it but it's not officially sanctioned by the school this is basically something i made for myself to study for step two uh this summer kind of going back all over all my surgery notes and the books and test questions or cuban questions that i used to study for both my surgery shelf and for step two so um you know will all of this absolutely be on your shelf no but i tried to cover what i remember being important and what the review books and the cuban questions seem to hit over and over again so you'll also notice that i'm not going to teach you a lot of surgery in the next two hours because there's not a lot of surgery on your shelf so i tried to pick out the medicine concepts that are related to surgical patients which is really the the most common thing you're going to see in these clinical vignettes so i tried to make this powerpoint fairly interactive it's not like hardcore pimping but it was my goal to make this a way to kind of see what you know and see what you still need to study before friday so there are questions uh please participate if you would like to harlangen you guys have little buttons and stuff you can push so please participate also if you know the answer and keep me honest if they're saying stuff and i'm not repeating it let me know if you're getting lost or if i'm not remembering to repeat things like i should so any questions before we get started yes ma'am yes so it is being audio and videoly recorded right now so the actual presentation is going to be posted dr hinzi is going to send it out first thing tomorrow morning and the slides also will be sent to you guys tomorrow if you want to review it so i'm going to go kind of fast so unless you are a compulsive note taker it might just be easier to to listen and enjoy so all of this material will be available for you guys tomorrow all right so we'll begin like most of our patients begin before surgery in the pre-operative evaluation so um you know surgeons love to operate there are very few absolute contraindications to surgery but there's one that seems to come up over and over in the in the cubing questions for surgery anybody know it when can you absolutely not do surgery any ideas besides patient death that one doesn't count so diabetic coma dka is an absolute contraindication to surgery or sky high glucose just because the risk of operative complications and infection is just too high so that's one of your number one absolute contraindications to surgery poor nutritional status is another thing that's going to make the surgeons wary to take someone to the or and there are three things we look at that are measures of nutritional status anybody when would we think someone's nutrition sucks albumin so if the albumin's low what else we can weigh them that's easy if they've lost more than 20 percent of their body weight that's also a marker of poor nutritional status and the other one the plastic surgeons check it a lot pre-album pre-albumin i agree that's not the one i put in here it was transferrin so albumin less than three a transferrin less than 200 or overall weight loss is greater than 20 percent of the body weight are all pretty strong indicators of poor nutrition so if the surgery is not emergent these are good reasons to delay surgery and maximize nutrition so if we're trying to maximize someone's nutrition what's the best way to do that should we shove them full of tpn or what is that the best way no what's the best way yes enteral feedings are always preferred if it's possible to feed somebody through their gut that's always going to be a more optimal way to get nutrition into somebody so severe liver failure is also a reason that surgeons will delay surgery if possible or not take a patient to the or right away and there are some things we can check to measure liver function what are those bilirubins so like a bilirubin we're cutting somebody open what are we particularly interested in coags yeah so we for sure want to take a look at the pt um so bilirubin pt we're also interested in the ammonia level or signs and symptoms of encephalopathy those are some things that are really important to look at in the pre-operative evaluation so good and if they're a smoker what is our best advice okay quit yes good and if possible um two months before surgery just because smoking affects wound healing uh because of the the way it negatively affects the remodeling of tissue so would really like our smoker friends to stop smoking two months before surgery particularly in plastic surgery cases i know my attending was a real big stickler if he was going to do a flap reconstruction on somebody he was not going to do it if they if they were still smoking so that's important and also with our smoker patients what is important as they're coming out of anesthesia we've always got a pulse ox monitor on our patients as they're coming to as the anesthesiologist is waking them up do we want to keep their stats right at 100 why not absolutely so smokers people with copd they tend to be chronic co2 retainers so the only drive they have or the strongest drive they have for respiration is hypoxia so if we keep their stats too high that's going to suppress their respiratory drive and actually might cause more problems in the waking up phase after surgery than then would be worth all right so goldman's index you can actually calculate a number from goldman's index to calculate pre-operative or operative risk so really what you need to know about it not necessarily how to calculate it but what it does so it tells you about a patient's risk during surgery and it allows you to kind of weigh the risks and benefits of taking somebody to the or so what you do need to know for your test not necessarily calculating the score but what's the most important factor what's the what what chf so congestive heart failure uh the ejection fraction these are all things we're paying very close attention to in the preoperative evaluation because chf gives us the biggest amount of points in goldman's index and it's the biggest predictor of perioperative mortality so if we have a patient with known chf i think i spilled the beans on this one already what are we checking ejection fraction yeah so we're going to order an echo uh if the patient has known chf and if there are ejection fractions in the toilet if it's less than 35 percent no surgery for them if we if it's absolutely unless it's absolutely necessary so the second most important factor for predicting uh mortality associated with surgery yes so angina ish but more more importantly a recent mi so six months is the cut off um and it's kind of a a surrogate for their cardiovascular status so angina would factor in there but really we're going to be super concerned if there's been a heart attack within six months so what are we checking on all our pre-out patients here everybody gets one of these if they're over 50. ekg before surgery so if the ekg is abnormal then we'd send them for a stress test if the stress test is abnormal we got to send them to the cath lab and do revascularization either with or reperfusion either with stenting or revascularization with a cabbage so unless the surgery is urgent we really want to make sure that they're cardiovascularly optimized before we take them to the or put them under anesthesia so some other things we can check also that would show up on the ekg arrhythmias are a strong predictor of whether or not someone's going to do well with surgery if they're old they're less likely to do well with surgery they're less likely to do well with surgery if the surgery is emergent and aortic stenosis is also a predictor of complications associated with surgery so what else should we check particularly with number six we already got our ekg pfts sure but we're not especially concerned about that if someone's got a history of valvular disease well first we're just going to listen so and this is the way they try to sneak some medicine in with your surgery questions they might describe a patient who comes in for his pre-operative evaluation and they might describe the as murmur so you're gonna have to reach back into your memory banks from step one land and remember what the murmur of aortic stenosis sounds like and it is late systolic it's a systolic ejection murmur and it's got that characteristic crescendo decrescendo so even though it seems very mediciney it could show up in a vignette concerning the pre-operative evaluation so before surgery what medications do we tell our patients to stop aspirin how how long before surgery do we need to stop aspirin yeah seven to ten days two weeks i think is even better if if they can what else would we want him to stop and says sure metformin why yeah so remember that was the big adverse reaction you had to memorize for step one with metformin lactic acidosis so those are the main ones aspirin and said also vitamin e because that can affect bleeding and clotting optimally two weeks before but seven to ten days is usually what we tell our patients warfarin also because of bleeding complications and we monitor the inr for that we want it to drop below 1.5 if possible and metformin which i don't have here but it's absolutely true due to its risk of lactic acidosis and then if the patient is diabetic requiring insulin we always instruct the patient to take half the morning dose since they are npo after midnight before surgery so if they are um chronic kidney disease and they're on dialysis when do they need to have dialysis before surgery yeah 24 hours before absolutely and why do we check bun and creatinine in a patient with a history of kidney disease what is that how does that affect surgery like sure their kidney function isn't that great but the surgeon shouldn't care about that just cutting on them for an hour absolutely so what he said was if you guys didn't hear him um people with chronic kidney