Kaplan Surgery

Intial survey - Airway

-

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
-

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
-

Penetrating injury to skull, must go to OR. Foreign body should be removed in

OR
Linear fracture can be fixed in ER, comminuted must be fixed in OR
Pt was unconscious at site of accident, but awake in ER and he is acting
normal/neuro exam normal, still needs CT of head. Any pt with lucid interval
needs CT of head
Signs of skull fracture at base
o Racoon eyes
o Fluid dripping from ear, or nose
o This means theres big trauma, might have cervical/spincal cord injury
o Needs ct of head and neck.
Pt trauma to head, loses conscious, lucid interval, goes unconscious again,
now patient has dilated fixed pupil
o Acute epidural or acute subdural hematoma
Lens shapped hematoma on ct
Epidural if completely normal
o Subdural is bigger trauma and usually sicker
Crescent shaped hematoma/semilunar.
If patient has subdural on ct and small, and no focal neuro signs,
then observe in hospital, check ICP if elevated treat medically
diuretics, mannitol, hyperventilation to decrease icp. Can
reduce o2 demand or brain also by sedation or hypothermia.
Patient with signs of alzheimers within weeks, patient has chronic subdural
hematoma.
o Ct scan, evacuate hematoma.

Neck Trauma
-

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

Surgical exploration of neck

o Vital signs are deterioration
o Expanding hematoma
o Spitting/vomiting blood
o Gunshot wounds to middle zone of neck
If above angle of mandible
Arteriographic dx and tx
If below cricoid cartilage
Arteriogram, esophagram, esophagoscopy, bronchoscopy

Spinal cord injuries

-

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
-

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
-

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
-

If patient is hemodynamically stable

o In women in pelvic fracture: need proctosigmoidscopy exam, pelvic
exam (to check for injury to vagina), and retrograde cystogram.
o In men: in men we have to check injury to rectum and urethra
(retrograde urethrogram first) before we rule out bladder damage
(then do retrograde cystogram)
Case where woman is bleeding to death into pelvis (shock not responding to
fluids)
o Check that patient is nto bleeding into abdomen FAST or DPL
o Surgery not best answer
o Usually bleeding from venous plexus so arteriograms are no good
o Best thing to do is XFIX
Blood in urine
o In case of blunt trauma need to know about associated bony injuries
o 1. Shot point blank above pubis blood in urine bladder injury
Need surgical exploration
o 2. Blunt trauma Multiple injuries including pelvic flacture, then blood
in urine
If rib fracture its kidney
If not evaluate urethra then evaluate bladder

o
o

o
o

o
o

3. Pelvic fracture, blood in meautus, wants to urinate cant, high riding

prostate
Urethral injury do regrograde urethragram
4. Male with pelvic fracture, but no blood, and urethral catheter wont
go stop there is injury to urethra
5. In bladder cystogram need 2 pics full and empty (if injury is at
trigone wont see injury when bladder is full, need to take pics with
bladder empty to see extravasation in trigone)
6. Blunt trauma, blood in urine, rib fracture kidney injury do CT
scan, dont usually need surgery but CT scan will tell you
7. Pt mva, rib fracture, abdominal contusion, hematuria. Ct scan shows
renal injuries dont need surgery. Then 6 weeks later develops SOB,
and flank bruit.
Renal artery and vein have formed AV fistula leads to CHF
Can also have pt develop hypertension months later and that
would be due to Renal artery stenosis
8. In child with small trauma and hematuria might mean congenital
anomaly, need urological eval, with u/s
9. Child with injury to pelvis, no blood in urine or meatus, but has
swollen scrotum
Do u/s, might tell us about testicular rupture
10. Large penile shaft hematoma
If penis was erect fracture history important (pt might lie)
Need emergent repair

Extremity fractures
-

Bullet wound in anterolateral thigh, wound embedded.

