Adam Shared Surgery - 130 Picmonics

Abdominal Aortic Aneurysm

Screen Males 65-75 Who've Ever Smoked

Ultrasound

Observation

Asymptomatic and < 5 cm in Size

Surgical Repair

> 5.5 cm in Abdomen

Emergent Surgery

Ruptured or Symptomatic

2 mins

Pulmonary Embolism Presentation and Diagnosis

Sudden onset Shortness of Breath (S.O.B.)

Tachypnea

Pleuritic Chest Pain

Hemoptysis

Hypoxemia

Sudden Death

Gold Standard: CT Pulmonary Angiography

X-Ray

D-Dimer

V/Q Scan

1 min

Acute Bacterial Parotitis 4544

Dehydrated post-operative patients and the elderly are most prone to develop this infection

Most common infectious agent is Staphylococcus aureus

Fever

Leukocytosis

Parotid inflammation

Painful swelling of the involved parotid gland that is aggravated by chewing

Tender, swollen and erythematous gland; with purulent saliva expressed from the parotid duct

Adequate fluid hydration and oral hygiene, both pre- and post-operatively, can prevent this complication

Small-Bowel Obstruction

History of prior abdominal surgery --> risk factor due to adhesion development (most common cause)

Crohn-related SBO usually results from chronic fibrosis late in disease process

Colicky abdominal pain, vomiting

Inability to pass flatus or stool if complete (no obstipation if partial)

Progression of SBO --> sounds may diminish and if ischemia occurs --> disappear altogether

Hyperactive --> absent bowel sounds

Distended & tympanitic abdomen

Complete proximal obstructions are characterized by early vomiting, abdominal discomfort, and abnormal contrast filling on x-ray

Dilated loops of bowel with air-fluid levels on plain film or CT scan

Partial: Air in colon

Complete: Transition point (abrupt cutoff), no air in colon

Mild leukocytosis and amylase elevation can also be seen

lschemia/necrosis (strangulation)

Bowel perforation

Bowel rest, nasogastric tube suction, intravenous fluids

Surgical exploration for signs of complications

Complicated SBO --> increased risk of ischemia, strangulation, and necrosis, warranting emergency abdominal exploration

Change in pain, fever, hemodynamics (hypotension, tachycardia), guarding, leukocytosis, metabolic acidosis

Peristaltic waves on the abdominal wall can also be observed

Some of the less common causes include hernia, neoplasm , volvulus, intussusception

Partial obstruction: supportive care and observation if no improvement in 12-24 hours --> surgery

Prerenal Acute Kidney Injury

Decreased renal perfusion

Tx: Intravenous isotonic fluid (eg, normal saline) to restore renal perfusion.

Volume depletion is further suggested by tachycardia

True volume depletion

Decreased EABV (eg, heart failure, cirrhosis)

Displacement of intravascular fluid (eg, sepsis, pancreatitis)

Renal artery stenosis

Afferent arteriole vasoconstriction (eg, NSAIDs)

Increase in serum creatinine ( eg, 50% from baseline)

Decreased urine output

Blood urea nitrogen/creatinine ratio > 20: 1

Fractional excretion of sodium <1%

Unremarkable ("bland") urine sediment

Decreased renal perfusion leads to a decreased glomerular filtration rate

If due to CHF then dont use IV fluid, use a diuretic

Use albumin for prevention of prerenal AKI following large-volume paracentesis in patients with decompensated cirrhosis

FEurea < 35% (used when the patient is on a diuretic because it messes with the FENa)

Retroperitoneal Hematoma 4501

Cardiac Catheterization

Anticoagulants

Hypotension

Tachycardia

Flat neck veins

Ipsilateral back/flank pain

Most hemorrhage or hematoma formation occurs within 12 hours of catheterization

Swelling of soft tissue

If the arterial puncture site is above the inguinal ligament, the hematoma can extend into the retroperitoneal space

Non-contrast CT scan of abdomen and pelvis or abdominal ultrasound

Treatment is usually supportive, with intensive monitoring, bed rest, and intravenous fluids or blood transfusion

Surgical repair of hematomas or retroperitoneal hemorrhage is rarely required

Avoid strenuous activity or lifting heavy objects for one week post catheterization

Radial artery approach leads to fewer local vascular complications

Thoracic Aortic Aneurysm

Associated with cystic medial degeneration

Balloon-like dilation of the thoracic aorta

Hypertension

Bicuspid aortic valve

Connective tissue disease (Marfan and Ehler Danlos)

Also historically associated with 3° syphilis (obliterative endarteritis of the vasa vasorum) and aorta can present "tree-bark" appearance

Major complication is dilation of the aortic valve root, resulting in aortic valve insufficiency (aortic regurgitation).

