Surgery Shelf

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What are the rules with stopping meds before surgery?: anti HTN meds continue preoperative except diuretics and ACE inhibitors
Hold aspirin for 10 days
hold insulin on day of surgery
hold NSAIDS and COX-2s
When should one stop smoking before surgery?: 8 wks
What is the ASA guide to surgical patients?: P1- normal healthy
P2- mild systemic disease
P3- severe systemic disease
P4- severe systemic disease that is a constant threat to life
P5- moribund pt who won't survive w/o operation
P6- brain-dead- donor
E- emergency
What labs and steps must be done to assess health?: consent
CBC, CHEM 7 w/ LFTS, Coags
Type and cross
ECG
Chest X-ray
UA
When is an echo needed to evaluate a surgery pt?: if ejection fraction is < 35%
Who is at high risk of of cardiac probs in surgery?: history or ECG evidence of MI, angina, angio-documenteed CAD, prior CABG
Who is at intermediate risk of cardiac probs in surgery?: noncoronary atherosclerosis
who is at low risk of cardiac issues in surgery?: no clinical atherosclerosis, but high risk factors
What is the role of the following cardiac problems in surgery evaluation: CHF MI/ CAD HTN Valvular disease Arrhythmia: CHF- risk of pulm edema. pneumonia
MI/CAD- mortality risk 3x higher. 25%
HTN- >160/110- risk of hypotension, neurologic probs, MI, renal failure
Valvular- only aortic disease > 1 cm2; MVP- needs prophylaxis- ampicillin/gentamicin 30 min before incision; amoxicillin or 2nd dose at 6 hrs.
Arrythmia- 18% mortalitiy risk. SVT, afib, aflutter more dangerous
What are the risk factors for pulmonary complications during surgery?: Known pulmonary disease
abnl PFTs- FEV < 11, max breathing capacity < 50% predicted, smoking, age > 60, Obesity, Upper abdominal or thoracic surgery, long OR time
What should be done preop to evaluate lungs?: FEV1, MBC
ABG
CXR if over 40
What effects does ab surgery have on the lungs?: (major ab surgery decreases vital capacity by 50% and FRC by 30%
What is an AMPLE history?: Allergies
Meds/Mech of injury
Past Medical Hx/Pregnancy
Last Meal
Events surrounding the mech of injury
What are the ABCDEF of primary survey?: Airway (watch C-spine)- jaw thrust/chin lift, clear foreign bodies, nasal, oral airway. Obtunded/unconcious pts should be intubated. Surgical airway- cricothyroidotomy
Breathing- O2, look for tension pneumo, flail chest, hemothorax, open pneumo,
Circulation (bleeding)- 2 large bore IVs, assess circulatory status- cap refill, pulse, skin color, direct pressure on bleeding
Disability- rapid neuro exam- alert verbal, pain, unresponsive; pupils,
Environment/Exposure- undress, hook up monitors- cardiac, pulse ox, bp
Foley
What is adequate urinary output for an adult, >1 y/o, <1 y/o?: adult- .5 cc/kg/hr
kid- 1 cc/kg/hr
<1- 2 cc/kg/hr
What are signs of urethral transection: blood at the meatus
high-riding prostate
perineal or scrotal hematoma
pelvic fracture.
What is resuscitatin? IV fluids: IV fluids- 2L of ringers or saline.
Peds- IV bolus of 20cc
3-1: L of fluid to L of blood loss.
Colloid vs. Crystalloid: Crystalloids- Na based solutions, provide a transient increase in Intravasc volume
- 1/3rd of an isotonic solution will remain intravasc.- crystalloid diffuse easily.
- Colloid- don't diffuse as easily, remain intravasc for longer. smaller volumes for resuscitation- costly and carry risk of transfusion rections and viral transmission, do not improve outcome
What are the classes of hemorrhagic shoc?: I- 15% blood loss, 750 ccs of loss, < 100 HR, nl pulse pressure, systolic BP, UO, no alterned mental status. Crystalloid 3-1.