o No need for further evaluation. Clean, tetanus, thats it no major
arteries
Bullet in anteromedial
o Normal pulses, no hematoma
o This is anatomical proximity, and needs to be evaluated.
Do Doppler studies for integrity of vessels
Bullet anteriomedial thigh, except posterial lateral, with large expanding
hematoma
o Eveidence of arterial injury (could also be lack of pulses)
o Need surgical exploration for dx,tx.
Patient has bullet wound in arm
o Has hematoma, nerve damage, bony damage
o Stabilize bone, fix artery, then do nerve repair.
This can lead to comportantment syndrome due to delay of
arterial fix and then reperfusion, may need fasciotomy
In low velocity bullet wounds damage is just trajectory of bullet
High velocity (high power rifles) big exit wound damage is beyond
trajectory
o Need extensive debriment, and amputation due to extensive damage
to tissues

Crush injury
o Check potassium, myoglobin in urine, also compartment syndrome
may happen

Burns
-

Max is 50%, if burn greater than 50% use 50 anyways

Head is 9%, arms are 9% total each (4.5 each side), legs are 9% on each
surface and thorax is 18% on each side
o Formula kg * percent * 4
o Half in first 8 hrs, 2nd hal fin the last 16 hrs
o Add 2L of D5W
o 2nd day get half as much, third day should be fine and will see massive
diuresis
o Other thing people are doing 1 L/hr and adjust based on urinary output

Disorders of Children
-

Developmental dysplasia of hip/congenital dislocation of hip

o Uneven gluteal folds, one hip dislocated with jerk and click.
o Do ultrasound
o Treat with abduction splinting, pavlik harness
Leg perves disease/avascular necrosis of capital fermur epiphysis
o 8 year old, knee pain, limping, gait issues, guarded motion
Could be knee or hip pain in children with hip pathology
o Dx with xray
o Tx unclear
Slipped capital femoral epiphysis
o 13 year old obese, pain In groin, limping, sole of foot pointing to other
foot. Hip cant be rotated internally
o Orthopedic emergency/surgical emergency
Septic hip
o Toddler has had flu (febrile illness), walking around fine, now refuses ot
move leg
o Slight abduction and external rotation
o Cant move it
o txL aspirate and drain (emergency)
acute hematogneous osteomyeleitis
o febrile illness, no trauma, persistent pain in bone
o do bone scan since xray wont show anything yet
o treat with antibiotics
bow leg (genu varum)
o normal until 3
genu valgum (knocked knee)
o normal until 8
Osteochondrosis of tibial tubercle (osgoode schlatter)
o 14 year old injured knee, pain over tibial tubercle, no swelling
o if theres no swelling of knee theres nothing wrong with knee in
o immobilization ofknee for 6 weeks in cast
club foot (palathesic genuvarus)

baby born with both feet turned inward

plantar flexion ankle, eversion of foot, adduction of forefoot and
internal rotation of tibia
o child would be walking on his toes on the top of foot
o treated with serial casts, fixing deformities from distal to proximal
before age of 1 or 2
supracondylar fracture of humerus
o can lead to vascular compromise of forarm
o have to keep checking pulses/Doppler studies
o
o

Tumors in children
-

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)

Adult ortho injuries

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Anterior dislocation of shoulder

o Hold arm near body, externally rotated
o Damage to axillary nerve
Posterior dislocation
o Happens when there is uncoordinated contractions (electrical burns,
seizures)
o Xray wont show it
o Holds arm normal position across body

Pre-Op assesment
-

Cant do surgery if EF < 0.35

Goldmans criteria
o Age, bed ridden, emergency operation, enter body cavity, MI recently,
arrhythmia, CHF.
JVD in a non trauma patient means CHF operation is very
high risk.
First getting him out of CHF then do surgery (bblocks,
diuretics etc)
Wait 6 months after MI.
Can sometimes do revascularization first in patients with
unstable angina before doing other surgeries
Patient with lung disease first check PFT esp FEV1 (if
abnormal) then check PCO2. If abnormal ask patient to quit
something for 8 weeks, improve fev1 and pco2 medically until
FEV1 improves then surgery.
If liver diseae/liver failure CI to do surgery
Also need to check nutritional deficiency if severely
malnourished can do hyper alim for 5 days or so and should be
enough. (intensive nutritional support delivered to GI tract)

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
-

If nothing is wrong, but patient is confused do blood gases lack of o2 to

brain
ARDS
o Patient has already been very sick
o Low Po2 with lots of oxygen
o Patchy infiltrates
o Tx: PEEP, dont use high volume, check for other signs of
infection/sepsis

Abdominal distention
-

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

Fluid and electrolytes

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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.