disease who have uremia uremic toxins actually interfere with platelet function so even though if you check a cbc the platelet counts will be fine there's still an increased risk of bleeding because the uremic toxins prevent them from interacting in a normal way so particularly if the bun is super high above 100 we would definitely worry about that so that's one of the reasons we want to make sure they get their dialysis before surgery and we monitor their bun and creatinine closely so what would you expect on the coag panel kind of told you already the platelets are normal they'll try to throw you off with that one but the bleeding time is still prolonged because bleeding time doesn't necessarily measure platelet number but definitely platelet functionality okay so if you are a whiz with the ventilator you're a better med student than i i kind of boiled it down to the to the four things you really need to know to answer questions about these surgical icu patients so assist control what do we use this for or how much is the machine actually doing for patients when when they're on a cyst control setting yeah so um we set on the machine we set the title volume that we want the patient to receive and the rate the minimum rate that's acceptable for us for the patient to be breathing but if the patient you know is exercising their respiratory muscles and takes a breath the ventilator will go ahead and give that predetermined volume that's different for pressure support where the patient is going to breathe however often they're going to breathe but the machine provides pressure support so that if they're not able to take in the whole tidal volume on their own the ventilator will give a little bit of oomph a little bit of help with that and as i noted on this slide this is an important weeding weaning setting that's probably where you'll see it if you see it in a clinical vignette you've got someone that's been vent dependent after a bad accident or whatever and you're trying to wean them off the ventilator so they can be downgraded pressure support setting is an important stepping stone in that process and then cpap my daddy's got one of these so again the patient has to have sufficient respiratory drive to to breathe on their own but a cpap gives continuous positive pressure in order to make sure those alveoli stay open in order for gas exchange to occur and then peep yeah so again um this is more important keeping those alveoli open as i've noted on the slide where you'll see this is as the setting that's used in patients with ards so the alveoli are are collapsing and that's what's causing the problems in patients with ards not being able to facilitate gas exchange the peep setting is going to keep those open in order to in order to facilitate that so if you have a patient on a ventilator how what test do you want to order with some regularity to check how well the ventilator is working abg absolutely so you're going to check your oxygenation status and then how well your co2 is being is being taken care of as well so if the pao2 is low what does that tell you is your patient getting enough oxygen no so how do we want to remedy that absolutely so we'll increase the fio2 if our pao2 is unacceptably low on the abg if the pao2 is too high yeah we'll decrease it why how what what is there such a thing as too much oxygen and what does too much oxygen do yeah free radical damage so it can actually paradoxically end up worsening ards or or lung injury if you have too high concentrations of oxygen so if we're taking a look at our pa pa co2 if it's too low and our patient is alkalotic what should we adjust on our ventilator settings ooh i can't hear you so we could what would we want to do to frequency we want to we want to make them breathe faster or slower we would want to make them breathe slower because if their pa co2 is low that means they're blowing it out right they're breathing too much they're like hyperventilating is that the only way we could adjust this pa co2 tidal volume so frequency and tidal volume are the two parameters you could change and i think i might attach you this way back in first year in physiology which one is better to adjust do we want to adjust rate or do we want to adjust tidal volume to get the most bang for our buck in terms of efficiently getting rid of co2 tidal volume why multiplicative effect what do you mean um oh so you didn't press your button that's okay uh so what he said is it was a multiplicative effect and it's because you multiply rate and title volume together to get your minute ventilation i agree with that the only thing i would add in that you might want to look for in the answer choices is when you're increasing your respiratory rate you're also increasing ventilation to the dead space so when you increase rate you're getting more air to your alveoli sure but you're also getting more air to the dead space in your trachea and your bronchi and stuff like that whereas when you increase your tidal volume that gives more benefit to the amount of air that's going into the functional spaces where gas exchange can occur so that's a pretty classic question and a good thing to remember how physiology does apply to real life so then conversely if the paco2 is high and the patient's acidotic we could increase either rate or tighter volume but again tidal volume is going to be preferred because we're not wasting any of that additional oxygen on dead space so okay very good so for acid-base disorders you'll see these acid-base disorders on pretty much every shelf exam you take this year so it's good to get it down early and then then you can get the questions right on the rest of the exams also so remember when you're worried about acid-base status obviously the first step is going to be to check the ph you can get that on your abg and if it's less than 7.4 you've got an acidotic situation the next step is going to be to detect the bicarb and the pco2 because then you can see where the problem is do we have a problem with the kidneys or a metabolic issue or do we have a problem with co2 retention or or blowing off of co2 so if the bicarb and the pco2 are both high what type of acidosis do we have respiratory very good so if our pco2 is high right we're retaining our pco2 and because of the carbonic anhydrase anhydrase equilibrium equation more pco2 means more protons and that gives us acidosis so if bicarb and pco2 are both low then what type of acidosis do we have the other one metabolic right so we have too little bicarb then the problem is is with metabolism so once you have determined you've got a metabolic acidosis the next best step best step on your test should be to see if they gave you electrolytes so that you can calculate the anion gap so remember the equation for anion gap you're likely going to need to use that on one of your questions on friday and it's just sodium minus the negatively charged components chloride and bicarb and what's normal eight to twelve eight to twelve somewhere in there there's a more sophisticated equation where you can calculate the normal anion gap based on the patient's age but that's an internal medicine thing we don't care about that now so 8 to 12 is a good enough ballpark for normal and what are some things that can cause an anion gap acidosis or just give me the cute acronym that was in first aid mud piles right so what are these see if i can remember m is methanol i think is you uremia d dka p yeah okay parallel the right i isonizin l the most common one lactic acidosis e ethylene glycol or ethanol sure then s salicylates good okay so the non-gap acidosis are easier to remember for me there are fewer of them what are they the main one main one's diarrhea right because your um colonic and intestinal secretions are high in bicarb so if you're pooping a whole bunch you're going to poop out a lot of your bicarb and low bicarb indirectly gives us a metabolic acidosis so some other random ones that are more internal medicine things are the renal tubular acidosis and then abusive diuretics or overuse of diuretics so um so if our ph instead of being low is too high is greater than 7.4 we've got an alkalosis on our hands and again the next best step is to check the bicarbonate and co2 and if they're both low what type of alkalosis do we have bicarbon co2 are both low what type of alkalosis is that respiratory right because low bicarb we just talked about that that should give us an acidosis so low bicarb isn't going to give us an alkalotic situation it's got to be the co2 and if they're both high then conversely that's a metabolic alkalosis so to determine between the main classes of metabolic alkalosis you can check the urine chloride and vomiting because you're puking up hcl which is rich in chloride you're going to have low chloride when you check it because you're ejecting it into the outside world if the chloride is high then it's something a little bit more mysterious it might be some kind of hyper aldosterone state or one of these random genetic nephron electrolyte transporter problems like barters or gittleman's so that's kind of down and dirty the stuff that you need to recall pull out of the memory banks for the acid-base questions you might be asked so as far as electrolytes low sodium what causes hyponatremia yes too much water fluid overload so if you remember from second year hyponatremia is not a sodium problem right it's not that you have too little sodium it's that you have too much water so the first the next best step if you see on your chemistry that you've got a patient with hyponatremia you want to check the plasma osmolarity because there are some mimickers of hyponatremia where you've either got high glucose and that makes it look like your sodium is too dilute so you want to check the plasma osms to to rule that out and then the next step is to take a look at