoptic
bronchoscopy to see injury and for intubation
Abdominal Trauma
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Blunt trauma:
o Anyone with acute abdomen/signs of peritoneal irritation needs
exploratory laparotomy
Bleeding or not
o Anyone in bleeding dont know where (low cvp.)
Cant be head, not enough room
If neck not distended like crazy not bleeding in neck
Do CXR (normal), means they arent bleeding in the chest
Pelvic fracture check by pelvic exam
Femur fracture check by pelvic exam
Abdomen if none of the other places bleeding, bleeding most
be in abdomen. We dont do exploratory laparotomy unless were
sure.
Do CT scan first (if they are hemodynamically stable)
If not stable focus abdominal ultrasound/diagnostic
peritoneal lavage
o If high cvp think pericardial tamponade
Pelvic Fractures
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o
o
o
o
o
o
Extremity fractures
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Crush injury
o Check potassium, myoglobin in urine, also compartment syndrome
may happen
Burns
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Disorders of Children
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Tumors in children
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osteogenic sarcoma (MC tumor) sunburst pattern, 2-3 months of bone pain
2nd most common large fuisiform tumor/onion skin ewing sarcoma (in
diaphysis of bones)
Pre-Op assesment
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Post Op Complications
Malignant hyperthermia
o Oxygen, fluids, cool person down, dantrolene, alkalinize urine to
prevent myoglobuniria
Post op fever
o 1. Wind - day 1 -- atelectasis
o 2. Water - day 3 - UTI
o 3. Walking day 5 DVT
Blood gasses that we see after PE = hypoxemia with hypocapnia
(low po2 and low pc02) in pulmonary failure we see low po2 and
high pco2. Do spiral CT scan of chest.
o 4. Wound day 7 wound infection
o 5. Wonder - day 10 drugs, deep abscess, what did we do
Get a ct scan if fever on day 10
o MIs happen either during operation or after 1-2 days.
If patient has alarming chest pain think of either MI or PE
depends on timing. Before day 5 its MI
Post surgery patient cant get clot busters, can give anticoag
(heparin) but not thrombolytics
Changes in ekg are first changes seen in post op or during
operation for an MI
o Aspiration of gastric contants do bronchoscopy to wash out and
remove particles
Steroids not helpful after the fact
Post op disorientation
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Abdominal distention
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Paralytic ileus
o occurs in the first few days post op.
o Abdominal distention, no passing gas, absent bowel sounds
o Prolonged by hypokalemia
Early SBO mechanical
o Due to adhesions
o Usually after paralytic ileus not resolving after 5-6 days
o Xray
Dilated loops of SB, and air fluid levels
Confirmed with CT scan shows transiotion point b/w proximal
dilated and distal collapsed bowel at site of obstruction
o Need surgery
Hypernatremia
o Lost water (or hypotonic fluids), became hypertonic.
o Every 3 meq/L that serum sodium is above 140, means 1L of water lost
o Tx: D5 1/2NS
If hypernatremia happens fast, and produces CNS sx, can correct
quicker with D5W or D51/3 NS
Hyponatremia
o Water has been retained.
1. Patient starts with normal fluid volume, and retains water due
to ADH
Correction via fluid restriction
2. Patient is losing lots of isotonic fluids (usually from GI), forced
to retain water if he has not had enough fluid replacement
Restore volume with isotonic fluids NS or LR.
o If it occurs quickly, have to fix with 3% or 5% NS
o If it occurs slowly (from SIADH), correction is via fluid restriction
Hypokalemia
o Happens slowly due to K+ lost from the GI or in urine
o Can happen quickly when K+ moves into the cells (seen when DKA is
corrected)
o Rx: K+ replacement IV no more than 10 meq/h
Hyperkalemia
o Happens slowly when kidney cant excrete K+ (kidney failure or
aldosterone antagonists)
o Rapidly if K+ is being dumped from the cells (crush injuries or dead
tissue/acidosis)
Rx: hemodyliasis is ultimate treatment
Before that use 50% dextrose and insulin to push K+ into
cells
Can also do NG suction
IV calcium (fastest correction)
Diseases of Gi System
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Esophagus
o GER
If Dx is uncertain, do pH monitoring with correlation to sx.
In long standing GERD, do endoscopy and bx to check for
barretts esophagus
If long standing, cant be controlled with PPI/meds, then we do
surgery.
Imperative if ulcers/stenosis/ or if there are severe
dysplastic changes
o In dysplastic changes resection is needed,
otherwise do laparascopic nissen fundoplication
o Cancer
Progression of dysphagia
Weight loss always seen
Sq Cell Ca, in smokers.