Mid and lower GI

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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

Starts as mechanical obstruction, then patient gets septic (fever,

wbc, pain, peritoneal irritation, sepsis etc)
EMERGENCY SURGERY
Carcinoid syndrome
Small bowel carcinoid tumor with liver mets
Flushing of face, diarrhea, wheezing, RH valve damage (JVD)
24 hours urine for 5Hydroxyindolacetic acid (5HIAA)

GI bleeding
-

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

In old. Develop acute abdomen in person with afib or recent MI

Dx is late because old people dont have impressive acute abs
(minimal sx)
Source is usually clot that breaks off and lodges in the SMA
Usually dx is late when there is blood in lumen and acidosis
sepsis has developed.
In early cases arteriogram and embolectomy save the day

Hepatobiliary
-

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

If pt is very sick might need to do percutaneous

transhepatic cholecystostomy temporarily.
o Ascending cholangitis
Stones reached common duct producting partial obstruction
and ascending infection
Much sicker temp 104-105, chils, high WBC, SEPSIS
VERY HIGH ALK PHOSPH
TX:
IV antibiotics, emergency decompression of common duct
by ERCP or percutaneous through liver (PTC)
Then must do cholecystectomy
o Biliary pancreatitis
When stones become impacted distally in the ampulla
Obstructing both pancreatic and biliary ducts.
Stones pass spontaneously, get mild and transitory episode of
cholangitis
Get manifestations of pancreatitis (elevated amylase/lipase.)
u/s shows gallstones in gb
TX:
Npo, ng, iv fluids. Followed by cholecystectomy
May need ercp and sphncterotomy to dislodge stone
Pancreas
o Acute pancreatitis
Complication of gallstones, or alcoholics.
o Acute edematous pancreatitis
In alcohlic or pt with gallstones.
Epigastric midab pain starts after heavy meal or heavy drinking
Constant, radiates to the back, N/V, and continued retching after
stomach is empty
Elevated amylase/lipase diagnostic.
Key finding to establish edematous nature is elevated
hematocrit.
Tx:
Pancreatic rest
Npo, ng, iv fluids
o Acute hemorrhagic pancreatitis
Begins edematous, but low hematocrit.
WbC, increased blood glucose, and low serum calcium.
Next morning hematocrit is evne lower, serum calcium stays low
even with replacement, BUN increases and we have metabolic
acidosis develop.
May die, due to multiple pancreatic abscesses and bleeding.
Daily CT scans and drain abscess
Tx: IV imipenem if signs of infection
o Pancreatic abscess
Some one not getting CT scanned, and has persistent fever,
WBC about 10 days after pancreatitis.

Imaging will then reveal collections of pus

Have to drain percutaneous and tx with imipenem/meropemen.
Psuedocyst
Late sequel of acute pancreatitis or abdominal trauma
5 weeks after initial problem.
Collection of pancreatic juice outside pancreatic duct and
pressure sx.
DX:
CT or U/S
Tx:
If 6 cm or smaller or present for les sthan 6 weeks can be
observed
If larger than 6 cm or older than 6 weeks they might
rupture/bleed
o Treat with drainage of cyst percutanously or
endoscopic
Chronic pancreatitis
Repeated episodes of pancreatitis (usually alcoholic)
Develop calcified pancreas
Leads to steatorrhea, diabtes, constant epigastric pain.
Tx:
Insulin, pancreatic enzymes
Pain is resistant
ERCP may help

Breast
-

Mammography started at age 40

Earlier if FHx, but not before age 20
Fibroadenomas
o Seen in young women, firm, rubbery mass, moves easily.
o Dx:
Either FNA or sonogram
o Removal is optional if symptomatic
Giant juvenile fibroadenomas
o In young adolescents.
o Rapid growth, need to remove to avoid deformity
CYstosarcoma phyllodes
o In late 20s, grow over many years, become large and can distort
breast.
o Benign but can become malignant sarcomas.
o CNB or incisional bx is needed (FNA not enough)
o MUST REMOVE
Fibrocystic changes, cystic mastitis
o 30s-40s. goes away with menopause
o Bilateraly tenderness related to menstrual cycle. Multiple lumps that
come and go.