the patient and assess the volume status so if your patient is hypervolumic they're puffy their lungs are crackly and wet and they've got hyponatremia on chemistry what might cause that yeah so the big three chf nephrotic syndrome or cirrhosis can all cause fluid retention and lead to hypervolemic hyponatremia well that's the same thing twice isn't it so pretend that second arrow is pointed down and you have got a patient with dry mucous membranes skin tenting they look like their volume depleted but there's still hyponatremic on chemistry so what could cause that yeah diuretics or vomiting or uh this isn't the psychiatry shelf but if someone's just um oh vomiting free water never mind so diuretics or vomiting are going to be your main ones and then if their volume status is stone cold normal but they're hyponatremic the big cause there is siadh so the next best step once you've established that especially if the patient is a smoker would be what chest x-ray siadh is a perineoplastic syndrome associated with lung cancer so okay so how do we treat hyponatremia kind of depends right it depends on the volume status in general the garden variety answer is fluid restriction and diuretics but if they're hypovolemic what do we want to do hypotensive tachycardic dry mucous membranes skin is tinting you've got to volume resuscitate them right so even though they're hyponatremic we're going to want to give them fluid to correct for hypo hypobolemia something i always found confusing when i was taking practice questions and when i was taking the real test is what is the role of hypertonic saline when do we use this as opposed to just fluid restrictions and diuretics and there are some pretty clear-cut criteria does anyone know them so if you've got severely symptomatic hyponatremia so if you're like seizures altered mental status like severe severe symptoms or if the sodium is super super low i've seen cutoffs either 110 or 120 i don't think the test is going to be dirty and say 115 but i mean you'll you'll see it's very very low or the patient is symptomatic from their hyponatremia so why don't we go willy-nilly with this hypertonic saline and correct all our sodium up to normal in like five minutes central pontine myelinolysis is the big fear from lawsuit city right so we want to make sure we replete the sodium or correct the volume problem rather very slowly so we don't induce this life-threatening complication and what's an appropriate rate of correction of the sodium it's between 0.5 and 1 ml equivalent per hour or between 12 and 24 ml equivalents a day any faster than that and you're asking for central pontine myelinolysis so for hypernatremia again the problem is not with sodium it's with water so when we've lost too much water with respect to our sodium content so the treatment for this is we want to replace the water so we're going to replace fluid with a hypotonic solution and if we go faster than 12 to 24 mil equivalents per day what do we worry about what's the complication cerebral edema good so cerebral edema is the feared concentration here got a lot of fist bumps going on over there okay so some other electrolyte abnormalities and how they might present in a clinical vignette if you've got a patient with numbness uh those two dead people sign or prolonged qt interval what electrolyte is out of whack calcium too high or too low too low so that's hypocalcemia and what about the classic bone stones groans psychiatric overtones that's hypercalcemia and and what we worry about with hypercalcemia is this shortened qt interval with hypocalcemia as you can see on the slide you've got a prolonged qt interval so anytime you see that the calcium is either too low or too high an ekg would be an appropriate next best step to make sure your patient isn't at risk for developing torsodas okay so what about a patient with para paralysis ileus or st depression and new waves on the ekg hypokalemia and how do we treat hypokalemia we'll give them potassium good so we'll put potassium into the iv fluids we just want to make sure that we monitor their renal function if their creatinine is too high if they're in renal failure we can bump them into hyperkalemia pretty quick so which brings us to this last situation p t we peak t waves and other ekg changes like a prolonged pr qrs that's hyperkalemia and the treatment of this is super super important so what do we want to do to a patient with hyperkalemia calcium gluconate first that's going to stabilize the cardiac membranes what else so we can give insulin and glucose to shift the potassium into the cells um albuterol or a beta yeah a beta agonist can also shift potassium intracellularly and then if it's really bad we really have to to do dialysis to get the potassium out of the body so very good okay excellate we don't really use that very much at university hospital but they still use it at the va from time to time that makes you poop out potassium so it's another way to kind of get it out of the body okay so for fluid and nutrition the maintenance ivf of choice d5 half normal saline and we can add 20 ml equivalents of kcl if the patient is peeing and for maintenance fluids how do we calculate it up to 10 kilograms how much fluid do they get this is also muy importante what yeah so there's different uh formulas whether you're calculating daily requirement or hourly requirement i've got the daily requirements here so 100 milliliters per gig per day for the first 10 then 50 milliliters per gig today per per day in the next 10 and 20 milliliters per gig per day um all kilograms in excess of 20. so as we discussed before enteral nutrition is always preferable over parenteral nutrition and really we only use tpn when we have to when there's a problem with gut absorption that would prevent us from getting the patient nutrition in early okay so our burn patients for circumferential burns well first of all what degree burn do we have going on here it's erythematous it's it's fairly painful but not peeling so that's first degree and what layer of skin is involved epidermis and so in this uh second example we've got loss you know loss of integrity of the epidermis it's very painful oh there you go jk second degree burn and then lastly this example of a third degree burn um shows you that it can either become dark or pale uh and really we have no sensation here because the damage to the skin goes all the way through the dermis and starts to to affect the nerves so even though this doesn't hurt this red stuff all the way around the area of the third degree burn hurts like hell so just because the patient has a third degree burn doesn't mean something doesn't hurt okay so particularly what are we worried about in circumferential burns compartment syndrome very good so we'll look out for those signs and if we see them we'll definitely want to consider a bedside surgical procedure to relieve that pressure if a patient comes in with kind of burned hairs in their nose they're wheezing they've got black stuff all the way around their mouth what's the complication we would fear there so we're worried about their airway um they could develop laryngeal edema so we're going to have a low threshold for intubation there and then if a patient who was kind of uh in a house fire or something comes in with confusion they've got a headache and their skin is really really red carbon monoxide we'll want to check the carboxy hemoglobin remember that a pulse ox doesn't do you any good here why is that yeah absolutely so carbon monoxide actually causes a leftward shift of that hemoglobin oxygen dissociation curve and the hemoglobin molecules are more saturated good so the treatment here we want to give them 100 o2 and if we have a lot of carbon monoxide on board we might consider hyperbaric treatment okay so clotting what is the cause of clotting that we worry about in old people particularly me i worry a lot about this not for me but for my future patients giving you a hint and it's not being helpful cancer yes cancer is a hypercoagulable state so in old people that have a sudden uh you know increase in clots hypercoagulability we're gonna worry about cancer what about a patient who's got some new clots and they're edematous they got high blood pressure and foamy pee might be a cause of a hypercoagulable state that would cause edema hypertension and foamy p not cirrhosis but it's an osis nephrosis so nephrotic syndrome is a hypercoagulable state because um remember in nephrotic syndrome we're losing protein in the urine and some of the first proteins to go are things like antithrombin iii and a lot of other clotting factors so nephrotic syndrome in and of itself is a hypercoagulable state so that's important to remember this is kind of one of those instances where medicine sneaks into your surgery shelf if a young person has a positive family history of clotting the most common inherited coagulable hypercoagulability is factor 5 leiden and why do we care about antithrombin 3 deficiency as surgeons or at least as surgery students what can't we give to someone with at3 deficiency heparin because it won't work very good so a young woman who has multiple spontaneous abortions lupus anticoagulant we might could be concerned about that and in a patient post-op who has thrombocytopenia but increased clotting they've got some arterial clots or some venous clots and maybe they received heparin yes good hit so sometimes they'll they'll you know be real obvious and tell you that they gave the patient heparin and sometimes they'll just say it's a post-op patient and most post-op patients um receive heparin so either way anytime you see low platelets plus clotting think hit those are kind of the two factors that should trigger that alarm in your mind so if it is hit what do we treat it with protamine oh so protamine is the antidote for heparin but um yeah so it's