Adenocarcinoma in long standing GERD
Dx: endoscopy and bx, first do barium swallow before endoscopy
to prevent perforation
CT scan assess operability
Tx: usually palliative surgery
o Mallory weis tear
After prolonged foreceful vomiting
Bright red blood comes up.
Endoscopy establishes the Dx
Tx: photocoagulation
o Boerhaave syndrome
Prolonged, forceful vomiting leads to esophageal perforation
Continuous, severe, wrenching epigastric and low sternal pain
that is sudden
Fever, leukocytosis, SICK pt.
Dx: Contrast swallow (gastrografin/water soluble first, and then
barium if gastrografin is negative)
Tx: need emergency surgical repair
Stomach
o Gastric adenocarcinoma
Seen in elderly. Anorexia, weight loss, and vague epigastric
distress
Dx: endoscopy and bx. CT can help.
Tx: surgery is best tx
o Gastric lymphoma
Similar to gastric adenomcarcinoma
Tx: based on chemo or radioation. Surgery is done if possibility
of perforation as tumor cells die.
MALTOMA can be reversed by eradication of H. pylori.
Small bowel
o Mechianical obstruction
Due to adhesions.
Colicky ab pain, protrated vomiting, progressive distention, no
passage of gas/feces.
First will have high pitched bowel sounds.
Xray
Distended loops of SB, air fluid levels
TX:
NPO, NG suction, IV fluids
Surgery is done if conservative mgmt. fails w.in 24 hrs if
complete, a few days if partial.
o Strangulated obstruction
GI bleeding
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MC from upper gi which is from nose to ligament of treitz. Only 25% are from
colon or rectum, and minority occur in jej or ileum.
o GI bleeding from colon is due to angiodusplasia, polyps, diverticulosis
or cancer
o When young person has GI bleed most commonly its from upper GI or
hemmorhoids if present
o In old person it could be from anywhere
Vomiting blood
o Bleed from upper GI. Same if its blood recovered by NG tube in a
patient who has rectal bleeding (upper gi again)
Then we do GI endoscopy. Check mouth and nose first
Melena
o Indicates digested blood and usually upper GI.
o Start with upper GI endoscopy
RBPR
o Can be from anywhere in GI
o First if patient is actively bleeding pass NG tube and aspirate gastric
contents
If there is blood it must be upper GI bleed
If no blood is retrieved (fluid is white/no bile, then theres no
bleeding from nose to pylorus.
Then follow with upper GI
If no blood retrieved and fluid is green (bile) then entire upper GI
is excluded.
o If there is still active bleeding and weve exluded upper GI
Check hemorrhoids (anoscopy) first
Colonoscopy not helpful during heavy active bleeding
If heavy bleeding do angiogram
If small bleeding do tagged red cell study.
Tagged blood will pool somewhere, then we can do
angiogram.
o Patients with recent hx of bleeding with no active
In young pts start with endoscopy
In older do both endoscopy and colonscopy
In child think meckels, start with technetium scan (for ectopic
gastric mucosa)
Acute Abdomen
Perforation
o Sudden onste, constant, generalized, severe.
o Signs of peritoneal irritation (tenderness, guarding, rebound)
o Free air under diagphragm in upright xray confirms
o EMERGENT SURGERY
Obstruction
o Could be due to duct obstruction ureter, cystic, or common duct
o Onset of colicky pain
o Patient moves constantly to find comfort
Ischemic process
o Combines severe ab pain with blood in the lumen of gut
Primary peritonitis
o Suspect in child with nephrosis and ascites or adult with ascites who
has mild generalized acute abdomen
Will also have fever, wbc. Cultures of ascetic fild yield single
organism.
o Tx: antibiotics (NOT SURGERY)
Generalized acute abdomen
o Tx is exploratory laparotomy if its not primary peritonitis
o Rule out things that mimic acute abdomen first MI (ecg), lower lobe
pneu (cxr), PE, or things that dont require surgery (pancreatitis)
Acute pancreatitis
o In alcoholic with upper acute abdomen
o Rapid onset of inflammatory process, pain is constant, epigastric,
radiates to back, n/v/retching.
o Dx: serum/urinary amylase, lipase.
CT if dx not clear.
o Tx: npo, ngt, iv fluids.
Biliary tract dz
o Fat women, forties, five children, right upper quadrant ab pain.
Acute diveriticulitis
o Acute ab pain in LLQ. Middle age or older
o Fever, wbc, physical findings of peritoneal irritation in LLQ.
o Dx: CT scan is dianogstic
o TX: npo, iv, antibiotics.