II- 750-1500; crystalloids, monitor response

III- 1500-2000; crystalloids followed by blood matched;

IV- 2L bolus, followed by unmatched.
What is cardiogenic, neurogenic and septic shock?: cardiogenic: blunt myocardial injury, tamponade, tension pneumo, air embolus, MI

Neurogenic- sympathetic denervation in pts w/ spinal injury

septic- infection- delay in ED arrivial; or penetrating ab injuries.
What is trauma series for rads?: C-spine, chest, pelvis.
DPL and FAST for intraabdominal bleeding.
what are the latyers of the scalp?: skin, CT, aponeurosis, loose areolar tissue, pericranium.
what is the role of the scalp in head trauma?: - highly vascular structure.
- source of major blood loss
- loose attachment between the galea and pericranium allows for large collections of blood forming a subgaleal hematoma
- disruption of the galea should be corrected and may be done so with single layer, interupted 3.0 sutures.
- prophylactic abtics are not indicated in simple scalp lacerations.
How do you calculate Cerebral Perfusion Pressure?: MAP-ICP
What is the rate of CSF production?: 500 cc/day
150 cc of CSF circulating at a time
what are the indications for a CT scan of the brain?: neuro deficit
Persisting depression or worsening mental status
Moderate to severe mech of injury.
Describe the following skull fractures: Linear Stellate Depressed Basilar Open: Linear- important if over the middle meningeal artery- or major venous dural sinuses
Stellate- suggestive of a more severe mechanism of injury than linear skull fractures
Depressed- risk of underlying brain injury and complication - meningitis and Post-traumatic seizures
Rx- involves surgical elevation for depressions deeper than the thickness of the adjacent skull
Basilar- clinical Dx and sign of a significant mech of injury- Sx- Raccoon's, retroauricular (battle's, otorrhea, rhinorrhea, hemotympanum, and CN palsies
Open- needs careful debridement and irrigation. Avoid blind digital probing of the wound.
What are some diffuse intracranial lesions seen in cerebral trauma?: Cerebral concussion- transient loss of consciousness occurs immediately following blunt, nonpenetrating head trauma, caused by impairment of the reticular activating system
Recovery is often complete; residual effects such as headache may last for some time.

DAI- caused by microscopic shearing of nerve fibers, scattered microscopic abnlties, frequently requires intubation, hyperventilation, CPP monitoring, and admission to NICU; comatose pts, mortality is 33%
What are focal intracranial lesions?: cerebral contusion- brain impacts the skull- occurs directly under the site of impact. focal deficits, mental status can range from confusion to coma

Intracerebral hemorrhage- traumatic tearing from blood vessel

Epidural- middel meningeal artery- biconvex or lenticular lesion. May have a lucid interval. - early neurosurge- hematoma evac.

Subdural Hematoma- bridging veins, 2ry to acceleration-deceleration.- acute, subacute, chronic; acute-> early neurosurge, alcoholics and elderly- increased susceptibility.
What is the management of Mild to Moderate head trauma?: any pt with a persisting or worsening decrease in mental status, focal deficits, severe mechanism of injury, penetrating trauma, open or depressed fracture, or seizures should be admitted
- pts w/ mild and sometimes moderate head trauma, brief or no LOC, no focal deficits, and intact mental status, and normal CT scan , reliable family members who can observe can be dispoed.