what what is that harlan gin synthetic synthetic heparin like leparoon or agatraban yes so leparoon or agatraband are going to be our drugs of choice we obviously want to get heparin out of the picture as soon as possible but we don't necessarily need to reverse it because remember with heparin the problem is we get an antibody that's formed to heparin bound to pf4 so just reversing the heparin isn't necessarily going to going to correct the problem so with bleeding if we see an isolated decrease in platelets what are we thinking maybe in a young woman itp it's idiopathic well itp and if we have a patient with normal platelets but increased bleeding time and ptt this might be another young woman who's got heavy periods nose bleeds bruises really easily but the platelets are normal but the bleeding time is high bonus brands it's a van willow brands so again this is a problem with platelet function not necessarily platelet number and why do we care about this medicine stuff because if our surgery patients have it it's going to make a difference to how we treat them in the or so lastly if the platelets are low the coagus are high fibrinogen is low d dimer is high and you see schistocytes on the smear are we worried yes what are we worried about dic that is badness so some important causes to remember gram negative sepsis because of the lps can cause dic disseminated carcinomatosis can cause it and then some random ob stuff that we care a little bit less about at this stage okay so for a patient with a burn remember the rule of nines and how it's a little bit different between adults and kids and remember the parkland formula for determining fluid resuscitation of a burn victim so you'll see some discrepancy in the sources as to whether to use three or four and for kids whether to use two to four i've even seen six to eight i think it was in the pista packet these are the numbers that i found in the most sources so these are the ones that i memorized for my test but you know again it kind of depends on what source you're using things to remember about burn burn patients they are more susceptible to infection but we don't give them iv or po antibiotics why is that yeah it breeds resistance very good so we're going to give topical antibiotics instead and there are three main topical preparations we give to burn burn patients and you'll want to know the differentiating factors between them so one factor or one topical medicine doesn't penetrate escher eshar but can cause leukopenia which one is that oops okay yes silver sulfadiazine very good so the side effect of silver sulfidizing that you need to remember is glucopenia and it's not the best for third degree burns because it won't penetrate that that sharp so what does penetrate the sr but is very very painful mafinide mapinide and then the third one also doesn't penetrate the usher and the side effects that you watch out for are hypokalemia and hyponatremia silver nitrate very good so i definitely had a question about one of these determining between the three of these agents based on their side effects so go back and review this before your test if you have time so some other random burn stuff got a chemical burn particularly in your eyeballs what do you want to do flush it even before you come to the er if you've got an electrical burn the next best step very good because what's going to kill you the arrhythmia after the electrical burn so first best step for an electrical burn is an ekg if that's abnormal we got to monitor them on telemetry for two days um if we've got a burn patient especially an electrical burn patient who's got a urine dipstick positive for blood but there's no rbcs seen on the microscopic exam does that tell us their pee is red but there's no red blood cells in it rhabdo very good so rhabdomyolysis causing myoglobinuria causing renal failure so that's another kind of medicine-y thing that they could sneak in there so if we find myoglobin area what do we check what would kill you potassium absolutely because if you've got rhabdo your cells are bursting and dying that intracellular potassium gets out and can cause fatal arrhythmias so we got to check the potassium so what if a burned extremity becomes really tender numb white cold and we can't get a doppler bowl pulse what is that called some bad stuff compartment syndrome so the swelling can cause compartment syndrome the criteria are those five ps um or old school way would be to measure the compartment pressure greater than 30 millimeters of mercury and how do we treat it yeah fasciotomy and they even do it at the bedside i've heard i didn't do the burn rotation but i hear you get two dbs with some frequency did anyone do them flashy out of me yeah was it scary surgery scares the poop out of me it really does that's why i'm not doing it anyway glad someone will okay so trauma uh very very high yields on this exam so you can get a lot of test questions uh you know bang for your buck points wise if you review review your trauma stuff so what do we do with an airway if our patient comes in and is unconscious innovate good what if the gcs is under eight innovate what if a dude gets stung by a bee and he's starting to get strider and he's doing some tripod posturing innovate what if a dude gets stabbed in the neck but his gcs is 15 he's talking to you like nothing's wrong but he's got this expanding mass in his lateral neck innovate yes what if a guy gets stabbed in the neck and you hear some crackly sounds when you're palpating around his neck it feels like rice krispies under his skin be careful while intubating with the fiber optic bronchoscope yes so um that crackly rice crispy stuff that subcutaneous emphysema and you might have a laryngo injury or an airway injury so you'll want to take a look at what you're doing with the fiber optic bronchoscope if at all possible so what about a dude with huge facial trauma can't really see what's nose and what's face and what's mouth and all that stuff um and the gcs is seven crike good so when you can't assess where you're putting your your tube your airway this is a good a good indication to do a crypto thyroidotomy all right so you innovated your patient next best step what did you do in the pit listen for breast sounds good it's almost too easy right you gotta take your stethoscope out and listen if they're decreased on the left after you've placed your airway pull it back because you have intubated the right main bronchus so what do we do pull it back and next step well listen again let's say we know we got it now you do usually get a chest x-ray but we also want to check the oxygenation status so okay speaking of chest x-rays check these out so um what do you think about this one right here is anything there worrisome to you so this patient might come in hypotensive their chest really hurts because they were in a really high velocity accident they're dyspnic there's some new murmurs yeah so this is traumatic aortic injury so the treatment here or like yesterday they got to get there soon because we need surgical reconstruction um with a clip so this is traumatic aortic injury uh what about this pay no attention to this word right here so what is this chest x-ray so that's a pneumo that's a pneumothorax and can you see the the darker lung fields here it's a little more hyperlucent because it's air there's no lung tissue so this little shrively dude here is the collapsed lung as they've so nicely told us um we've got a pneumothorax so what might we see on physical exam with our pneumothorax friend what might we hear so we hear absent or decreased breast sounds on this side hyper resonance to percussion what what if it's attention pneumo sure yeah so we definitely want to pay careful attention to the neck veins because if they were distended and the trachea were deviated away from the side then we'd be worried about attention pneumo so what about this one does this look like a normal chest x-ray or not that looks pretty crappy so what does this patient have let's say um we listened over here and we hear decreased breath sounds it's dull to percussion um yes that's a hemothorax very good so what are we gonna do chest tube very good chest tube so what are the indications to take somebody with the hemothorax to the or so that's another thing they like to ask about on the shelf when do you go to the or so yes so if there's high output greater than a liter and a half in the first the first immediate uh time when you put the chest tube in then we take him to the or or if there's greater than 200 ccs per hour over the first four hours so high output is a reason to take someone with a hemothorax to the or otherwise you just kind of let it drain and this last one also looks bad so this patient also may have had some rib fractures on this side they had a really bad car accident where they tested the steering wheel if this were described in a clinical vignette it might be called the white out lung yeah it's a pulmonary contusion very good and treatment for pulmonary contusion do we take him to the or no basically just good point pulmonary toilet we want to make sure that they're they're expanding their lungs if they've got some pain from their rib fractures we need to control their pain um but these people don't get surgical intervention we just want to make sure that they're coughing clearing their secretions and taking deep breaths okay so a little bit more about chest trauma if a patient has inward movement of the right rib cage upon inspiration what is that so that's paradoxical movement right if it moves in when when you inspire um so that's flail chest from rib fractures that are three consecutively and how do we treat it how do we treat flail chest what hair flock good so we want to control pain and you are psychic and read my mind to the next question what do we do for pain control we give