Most cool down, if they do not, will require emergent surgery.
Radiologically guided percutaneous draingge of abscess may
precede resection.
Elective surgery for those who have had at least >2 attacks
Volvulus of sigmoid
o In old people. Signs of intestinal obstruction, severe ab distention
o Dx: XRAY is diagnostic
Shows airfluid levels in small bowe, distdend colon, huge air
filled loop in RUQ that tapers down toward LQ parrots beak.
o Tx: proctosigmoidscopic exam resolves acute problem. Rectal tube is
left in
Recurrent cases need elective sigmoid resection
Mesenteric ischemia
o
o
Hepatobiliary
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The liver
o Primary hepatoma
Only in people with cirrhosis
Develop vague RUQ pain, weight loss.
Marker = alpha-fetoprotein.
CT scan will show location/extent
Resection if possible
o Met to liver
More common than primary.
Found by CT while treating primary, or if CEA rising in those with
colon cancer
If met is confined to one lobe, and slow growing can do lobe
resection.
o Hepaticadenomas
Complication of OCP. Tendency to rupture and bleed massively in
abdomen
CT is dx, and emergent surgery needed
o Pyogenic liver abscess
Complication of biliary tract dz, esp acute ascending cholangitis.
Fever, wbc, tender liver
Dx: CT scan.
Tx: Percutaneous drainage.
o Amebic abscess
MEXICO
Similar to pyogenic
Tx: metronidazole
Can begin empiric tx in those clinically suspected, if they
improve its continued, if it does not improve then
drainage is done.
Jaundice
o Hemolytic Jaundice
Unconjugated (indirect) only. No bile in urine.
Workup to determine what is killing RBCs
o Hepatocellular jaundice
Elevation of both bilis.
High LFTs, and small increase in Alk P
MC hepatitis
Do serologies to determine cause of hepatitis first
Obstructive jaundice
Elevations of both, increase in LFTs, very high Alk P.
First U/S for dilatation of biliary ducts
If caused by stones (the stone obstructing the duct is not usually
seen) but stones are seen in GB
In malignant obstruction
Large, thin walled, distended gb is seen (Courvoisier
terrier sign)
o Obstructive jaundice by stones
Fat Female Forty fertile
High alk phosph, dilated cuts on u/s, non dilated GB full of
stones.
Do ERCP to confirm dx, do sphincterotomy to remove CBD stone
Follow with cholecystectomy
o Obs jaundice by tumor
Usually adenocarcinoma of head of pancreas, adenocarcinoma
of ampulla of vater or cholangiocarcinoma from CBD itself.
If suspected tumor on U/S then do CT scan.
Follow with percutaneous bx
If CT is negative
Then do ERCP (ampulla cancers cause obstruction when
they are small and not seen on CT, but can be seen on
ERCP, and cholangiogram will show intrinscit tumors from
the duct or any pancreatic tumors not seen in CT.
Gallbladder
o Asymptomatic Gallstones are left alone
o Biliary colic
When stone temp occludes cystic duct
Colicky pain in RUQ, rads to R shoulder, and beltlike to the back.
Triggered by ingestion of fatty food + N/V
NO signs of peritoneal irritation or systemic signs.
Self limited - 10-30 min
Dx:
U/S establishes dx of gallstones and elective
cholecystectomy is indicated
o Acute cholecystitis
Starts as biliary colic but stone stays in cystic duct and then
inflamm obstructs GB.
Pain is constant, fever, WBC, with signs of peritoneal irritation in
RUQ.
Dx:
U/S (gallstones, thick walled gb, pericholecystic fluid
Tx:
NG suction, NPO, IV, antibiotics cool down most cases
then do elective cholecystectomy.
If they do not respond/cant cool down, then we need to
do emergent cholecystectomy.
o
Breast
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Endocrine System
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Thyroid
o Thyroid nodules
In euthyroid pts think of cancer.
Dx: FNA
If benign do notintervene
If malignant or indeterminate must do thyroid lobectomy.
Total thyroidectomy should be done in follicular cancers
In hyperthyroid patients
Almost never cancer but might reason for hyperthyroid
Do labs TSH (low), T4 (high)
Nuclear scan will show if nodule is the source
Treated with radioactive iodine or if they have a hot
adenoma can be treated with surgical excision of affected
lobe
Hyperparathyroidism
o Usually due to finding high calcium in labs
o Repeact calcium and check for low phosphorus and rule out bone
cancer (mets)
o If findings persist do PTH determination
o Elective intervention is justified even if asymptomatic
90% have single adenoma removal is curative.