Mammogram is theonly thing needed if no persistant or dominant

mass
If theres a mass need to do aspiration
If fluid is clear and mass goes away, thats it
If mass persists or recurs need bx,
If bloody fluid, must send to cytology
Intraductal papilloma
o In young women (30s) bloody nipple discharge
o Need to do mammogram, but papillomas will not show up too small.
o Galactogram may guide resection
Infiltrating ductal carcinoma
o MC breast cancer.
DCIS
o Cannot metastazie (no axillary sampling needed) but high incidence of
recurrence.
o Need only local excision
o If many lesions can do total simple mastectomy
o

Endocrine System
-

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)

If theres no suppression do 24 hour urine-free cortisol. If

elevated due high dose suppression
Suppresion at high doses means its pituitary adenoma
No suppression at high doses means adrenal adenoma or
paraneoplastic syndrome (ectopic acth)
Then do imaging studies (MRI for pit, CT scan for adrenal)
Tx: removal of tumor

Surgical Hypertension
-

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

Pediatric First 24 hours

-

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.

MC I sblind pouch in the upper esophagus and a fistula beween LE and

tracheobronchial tree.
o Check for VACTER
o Tx: Surgical repair, if it needs to be delayed do gastrostomy to protect
lungs from acid
Imperforate anus
o Noted on physical exam, part of VACTER anomlies
o If no fistula present need to do colostomy if its a high pouch. If pouch
close to anus can do primary repair right away.
Double bubble and green vomit
o Large air fluid level in the stomach, and a smaller one to its right in
first part of duodenum
Duodenal atresia, annular pancreas or malrotation
Malrotation is emergency
Dx with contrast enema or upper GI.
Intestinal atresia
o Shows up with green vomit
o NEGATIVE double bubble but has multiple air fluid levels in abdomen
o

Few days old to 2 months old

-

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

If HIDA scan shows up everywhere in biliary tree then its not

biliary atresia, but if dye is stuck in liver then he does have it
o Will need surgery and maybe liver transplant
Hirschsprung dz (aganglionic megacolon
o Chronic constipation
o Rectal exam may lead to explosive expulsion of stool and flatus and
relief of abdominal distention
o Xrays show distended proximal colon (normal) and normal-looking
distal colon (aganglionic part)
o Dx: full thickness bx of rectal mucosa

Later in infancy
-

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
-

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
-

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

Cornea is cloudy with greenish hue

Eye feels hard as a rock
Tx:
Emergency drill hole in iris with laser to provide route for
drainage
Can also administer carbonic anhydrase inhibitors
(Diamox) and topical beta blockers or alpha-2-agonist
Mannitol or pilocarpine can also be used
Orbital cellulitis
o Emergency
o Eyelids are hot, tender, red, pt is febrile.
o Key finding: eyelids are rpied open and pupil is dilated and fixed with
limited motion
Pus in orbit
o Dx: emergency CT and drainage
Chemical burns
o Require massive irrigation
o After prying it open and washing for an hour transports to ER.
o Continue irrigation with saline, corrosive particles are removed before
patient is sent home and pH is tested to make sure its all gone
Retinal detachment
o Emegerncy
o Pt reports seeing flashes or having floaters in the eye (more floaters,
means its worse)
o Tx with laser spot welding to protect remaining retina
Embolic occlusion of retinal a.
o Emegerncy but not much can be done
o Old patient, sudden loss of vision in ONE eye. After 30 min damage is
IRREversible
o Get patient to breathe into paper bag, someone press hard on eye and
release
Vasodilate and shake the clot to more distal location

Neurosurgery
-

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
-

Hyperacute rejection

Vascular thrombosis that occurs within minutes due to preformed

anitbioties.
Prevented by ABO matching and lymphocytotoxic cross motch
Not seen clinically
Acute rejection
o After the first 5 days, within 3 months
o Occur even if pt is on immunosuppression
o Dx:
Signs of organ dysfunction
Confirmed with bx
o In case of liver
First rule out biliary obstruction by u/s and vascular thrombosis
by Doppler.
o Tx:
First line therapy is bolus of steroids
If that doesnt work can use anti-lymphocyte agents but are very
toxic
Chronic rejection
o Seen months to years after transplant
o Gradual loss of function
o Irreversible
o
o