nerve block what if this patient is screaming and crying doctor i hurt i need some morphine i need some demerol why not yes because opiates can decrease the respiratory drive which we don't want in our patient with the rib fracture okay so patient has confusion petechial rash in the chest axilla neck acute shortness of breath maybe after a really bad car accident that embolism that was on house the other day do you guys see it yeah yeah see now you'll never forget it so when do we suspect a fat embolism long bone fracture usually femur is classic so if we have a patient who dies suddenly after a third year medical student removes the central line that's not funny cause that would be like the worst thing ever that's an air embolism so you also suspect air embolus when there's lung trauma using a ventilator that's uh overzealous with the tidal volume or during vascular surgery um where the vessels are being violated okay so more on cardiovascular if the patient is hypotensive and tachycardic what's that shock right so we worry about shock any time we see on vital signs hypotension and tachycardia if the neck veins are flat and the central venous pressure is normal what type of shock is that probably the most common type of shock yes hypovolemic so maybe with hemorrhage if it's in the right clinical situation so the next next best step here gotta do fluid resuscitation so two large bore peripheral ivs got to give two liters of normal saline or lactated ringers over 20 minutes and then followed by blood if we don't see an appropriate rise in the vital signs if we hear muffled heart sounds we see some jvd and our ekg shows electrical alternans and we see some pulses paradoxes on inspiration tamponade so now we're real worried what are we going to do to confirm pericardial tamponade we do fast we can do that quick ultrasound if it's readily available but if you really have strong clinical suspicion you go ahead and treat then what's the treatment needle decompression so we got to get that blood out of the pericardial sac so the heart can can contract properly so if we have kind of talked about this already decreased breast sounds on one side tracheal deviation away from the collapsed lung tension pneumo and next best step do we want to get a chest x-ray shove a needle in it so we do not need to confirm tension pneumo if we have the strong clinical suspicion like the the physical exam findings i've outlined here so chest x-way will be wrong needle decompression will be right and after you decompress with the needle add a chest tube okay so this is a busy slide and i'll let you guys review this on your own but the differences between the types of shock does come up in test questions particularly the differences between like neurogenic shock after a spinal cord injury versus hypovolemic versus cardiac so pay special attention when you're studying to what you see on physical exam whether they're hype tachycardic or bradycardic for example and pay special attention to what your pressures would be measured by your swan ganz catheter okay so head trauma remember how to calculate a gcs and i've just listed the maximum for the glasgow coma scale on this slide so the best you can get for eyes is a four motor is six and verbal is five so um expect a question where you're given a clinical vignette and you're asked to calculate the glasgow coma scale what if you get this well actually i should ask this first if a patient comes in with head trauma or they've ever been unconscious what's the next best test ct right because we want to see if there's any kind of bleeding we're looking for this badness right here so what is this badness that's an epidural hematoma it's that uh by concave disc what about this badness that subdural is it acute or chronic it is acute how do you know yeah so acute blood is is is bright on a ct old blood and it's kind of a small one but you can see it here this little crescent is dark it's already been partially reabsorbed and remodeled so that's a chronic subdural this would be like an old person whose mental status has been going down the crapper for the past two weeks like they're getting more demented and they've never been demented before and then they fell off a horse two weeks ago that would be a chronic subdural acute subdural is like after a really bad high velocity car accident so symptoms to look for that indicate increased intracranial pressure include hematoma on a ct or edema papilloedema on fedoscopic exam or tumor can all cause increased intracranial pressure and what are some symptoms how do we know our patient has increased icp by what they're telling us headache projectile vomiting that's always fun and then any type of change in mental status and how do we treat increased icp elevate the head of the bed we can give manna tall to help relieve some of the pressure what else and we hyperventilate we hyperventilate so the pco2 is lower than normal it's between 28 and 32. okay so when do we do surgical intervention or what would we do what would we do for surgical intervention have you seen the neurosurgeons do it that's also pretty scary that makes me want to poop my pants also so ventriculostomy or or a burr hole it can do a burr hole for some of these um hematomas the ventricular to me that's a little bit more controlled in the or sometimes that's a little bit less scary but okay so for neck trauma review your anatomy and make sure you've got the difference between zones three two and one and the differences in treatment or work up when the injury is in one of these three places so for penetrating trauma anytime we have a gunshot wound or a stab wound we want to make sure we know where in the neck the issue is occurring so zone three what are the boundaries yeah so above the angle of the mandible and what do we do if there's a penetrating trauma there yes we want to check um the aorta with an aortogram or aortograph aortogram and triple endoscopy so we've got a lot of passages up up in zone three right the trachea is up there the esophagus is there we really want to make sure all those major passageways are are still viable and uninjured so zone two is between the angle of the mandible and the cricoid and the workup there is a little bit different we want to do 2d doppler to to check the patency of the vessels and we may want to do exploratory surgery i couldn't find a definitive answer in the books that i read about it i kind of just said plus minus for zone 1 that's below the level of the cricoid and the work up there we want to check the aorta so okay so what about penetrating abdominal trauma if we have a gunshot wound to the abdomen where are we going if we see this on chest x-ray where are we going yes immediately right this is free air under the diaphragm even if you suck at interpreting x-rays make sure you can pick this out okay uh and as we said gunshot wound to the abdomen um we need to go the or and get xlap plus a tetanus shot if it's warranted so what about a stab wound and the patient is unstable and they've got rebound tenderness on physical exam or yes do not pass go what if they've got a stab wound if the patient is stable yeah so we'll kind of want to shove a finger in it right see if we have violated the peritoneum if there's evisceration the other thing we'd want to check is whether there's intra-abdominal bleeding so the fast exam is a pretty good way to do that in the in the er quickly um or the dpl the diagnostic peritoneum lavage if the fast doesn't give us the answer we're looking for and then if either the dpl or the fast or positive or so what if we've got blunt abdominal trauma and the patient is hypotensive tachycardic or so anytime we've got an unstable patient or okay so more on blunt's abdominal trauma if they're unstable or if they're stable what's the next best step ct yeah so we're gonna do an abdominal ct if they're stable enough to go to the scanner if we see a lower rib fracture plus bleeding into the abdomen what are we going to worry about causing the bleeding yeah spleen or a liver laceration depending on the side right spleen on the left liver on the right uh if you've got a lower lip lower rib fracture plus they're peeing blood kidney so a kidney laceration could cause those symptoms if they've got curse sign positive and um viscera in the thorax when we look at their chest x-ray yeah i've got a diaphragm problem right curse sign is where you have pain in your left shoulder so it's it's referred pain um referred pain because of the phrenic nerve i was never the best anatomy student but that i remember okay so handlebar sign that's where you've got pain and bruising kind of like if you're riding a bike and you flip over the bike where the handlebars would hit you right here what's right here pancreas so handlebar sign big bruising in the mid-upper gastric uh with some abdominal pain after trauma worry about pancreatic rupture the ct will show you that as well um if they're stable with epigastric pain this is a little bit vague i got a couple usmle world questions on this i don't know if you guys have seen them um so we'll want to get an abdominal ct to assess what's going on and if you see retroperitoneal fluid on your abdominal ct what might have been injured duodenum the duodenum so duodenal rupture they're stable it's not a really acute abdomen picture but when you do the ct to work up their epigastric pain if you see retroperitoneal fluid the duodenum might have been ruptured in a way that's going to cause retroperitoneal leakage okay so for a pelvic trauma if the patient is hypotensive tachycardic want to make sure they're not bleeding into their abdomen um you can lay down into your pelvis and the best way to stop that is by stabilizing the fracture if it's present if we've got blood at the urethral meatus and if it's a man obviously the prostate is riding high what are you worried