Cushing
o Hairy face, buffalo hump, obesity, stria, thin weak extremeties.
Osteoporosis, DM, HTN, mental instability.
o Dx:
Start with overnight low dose dexamethasone supprestion
(suppression at low levels rules out disease)
Surgical Hypertension
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Primary hyperaldosternoism
o Can be due to adenoma or hyperplasia
o Findings: hypokalemia in a hypertensive pt not on diuretics
Hypernatremia, metabolic alkalosis.
High aldo, and low levels of renin
If appropriate response to postural changes (increase in aldo
when standing) suggest hyperplasia
If no response then its an adenoma
Adrenal CT scan localizes, and then do surgical removal
Pheochromocytoma
o Thin, hyperactive women, attacks of headache, perspiration,
palpitations, pallor
o When pts are seen attack has subsided and pressure might be normal
o Start with 24 hour urinary vanillulmandelic acid (VMA), metanephrines
or free urinary catecholamines
o Follow with CT of adrenal glands/readionuclide studies for extaadrenal
sites
o Surgery requires prep with alpha blockers
Coarctation of aorta
o Seen in MC in young pts, HTN in arms, normal pressure/low pressure in
legs.
o CXR scalloping of ribs
o Spiral CT can with IV dye (CTA) is diagnostic
o Surgical correction is curative
Renovascular HTN
o 2 groups, both are resistant to usual medications, have faint bruit over
fnlank or upper abdomen
o DX: Duplex scan of renal vessels and CTA
o 1. Young women with fibromuscular dysplasia
TX: balloon dilatation and stending
o 2. Old men with arteriosclerotic occlusive disease
Tx is controversial due systemic disease from atherosclerosis
Esophageal atresia
o Shows up shortly after birth when first feeding is attempted.
o NG tube is passed, will coil up in upper chest on xrays.
Necrotizing enterocolitis
o In premature infants when they are first fed
o Feeding intolerance, ab distention, rapidly dropping platelet count
o Tx: stop feeding, broad spectrum antibioitics, iv fluids and nutrition
Need surgery if they develop:
abdominal wall erythema,
air in the portal vein,
intesintal pneumatosis
pneumoperitononeum
Meconium Ileus
o Babies who have cystic fibrosis (mother might have it also)
o Develop feeding intolerance, bilious vomiting
o Xray shows multiple dilated loops of bowel and ground glass
appearance
o Dx: Gastrografin enema is diagnostic and therapeutic
Hypertrophic pyloric stenosis
o Nonbilious projectile vomiting after each feed. Baby is hungry and
wants to eat
o Palpable olive size mass in ruq
o If no mass, do u/s
o Tx:
Rehydrate and correct alkalosis
Then ramstedt pyloromyotomy or balloon dilatation.
Biliary atresia
o 6-8 week old babies with persistent increasing jaundice
o Do serologies and sweat test then do HIDA scan
Later in infancy
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Intussuception
o In 6-12 month olds colicky ab pain
o Lasts 1 min and then kid goes back to normal until another episode
o Mass on right side, empty RLQ, current jelly stools
o Tx: barium or air enema diagnostic and therapeutic
Meckel diveriticulum
o Lower gi bleed in kids.
o Do radioisotope scan for gastric mucosa
Ophthalmology Children
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Amblyopia
o Vision impairment due to interference with the processing of images by
brain during first 6 to 7 years of life.
o Seen in child with strabismus.
if its not corrected early on there will be permanent cortical
blindness (even though eye is perfectly normal)
Strabismus
o Dx: reflection from a light comes from different areas of the cornea in
each eye
Should be surgically corrected at dx to prevent amblyopia
o If it develops later in infancy we will see an exaggerated convergence
Then use corrective glasses
o True strabismus does not resolve on its own
White pupil in a baby
o Is an emergency might be due to retinoblastoma or congenitall
cataract
o Should be attended to to prevent amblyopia
Opth in adults
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Glaucoma
o Acute angle
Severe eye pain or frontal headache starting in the evenining
or when pupils have been dilated for a while
Pt may report halos around lights
Pupil is mid=dilated and does not react to light
Neurosurgery
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TIA
o Sudden, transitory loss of neurologic function
o Usually due to high grade stenosis of the internal carotid
o Predictors of stroke, need elective carotid endarterectomy
Ischemic stroke
o Sudden onset without headache
o Neurologic deficits present for more than 24 hours
o Assessment by CT scan and therapy for rehab
o Can treat with t-pa if used with 90 min to 3 hours (up to 6 hours?)
First do CT scan to rule out exntesive infarcts or hemorrhage.
Organ transplant
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Hyperacute rejection