Other complications include compression of mediastinal structures (e.g., airway or esophagus) and thrombosis/embolism.

Spontaneous Pneumothorax

Accumulation of Air in Pleural Space

Tall and Thin Young Males

Bleb or Bulla Rupture

Underlying Disease

Hypoxemia

Chest Pain

Decreased Breath Sounds

Hyperresonance

Shortness of Breath (SOB)

1 min

Scaphoid Fractures 3415

Most commonly fractured carpal bone

Pain at the radial wrist proximal to the base of the thumb

Examination shows tenderness in the shallow depression at the dorsoradial wrist

"Anatomic Snuffbox"

Bounded medially by the tendon of the extensor pollicis longus

Bounded laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis

Carry a significant risk of osteonecrosis

Initial x-rays can be normal in nondisplaced scaphoid fractures

CT scan or MRI can confirm the diagnosis, or repeat x-rays can be performed in 7-10 days

The wrist can be immobilized briefly in a thumb spica splint if repeat x ray is used

Displaced fractures should be considered for surgical intervention

Monitor with serial x-ray to rule out osteonecrosis

The radial artery supplies blood flow

Typically caused by fo rceful dors iflexion at the wrist

X-rays of the wrist in full pronation and ulnar deviation to better expose the scapho id

Radioscintigraphy bone scan in 3-5 days can also be used

Orthopedic surgeon if: tilt of lunate, fracture displaced >1 mm, nonunion on follow-up, osteonecrosis, scapholunate dissociation

Serial x-rays should be done in 2-week intervals to monitor healing after spica cast is used

Most commonly complicated by nonunion and avascu lar necrosis

Proximal fractures of the scapho id require longer immobilization (up to 12 weeks ) for adequa te healing

Compartment Syndrome 3398

Serial compartment pressure monitoring is useful in determining the need for definitive operative management

Compartment decompression by fasciotomy or for circumferential burns, escharotomy

Eschar resulting from circumferential, full-thickness (third degree) burn often leads distal ACS

Longstanding elevated compartment pressure --> tissue ischemia and tissue death

Pain out of proportion to injury

Pain increased on passive stretch

Rapidly increasing & tense swelling

Paresthesia (early)

Decreased sensation

Motor weakness (within hours)

Paralysis (late)

Decreased distal pulses (uncommon)

Compartment pressure >30 mm Hg

Delta pressure (diastolic blood pressure - compartment pressure)

Clinical diagnosis, confirmed with compartment pressure

Serial measurements should be performed even if initial pressures are within normal limits

Time to intervention is the most important factor predicting complete functional recovery of the limb.

All const rictive cover ings (casts, dress ings) should be removed and supplemental oxygen given

Supportive measures to maintain perfusion pressure include keeping the limb at torso leve l and treat ing hypotens ion if present.

Arteria l and venous occlusion in the extremity results in anoxic muscle necrosis (rhabdomyolysis)

Lead to acute renal failure (ARF), particula rly in volume-depleted states (eg, hemorrhage) , which worsens vasoconstr iction and cast formation.