about blood at the urethra high writing prostate so you might have a urethral or bladder injury associated with your pelvic fracture what's the next next best test i want to evaluate the urethra with a retrograde urethra gram do not put a foley if there's blood coming out of the pp don't do that so if the retrograde urethrogram is normal what might you want to check so it's not the urethra what might be bleeding the bladder so we'll do a cystoscopy or a retrograde cystogram and here we're looking for dye extravasating from the bladder and you have to do two views in this study to see whether or not the diet strategy estravisates into the peritoneum so if it's extra peritoneal not that big of a deal we just tell them to rest place a foley for comfort if it's intraperitoneal extravasation of dye that's a big deal and surgery needs to perform semi-urgently to repair the bladder injury okay so as far as ortho trauma some fractures that go to the or i've got listed on this slide anytime a depressed skull fracture is present go to the or anytime you've got a really severely displaced or angulated fracture go to the or any fracture where bone is sticking out into the air that's bad go to the or or a femoral neck or intratrochaic fracture goes to the or as well some common fractures if they give you a clinical vignette that describes shoulder pain after a patient had a seizure or had a really severe electrical that's a posterior shoulder dislocation what about an arm that's outwardly rotated and you've got numbness on the deltoid anterior shoulder dislocation and why numb over the deltoid nerve injury good uh an old lady fell on her outstretched hand and her distal radius is displaced that's cauli's fracture that's the dinner fork deformity that you might have read about the collie's fracture it's usually when an old person falls on their outstretched hand if a young person falls on their outstretched hand and you palpate their anatomic snuff box and illicit tenderness what's broken skapoid very good um so you all saw this guy in the er right i just punched a wall it wasn't in a bar fight i promise so what and there and their hand hurts whether they probably break yeah it's boxer's fracture it's a metacarpal neck fracture usually of the fourth or fifth uh metacarpal and the clavicle where do we usually break it between the middle and the distal thirds good um back to scaphoid fracture often when you get the x-ray what will you see first off nothing right the x-ray can often be negative and not having a high index suspicion for this fracture can lead to problems for your patient and maybe lawsuits for you so even if the x-ray is clear it's important to have a high index of suspicion for this fracture because you you can often see it early okay so here's kind of the things i was talking about the distress the depressed skull fracture that they might show you see right this would be normal this is abnormal this is kali's fracture with the dinner fork deformity of the radius um scaphoid fracture it's kind of hard to see this is where it's already been pinned surgically this shows a clavicle fracture you can see it is not a continuous clavicle and then femoral neck fracture versus intertrochanteric fracture so x-rays that they might that they might put on your exam okay so after surgery fever on post-op day one what is the most common cause very good atelectasis and how do we diagnose it can listen we can just take a chest x-ray um and usually the findings are pretty unimpressive just some kind of bilateral fluffy stuff in the lower lobes for atelectasis how do we treat it pulmonary therapy if you're if you're um my surgery attending you scared the crap out of the patient like you better get up and breathe deeper use your incentive spirometer or you're going to get pneumonia and die so scaring your patient can prevent atelectasis i don't know if i'd use that technique but whatever um so on post-op day one what if they have a really high fever to 104 they they appear very very ill so neck fashion is one thing that can cause a super high fever in the early post-op period the pattern of spread is along scarpa's fascia in the subcutaneous tissue and common bugs that can cause necrotizing fasciitis strep yep and clostridium i already put it up there okay so how do we treat it o-r-o-r and debris debris debris so heavy-handed debridement uh in the or with iv penicillin is how we treat necrotizing fasciitis so the other cause of a super super high fever and muscle rigidity like right after surgery in the pacu what malignant hypothermia and what's it caused by it's a genetic problem um oh well so what causes it the anesthetic that that's used during surgery there's succinylcholine or aloe halothane and the genetic defect is a problem with the rhianidine receptor so that nugget of information might have been in your brains from physiology but it actually could end up on your test on friday for surgery so how do we treat malignant hyperthermia dandruline sodium very good and angeline sodium works because it blocks that rhianidine receptor and decreases the amount of intracellular calcium okay so fever on post-op day three through five got a chest x-ray that looks like that fever cough and diaphoresis all right so here's the heart what's this that's consolidation that's pneumonia this is pneumonia and how do we treat it antibiotics right so we'll want to check a sputum sample to culture but we'll cover them with usually a fluoroquinolone in the meantime to cover for strep pneumo while we're waiting for the cultures to come back so another common cause of fever on postop day three four or five is fever dysteria frequency urgency uh particularly if the patient has a foley uti the next best test you ain't culture good and how do we treat them antibiotics right take out the foley or change it um and then treat treat them with antibiotics until the culture comes back so uh post-op day seven or beyond if there's tenderness at the iv site worried about a line infection and we treat it by taking a blood culture first to diagnose and then pulling the line and giving antibiotics if there's pain at the incision site edema in induration around that area but there's nothing draining what is that so it's red it's swollen it's painful but there's no drainage from the incision cellulitis good so the no drainage with that clinical picture tells us that cellulitis and what do we do to treat cellulitis leave it alone cut it open give antibiotics so we'll do blood cultures to make sure it's not bacteremia and then we'll start antibiotics if there's similar clinical picture with pain at the incision site but there is drainage that tells us we have a wound infection and how do we treat these no antibiotics we'll open the wound repack it if you're the medical student you have to change the nasty packing every day you know what i'm saying you guys had to do that too right it wasn't just me okay um so what if we've got pain at the incision site with salmon colored fluid that weeps from the incision dehiscence that's also bad news and how do we treat that so depending on the degree of dehiscence it it requires a trip back to the or so we'll have to give them antibiotics and then close the fascia because in dehiscence the problem is violation of the fascia and we can't just let that go so typically they need to go back to the or to get that primarily closed unexplained fever could be an abscess especially if there was intra-abdominal surgery in the recent past and we diagnosed that mainly with the ct and in the last resort we may need to do a diagnostic laparoscopy or laparotomy to see what's going on and treatment of an abdominal abscess and most abscesses for that matter drain it drain it so almost all abscesses with the exception of two that i know of need drainage so abdominal abscesses are no exception some other random causes of fever um thyroid storm thrombophlebitis particularly uh now this tripped me up on my shelf there are a couple of ob gyn questions on the surgery shelf usually after gynecologic surgeries um it's like after a c-section or after like a hysterectomy a patient could have unexplained fever you looked for all these sources and ruled them out they can have pelvic thrombophlebitis and the treatment there is antibiotics yes but also heparin because until you break up the clot that's got the little bacteria friends hanging out in there the antibiotics won't do any good so if they do give you a gynecologic surgery patient unexplained fever late in the post-op course think about thrombophlebitis okay so pressure ulcers these are gross they're caused by ischemia in a word and there are four stages so stage one is blanchable so that's always a good sign anytime you see a pressure ulcer you want to touch it make sure it blanches if it's stage two it it starts to look a little bit crustier and grosser there's a blister an actual break in the dermis stage three it starts to erode into muscle and stage four that's super bad news it goes all the way to the bone so um one thing i will point out because it was either on the midterm or the real shelf i can't remember and that's marjalyn's ulcer was that on the midterm so what's marjolin's ulcer and why do we want to do a biopsy to rule it out squamous cell carcinoma very good so in a chronic ulcer all that remodeling and cell turnover for repair can predispose to carcinoma arising in that area okay so treatment for stage one and two get a mattress put some cream on it no big deal stage three or four really needs surgery with a flap reconstruction in most cases okay so for thoracic surgery remember your pleural effusions be able to see them on a chest x-ray and anytime you have more than one centimeter of fluid in this little costophrenic angle or more than one centimeter on a lateral decubitus x-ray you've got to tap it you've got to do a