Discharge- look for persisting, worsening headache, dizziness, vomiting, inequal pupils, confusion.
What is the management of severe head trauma?: Pts treated aggressively- ABCs
- airway via endotracheal intubation, topical anesthesia, IV lidocaine and paralytics when necessary- (no increase in ICP)
- maintain BP w/ isotonic fluids
- ICP- hyperventilate,( last resort
Mannitol- 1g/kg- lowers ICP (not in hypotensive pt)
Corticosteroids- not useful
Phrophylactic anticonvulsant therapy w/ phenytoin 18 mg/kg IV. No faster than 50 mg/min.
Acute seizures managed w/ diazepam and phenytoin
early ICP measurement via ventriculostomy should begin in ED.
Treat teh pathology whenever possible.
How do you lower increased ICP?: HIVED
Hyperventilate
Intubate
Ventriculostomy
Elevate the head of the bed.
Diuretics- Mannitol
What are the zones of the neck: Zone I- below the cricoid cartilage
Zone III- above the angle of the mandible
what is the ant. triangle?: Midline, posterior border of the SCM and the mandible
what is the post. triangle?: Trapezius, post. border of the SCM, clavicle- paucity of vital structions in the upper zone (above the spnail accessory) Lower zone has the subclavian vessels, brachial plexus, and apices of the lungs
What do we worry about with platysma violation on penetration injury to the neck?: Vascular- life thretening- exsanguination, hematoma, comprimise of the airway, CVA- air embolis

Non-vascular
- injury to larynx, tachea includiong fracture of the thyroid cartilate, dislocation of the tracheal cartilage and arytenoids, airway compromise and difficult intubation
esophageal injury can occur and is life thretening.
How are the ABCs managed in neck injury?: A- anatomy may be distorted, and a patent airway can deteriorate. Start with endotracheal. but percutaneus can be used.

B- look for a false lumen in laryngotracheal or tracheal transection- can be fatal.; look for pneumohemothorax.

Circulation- pt remains unstable-> OR to control the bleeding.
- Injury to the subclavian vessels is suspected, IV access should be obtained in the opposite extremity, in the lower extremities.; hemopneumothorax is suspected, and central venous access is necessary, femoral line is the first option, placement on the side ipsilateral to dropped lung.
What is hyoid bone fracture suggestive of?: significan mech of injury
what should be done for an airway in laryngotracheal separation?: tracheostomy.
what is the secondary survey in neck injury trauma pts?: stabilization-> examine wound.
soft tissue films of neck and CXR.
Surgical exploration for: expanding hematoma, subcutaneous emphysema, tracheal deviation, change in voice quality, air bubbling through the wound.
Pules palpated for thrills, deficits, auscultate for bruits.
Neuro exam.
what is the management of neck injuries?: Zone II w/ instability or enlarging hematoma require exploration in the OR.
Zone I and II may be taken to OR or managed convervativiely w/ angiography. bronchoscopy, esophagoscopy, gastrografin, or barium and CT.
Can evaluation of the spine be delayed?: yes, if properly immobilized. can delay til stable.
What is the anatomy of the spine: how many of each bone (cervical, thoracic...) What is the most vulnerable? What's special about the thoracic spine? What is the speciala bout the thoracolumbar region? What is tpecail about the l: 7 cervical, 12 thoracic, 5 lumbar, 5 sacra, 4 coccygeal.
cervical spine is most vulnerable.
Thoracic is protected by the ribs. Spinal canal is narrow here, so injuries can be devastating.
Thoracolumbar junction is vulnerable due to the inflexible thoracic and flexible lumbar.
lumbosacral- proper spinal cord ends.
What Mechs of injury are suspicious for spinal injury?: diving
fall from > 10 ft
Injury above shoulders.
electrocution
MVC
rugby or football
What is are the classifications of spinal injury?: fracture/dislocation- mechanism, stable/unstable
level- sensory and motor, bony involvement
severity- complete or incomplete
What is neurogenic shock?: vasomotor instability from impairment of the descending symps in the spinal cord- loss of symp tone. flaccid paralysis, hypotension, bradycard, cutaneous vasodilation, normal to wide pulse pressure
what is spinal shock?: state of flaccidity and loss of reflexed immediately after injury.
Loss of visceral and peripheral autonomic control w/ uninhibited parasymp impulses.
May last from seconds to wks, does not signify permanent spinal cord damage.
- long-term prognosis cannot be postulated until spinal shock has resolved.
what are incomplte vs. complete spinal injuries?: complte- no preservation of neurologic function distal to injury.
what is sacral sparing?: perianal sensation, voluntary anal sphincter contraction, voluntary toe flexion and is a sign of incomplte injury- better prognosis.
Describe the following: Corticospinal tract spinothalamic tract posterior columns: corticospinal- posterolateral spinal cord; ipsilateral motor, tested by muscle contraction.