Compartment pressure >30 mm Hg or delta pressure (diastolic blood - compartment) <20-30 mm Hg --> significant CS

Caues: traumatic long bone fractures , trauma wit hout fracture (e.g., crush injuries, thermal burns, and vascular injury in extremities) ,

Nontraumatic causes (e.g., prolonged limb compression, animal venom exposure , and nephrotic syndrome)

Can progress to infection, and skin ulceration and tissue necrosis, possibly requiring amputation of the limb

Ankle-Brachial Index Interpretation 4494

Ankle-brachial index = higher ankle systolic pressure in lower extremity/higher brachial artery systolic pressure

Less than or equal to 0.90 - Abnormal

0.91 - 1.30 - Normal

Greater than or equal to 1.30 Suggestive of calcified & incompressible vessels; additional vascular studies should be considered

Ankle-brachial index (ABI) confirms the presence of peripheral arterial disease (PAD)

Glasgow Coma Scale

LOC Assessment

Score of 3 to 15

8 or Less = Coma

Eye Opening

Verbal Response

Motor Response

1 min

Syringomyelia

Cystic cavity (syrinx) within central canal of spinal cord

Fibers crossing in anterior white commissure (spinothalamic tract) are typically damaged first

Results in a “cape-like,” bilateral loss of pain and temperature sensation in upper extremities

Fine (deep) touch sensation is preserved

Associated with Chiari I malformation

Most common at C8–T1

Acute Abdominal/Pelvic Pain in Women 12160

Recurrent mild & unilateral mid-cycle (around day 14) pain prior to ovulation

Pain lasts hours to days

No peritoneal signs

Ultrasound: Not indicated

Rupture of the follicle releases the egg; concomitant release of some blood during process irritates peritoneum

Reassure patients

Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity

Nausea & vomiting

Unilateral, tender adnexal mass on examination

Can cause hemoperitoneum often while on anticoagulants

Diffuse severe abdominal pain, pleuritic chest pain, and shoulder pain (due to phrenic nerve irritation)

Gynecologic emergency typically occurring in premenopausal patients

Diffuse abdominal rigidity with rebound and guarding is present

Symptoms arise due to ischemia and eventually necrosis

Decreased hematocrit due to intra-abdominal blood loss

Twisting around its supporting structures (infundibulopelvic ligament or utero-ovarian ligament) which contains ovarian blood supply

Ultrasound + Doppler: Pelvic free fluid and possible adnexal mass if the cyst is incompletely drained

Enlarged ovary with decreased or absent blood flow

Dermoid cysts in particular have a higher likelihood of torsion than other types of ovarian masses

Treatment: prompt surgical laproscopy with detorsion, cystectomy, possibly removal of the adnexa (if necrosis despite restoration)

Untreated torsion may lead to chronic pelvic pain, infertility, hemorrhage, or peritonitis and sepsis

Necrotizing Fasciitis 2749

Streptococcus pyogenes (group A streptococci) is the most frequently recovered

Staphylococcus aureus

Clostridium perfringens

Polymicrobial

Bacteria spread rapidly through subcutaneous tissue & deep fascia , undermining the skin

Most commonly involves extremities & perineal region

Often antecedent history of minor trauma

Erythema of overlying skin

Swelling & edema

Pain out of proportion to examination findings

Untreated necrotizing fasciitis progresses to rapid discoloration of the affected site, purulent discharge, bullae, and necrosis

Air in the deep tissue can cause crepitus

Systemic symptoms (eg, fever & hypotension)

Imaging reveals extent and air in the tissue bed; If necrotizing fasciitis is suspected, therapy should not be delayed to pursue imaging

Requires surgical debridement & broad-spectrum antibiotics

Blue grey discoloration

Third Generation Cephalosporin + clindamycin + ampicillin

Can also result from significant peripheral vascular disease (ie, diabetes).

The most common form (type II) usually occurs in individuals with no concurrent medical illness usually from GAS

Type I is usually seen in patients with underlying diabetes and peripheral vascu lar disease usually polymicrobal

Staphylococcus aureus, Bacteroides fragilis, Escherichia coli, group A Streptococcus, and Prevotella species

Piperacillin/tazobactam or a carbapenem for GAS and anaerobes

Vancomycinw ill cover Staphylococcus aureus

Clindamycin is added to inhibit toxin formation by streptococci/staphylococci

Once culture information is available, antibiotic therapy should be narrowed based on identified pathogens

Nasal Polyps, Angiofibroma and Nasopharngeal Carcinoma

Protrusion of edematious, inflamed nasal mucosa

Secondary to repeated bouts of rhinitis; occurs in cystic fibrosis and aspirin-intolerant asthma, kartagener

Aspirin-intolerant asthma consists of asthma, aspirin-induced bronchospasms, nasal polyps