thoracentesis to see what type of effusion you're dealing with if it's transitive it's more likely to be a systemic cause like a congestive heart failure nephrotic syndrome or cirrhosis some random things they might throw in there if it's transitive with the low pleural glucose rheumatoid arthritis can actually cause that not surgical but whatever if there are high lymphocytes in a transitive effusion might be tbd and if it's bloody think cancer or a pe so if it's an exudative effusion it's more likely to either be due to a pneumonia or a cancer and a complicated effusion means there's bugs in there we can see them on gram stain there's ph that's low acidotic effusion or what you can't see there the glucose is low and the glucose is usually low because either cancer cells or bugs are eating it so that makes sense and if it's complicated we need a chest tube and were you guys pimped a lot on lights criteria no okay well light's criteria are how we determine whether it's transitive and we check the ldh and compare it to the ldh between the flu effusion fluid and the serum if that ratio is less than 0.6 we're transitive and if the protein ratio between effusion and serum is less than 0.5 for a chance of dative okay so a spontaneous pneumothorax remember these can happen in our emphysema patients when a sub-pleural bleb ruptures and the lung collapses or it can also happen spontaneously in a young healthy man usually they're tall and skinny and suddenly have some shortness of breath so we do a chest x-ray to diagnose it treat it with a chest tube and important for you guys are the indications for surgery when do we intervene in these folks who have the spontaneous pneumothoracies if it if it recurs on the same side or the opposite side if they're bilateral um or if the lung can't completely expand after after the pneumothorax also if they've got some kind of occupation that would be really bad if they suddenly passed out like if they're flying a plane or underwater or something um then we might want to do surgery and the surgery we do uh is the video assisted thoracic surgery or pleurodesis where we shove we shove some stuff in there to make the pleura stick and prevent lung collapse from happening again so lung abscesses remember i kind of hinted that there were a couple abscesses that we don't drain as a first treatment lung abscess is one of those so if we have a patient with a lung abscess we can see it on chest x-ray with an air fluid level that's that's what you would see or that's what they would describe and the initial treatment is not drainage but antibiotics and since staph or anaerobic bacteria are most likely to cause a lung abscess we're going to treat it with either penicillin or clinda so why would we drain it surgically if the antibiotics don't work or if it's super bad or if there's emphyma okay so if you have a patient with a solitary lung nodule what's your first step find an old chest strain chest x-ray and compare it very good so some things on a chest x-ray that would reassure us if we see a really small nodule like this one if popcorn calcification is described that usually means hamortoma which is common and benign concentric calcifications means um it's an old granuloma like a healed tb uh or if the patient's young it's tiny well circumscribed not as big a deal so the treatment is just close follow-up we don't necessarily have to go in there and and get out the the nodule itself however if it's big if it's speculated if the patient is old and it's been smoking for a million years we're going to be a little bit more suspicious of that nodule and we'll want to get the nodule out for tissue so depending on where it is if it's central and we can get to it from bronchoscopy we'll we'll biopsy it that way or if it's in the periphery we may have to do an open lung biopsy okay so about cancer these are the symptoms in your clinical vignette that tell you your patient has lung cancer they have weight loss they're coughing they can't breathe they're coughing up blood or they keep having recurrent pneumonia in the same side kind of a post-obstructive pneumonia is what they call it the cancer kind of gets in the way of mucous clearance so you keep having pneumonia on the same side so once you've diagnosed lung cancer there's four main flavors you need to know so what's the most common type in non-smokers adeno adenocarcinoma is the most common in non-smoking patients and it can occur in the site of old pneumonia like in the scar tissue there and adenocarcinoma is it peripheral or central 5050 peripheral so it's a peripheral cancer and it likes to go to the liver bone and brain and the weird place that adenocarcinoma likes to go that they might ask you about are the adrenals that's kind of weird and other weird thing about adenocarcinoma is that it is likely to cause an exudative effusion with high haloronidase a little known fact so what about we have a patient with these lung cancer symptoms that also has kidney stones constipation feels bad low parathyroid hormone and a mass in the central part of their lung what type of cancer is that squamous cell very good so squamous cell is central and it's perineoplastic syndrome is that it makes a parathyroid related peptide which causes hypercalcemia okay so a patient has shoulder pain ptosis a constricted pupil on one side and a puffy face facial edema a dead guy got his name on this type of tumor pancos good or superior sulcus syndrome and small cell is the cancer that likes to go there so that is superior sulcus syndrome or a pancreas tumor but it's typically caused by squamous cell what about a patient with ptosis that gets better after they look up for a minute that's also perineoplastic syndrome there are antibodies against the presynaptic calcium channels also some dead guys lambert eaton good so and lambert eaton is also associated with small cell carcinoma so um okay so an old smoker who's got hyponatremia but no jvd we talked about this a little bit earlier when we talked about electrolytes that's si adh and that also comes from small cell so almost all the paraneoplastic syndromes come from small cell except for parathyroid related peptide parathyroid hormone-related peptide okay so last one a chest x-ray it shows a peripheral mass it's cavitating and there are mets all over the place really advanced at presentation the only lung cancer we haven't talked about yet not small cell but large cell the large cell carcinoma is the other peripheral cancer so out of the four you need to know adeno and large cell are peripheral lesions squamous and small cell are central lesions so that's one way to distinguish them the other way they like to divide up lung cancers is between small cell and non-small cell and why is the divide there between small and non-small different treatments and that's what we care about on the surgery shelf right who gets surgery non-small cell small cell carcinoma come see um people like my attendings right now small cell carcinoma is very chemo and radiosensitive so we don't do surgery typically for small cell carcinoma but we can do surgery for squamous cell and other non-small cells okay so ards important in our sicu patients and the causes that you'll want to remember are gram-negative sepsis if we've got gastric aspiration pancreatitis can also cause ards how do we diagnose it three criteria so radiographic sure that's what i'm trying to show you here so radiographic criteria are bilateral fluffy infiltrates this one yeah so the pao2 over fio2 ratio over 200 and then the third one is so we've established here we see pulmonary edema the patient can't breathe very well the last criteria is to make sure this pulmonary edema isn't cardiac so the last one is yeah the wedge pressure less than 18. good so the first one shows us that our ratio is low so we've got hypoxia the chest radiograph shows our infiltrates and our pulmonary edema and this last criteria tells us that it's not the heart that's screwed up it's the lungs okay so how do we treat it what's our event setting peep very good okay so some murmur buzzwords so you can pick out these murmurs in your patience what's the systolic ejection murmur that um has parvus at tardis gets louder when you squat it's aortic stenosis what about another systolic ejection murmur that gets louder when you've elsava this might be a little kid or a teenager on his pre-sports physical hypertrophic obstructive cardiomyopathy the difference here is what happens with valsalva because valsalva decreases preload right back to physiology so valsalva decreases preload and if the problem is aortic stenosis it's going to get softer when we decrease preload because there's less flow going through the stenotic valve with hokum the the the obstruction actually gets worse when there's less preload because the ventricular wall can get closer to the valve so what happens with valsalva is how you tell the difference between those two our other systolic murmur has got a click light systolic murmur with a click might be a young woman mvp mvp um the last one is holosystolic that's what makes it different from the previous three it's all throughout systole radiates to the axilla mitral regurge okay so some more murmurs these are in your babies that you might be fixing in pd surge holosystolic murmur with a late rumble it's the most common congenital heart defect bsd continuous machine like murmur that's pda wide fixed and split s2 usually these don't need surgical correction asd very good rumbling diastolic murmur with an opening snap maybe they had rheumatic fever back in the day mitral stenosis uh a blowing diastolic murmur with a widened pulse pressure and the eponym parade you know those dead guys like the i don't even remember them it's been so long since i took step one you guys know though all those dead guy names like the water hammer pulse and all those