spinothalamic- anteriolateral aspect of spinal cord; contra pain and temp.

posterior columns- posterior spinal, ipsi vibration, posisition and light touch.
What is anterior cord syndrome?: compression of the ant. artery of adam klewicz.
full or partial loss of pain and temp and paraplegia.
flexion injures.
poor prognosis
what is brown-sequard syndrome?: hemi-section of the spinal cord- penetrating injury, disc, hematoma or tumor
ipsilateral loss of motor and vibration sense. contralateral pain and temp loss.
what is central cord syndrome?: injury to central cord- narrowing of the canal.
- hyperextension injury. buckling of the ligamentum flavum, ischemic.
weakness in upper extremities. distal worse than proximal.
better prognosi than other parial cord syndromes.- lower extremity recovery progressing to upper extremity, finally hands.

- whiplash and extremely weak handshake in a 70 y/o.
How do you manage spinal cord injuries?: ABCs
spinal immpobilization throughout resuscitation
- estimate level during 2ry survey
- Dx studies
- penetrating-> high dose methylprednisolone- 8 hrs of injury and not for penetrating inury.- loading dose of 30 mg/kg over 15 minutes during hour 1, followed by 5.4 mg/kg/hr.
What is the appropriate approach to imaging a C-spine injury?: image- 3 views.
if C1-T1 can't be seen, get a CT.
When are c-spine films warranted?: Tenderness along C-spine
Neuro deficit
good mech of injury
presence of distracting injury
pts w/ altered sensorium
Atlanto-occipital dislocation: Atlanto-occipital dislocation- flexion, survival to hospital is rare, NO traction
Burst fracture of C3-7: axial loading mech causing compression of a veertebral body w/ protrusion of ant portion of vert body ant. post portion of body post into the spinal canal- can couse injury- ant. cord.
stable if ligaments intact
Simple wedge fracture: flexion injury causing compression on the ant portion of the vertebral body.
- wedge shaped; stable if no ligment damage.
flexion teardrop fracture: flexion injury- anteroinferior portion.
- unstable fracture because it is associated with tearing of the post ligament and w/ neuro damage
Jeffereson fracture: Jefferson- C1 burst fracture, most common fracture; ant and post rings of C1; axial loading- falling directly on his or her head.; can have C2 fractures with it. All C1 fractures are unstable.- seen as an increase in the predental space on lateral x-ray and displacement of the lateral masses on the odontoid view.
C1 rotary subluxation: rotary subluxation- kids or in pts w/ RA; assymmetry between lateral masses and the dens on the odontoid view; pts will present w/ head in rotation and should not be forced to place the head in the neutral position.
Odontoid fractures: Odontoid- type 1 tip of the dents, 2: base of the dens, 3: through the base and body of C2- unstable
Hangman's fracture: Hangman's- fracture of both C2 pedicles; hyperextension. unstable. no spinal cord injury usually.
what are the types of anal fistulas?: intersphincteric- stays w/in intersphincteric plane
Transsphincteric- Fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter.
Suprashincteric- similar to transsphincteric, fistula loops above the external sphincter to penetrate teh levator ani muscle
Extrasphincteric: fistual passes from rectum to perineal skin w/o penetrating sphincteric complex.
What is Paget's disease of the anus?: adenocarcinoma in situ
What is Bowen's disease of the anus?: squamous carcinoma in situ
Extension Teardrop fracture: anteroinferior portion of the vertebral body
occurs as an extension injury w/ avulsio nof the fragment, rather than a compression mech
post ligaments are left intact, stable fracture
-
Clay shoveler's fracture: flexion injury resultin gin a n avulstion of the tip of the spinous process
may result from a direct blow.
unilateral facet dislocation: flexion-rotation injury
- stable, potentailly unstable if injury to post ligamentous structures.
- IDed on AP view of the c-spine.

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