Surgery often temporary relief, polyps recur; ultimate treatment should be management of underlying etiology

Not just aspirin, any NSAIDs

Can do aspirin desensitization if aspirin is required

Treatment includes management of the patient's underlying asthma and chronic rhinosinusitis

Avoidance of NSAIDs, and desensitization if NSAID use is required

Leukotriene inhibitors (zileuton) and leukotriene antagonists (montelukast) --> improved resp/nasal symptoms

Considered a pseudoallergy

Benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue; classically seen in adolescent males

Profuse epistaxis

Can cause nasal obstruction and nasal drainage

Malignant

EBV association; classically African children/Chinese Adults

Risk is thought to be higher in these locations due to diet (salt-cured food, early exposure to salted fish) and genetic predisposition

Pleomorphic keratin-positive epithelial cells (poorly differentiated squamous cell carcinoma) in a background of lymphocytes

Often presents with cervical lymph node involvement

EBV assays are often used to monitor treatment response and disease relapse

Invades adjacent tissues --> congestion, epistaxis, headache, CN palsy, serous otitis media (eustachian obstruction)

Nasal congestion with epistaxis, headache, cranial nerve palsies (eg , facial numbness), serous otitis media (eustachian tube obstruction)

Early metastatic spread to the cervical lymph nodes may cause a nontender neck mass

Nasopharyngeal endoscopy should be considered

Ileus

Intestinal hypomotility without obstruction

Constipation and decreased flatus

Distended/tympanic abdomen with decreased bowel sounds

Abdominal surgeries

Opiates

Hypokalemia

Sepsis

Bowel rest, electrolyte correction, cholinergic drugs (stimulate intestinal motility).

Peritonsillar Abscess (Quinsy) 2847

An acute bacterial infection of the region between the tonsil and the pharyngeal muscles

Most common in older adolescents and young adults, and drug or alcohol use increases the risk

Fever

Sore throat, difficulty swallowing

Trismus (spasm of the jaw muscles)

Muffled "hot potato " voice

Uvula deviation away from enlarged tonsil

Pooling of saliva

Ear ache

Can be fatal secondary to airway obstruction or spread of infection into the parapharyngeal space --> carotid sheath

Needle aspiration or incision and drainage (if aspiration fails to remove purulent material)

Antibiotic therapy to cover Group A hemolytic streptococci and respiratory anaerobes

Clinical diagnosis (no imaging required)

Emphysematous Cholecystitis 2940

Diabetes mellitus

Vascular compromise

Gallstones

lmmunosuppression

Fever, right upper quadrant pain, nausea/vomiting

Crepitus in abdominal wall adjacent to gallbladder

Complications include gangrene and perforation

Air-fluid levels in gallbladder, gas in gallbladder wall

Cultures with gas-forming Clostridium, Escherichia coli

Unconjugated hyperbilirubinemia, mildly elevated aminotransferases

Gas in the gallbladder wall, and occasionally pneumobilia (air within the hepatobiliary system)

Emergent cholecystectomy

Broad-spectrum antibiotics with Clostridium coverage (eg, ampicillin-sulbactam)

Can cause ileus (decreased or absent bowel sounds)

Anterior and Middle Mediastinal Mass 2590

Diagnosis of mediastinal tumors is based on chest-x rays and CT scans

Thymoma

Teratoma

One must also include other germ cell tumors

Teratomas distinguished from other germ cell tumors on imaging by the presence of fat or calcium, particularly if in the form of a tooth

Serum B-HCG can be elevated in 1/3 of patients with a seminoma

Patients with a nonseminomatous germ cell tumor have elevated AFP, some also have elevated B-HCG

Diagnos can be confirmed with biopsy

Testicular ultrasound should be per formed to exclude a small primary tumor

Thyroid neoplasm

Terrible lymphoma

Bronchogenic cysts are are benign entities

May be seen on the AP chest x-ray

Tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, and aortic aneurysms of the arch

All neurogenic tumors are located in the posterior mediastinum

These include: meningocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, and aortic aneurysms

MRI is the best modality to evaluate posterior mediastinal masses

Adam Shared "Surgery" - 130 Picmonics

Surgery

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