things what's that one aortic regurg very good um pulmonary stenosis i think that does give you a wide fix in split s2 the rest of the clinical picture will be different mainly what's going to help you with the right sided heart murmur is they'll tell you it gets louder with inspiration so all right sided heart murmurs if they're trying to lead you down that path they'll say in the vignette that it gets louder when the patient inspires whereas this one is probably going to be a little kiddo someone under the age of 15. okay so for gi what if your patient well your patient's wife actually tells you that their breath is really bad and when they wake up they've got some snacks left over in their mouth really gross thinkers good we treat that with surgery is it a true or false diverticulum good only contains mucosa um and they've got dysphagia to liquids and solids and this is the characteristic oh wait okay so good so who has dysphagia to liquids and solids and might have a barium swallow that looks like that hey callasia so that's the bird beak where we've got the spasm at the lower esophageal sphincter and we can treat that medically with calcium channel blockers the heller myotomy is the surgery we would do if medical management fails so what about epigastric pain that's worse after you eat or lie down might be wheezy they might be hoarse those are some atypical symptoms of oh i skipped that okay so over here dysphagia that's worse with hot and cold liquids that's diffuse esophageal spasm and this is the barium swallow of its characteristic with that so it's not just like achalasia where the problem is at the lower esophageal sphincter but you've got spasm at different areas in the esophagus but the treatment's the same calcium channel blockers or nitrates so what i was talking about down here is your garden variety gerd the wheezing the hoarseness and the kind of chronic dry cough those are atypical symptoms of silent aspiration where you're regurgitating some gastric secretions and then they go down to into the airway so indications for surgery this is important for you guys when do we operate on patients with gerd so if they have like scary scary complications like bleeding a stricture from all of the acid regurge ferrets like you said or they're at the maximum medical treatment and they're still symptomatic very good okay so hematemesis after vomiting subcutaneous emphysema pleural effusion what's on your differential for hematenesis after vomiting might be a drunk guy so mallory weiss wouldn't have the subcutaneous emphysema so subcutaneous emphysema means there was a total transmural tear so i was going with more javes here but mallory rice would be on your differential for hemotemesis for sure so next best test here chest x-ray first see what we can see we don't want to give barium here if we can help it because it's going to be more irritating if there's a rupture and the treatment we've got to repair it especially if it's a full thickness rupture oops so also on your differential for hematemesis especially if they're a big drinker they've got a history of cirrhosis think about gastric varices or esophageal varices and if they're in hypovolemic shock we do what we do for anybody with hypovolemic shock we resuscitate them check the abcs um give them lavage with a nasogastric tube and then resuscitate them if if they're hypovolemic so some other treatments for um for varices we can treat it medically with octreotide or somatostatin and then balloon tamponade if if it's very grave and we need to control the bleeding as soon as possible so the treatment of choice for varices we can band them or sclerotherapy thing i want you to remember i got tripped up on this on some of my cuban questions if we see varices incidentally when we're doing an endoscopy or something we don't treat them we only treat them if they're symptomatic so remember that and then progressive dysphagia or weight loss what are you worried about here if they've got dysphagia that's getting worse they're starting to lose weight cancer right esophageal carcinoma the different different types being squamous cell versus adeno and they are present in different locations of the esophagus our best first test if we're considering esophageal cancer barium swallow first but really we need endoscopy because with endoscopy we've got the capability to biopsy and prove the the cancer cells are there okay so for the stomach if we see acid reflux pain after they eat or when they're lying down and this isn't your garden variety gerd there's a kind of hernia involving the stomach hiatal hernia good and there's two main types type one sliding where the ge junction goes straight up into the thorax and the second type is paraesophageal where the area next to the ge junction slides up so the difference is with type 1 really it kind of depends on the symptoms you treat them symptomatically but type 2 those are more likely to end up in your or so in a patient with media epigastric pain that gets worse when they eat the risk factors would be h pylori nsaids or steroids that might be a ulcer gastric ulcer especially if it's worse worse after they eat um and for workup what we want to do we'll definitely want to get some kind of biopsy we can do a barium swallow first but really we'll want to do an egd so that way we can get a biopsy and make sure it's not something scary we can do our testing for h pylori but we can also make sure we're not dealing with the gastric cancer we'll want to do surgery if the lesion persists after maximum medical treatment that's kind of the running theme for most of these conditions so for gastric cancer adenocarcinoma is the most common and it's more common in the japanese population some random eponyms that you might need to know kukenberg associated with uh mets to the ovaries bloomer shelf is something you can feel on rectal exam in the in the shelf down there near the peritoneum ver cows node anyone remember where those are super clav very good sister murray joseph node belly button um lymphoma gastric lymphoma what's that associated with what other disease what types of patients get gastric lymphoma aids patients and malt lymphoma is associated with h pylori this is actually pretty cool this is one cancer we can treat with an antibiotic because if we give the right triple therapy to treat the h pylori the malt lymphoma often goes away also okay so some other random stomach stuff do y'all remember what mentriaris is so it's a protein-losing enderopathy so we might see that foamy p and also on egd we might see enlarged rugae in the stomach gastric varices different from esophageal varices these are often associated with splenic vein thrombosis and it can happen after chronic pancreatitis diet i can't even say this someone pronounce this word for me thank you and what is this associated with if a patient has this what are they going to come see you for this is also on your differential for hematemesis because that's where a vessel erodes into the into the stomach and so the bleeding occurs and we can have hematemesis so so that's what that is okay so we talked about gastric ulcers but if the mid-epigastric pain gets better with eating what type of ulcer are we likely dealing with it's at the top of the slide duodenal good and these are more likely to be associated with h pylori um healthy patients we can just go ahead and try them on a trial of medical management but we want to make sure that they're not bleeding occultly so we'll want to do an occult blood test fecal occult blood test and then there are a variety of tests we can do for h pylori which is the best one don't look at the slide or look at it so the best test is with endoscopy we can do a clone test and again this is best because we actually have tissue and we can exclude something scarier like cancer attributing to the problem so the treatment here is our triple therapy with the ppi and antibiotics and the breath and stool antigen tests can be done after therapy to make sure that we've cured the process so what are we worrying about if we treat our h pylori and the pain doesn't get better it's a medication refractory ulcer or there's lots of ulcers or there's ulcers and weird places in the duodenum solinger ellison so we're going to worry about ze syndrome here if the ulcers are refractory there's still symptoms or still ulcers after treatment and the best test for this is a secret secretin stimulation test and we'd find high gastrin even when we administer secretin that's supposed to suppress it so we treat this with surgical resection if we can find the tumor and even though the ulcers are in the duodenum the cancer or the tumor is actually more likely to be in the pancreas and more importantly what else do we look for if we've diagnosed ze syndrome in a patient there's a syndrome that this pancreatic tumor is associated with men1 so what else are we looking for here's the pancreas what are the other two things we look for pituitary and parathyroid good very good so in a patient with bilious vomiting postpartum pain and they just won the biggest loser and lost a buttload of weight what are we worried about i got pimped on this in the or and got it wrong it was very sad so this is sma syndrome have you guys read about this so sma syndrome happens after rapid weight loss because the duodenum is compressed in that area between the abdominal aorta and the sma so that compression can cause pain after you eat when blood flow is trying to rush to the area the treatment really is by restoring weight and nutrition if possible a reason why surgery is a more drastic and last resort option so as far as pancreatic problems are concerned mid-epigastric pain that radiates straight through to the back what do we worry about pancreatitis and what are the two most common etiologies drinking and eating at mcdonald's right gallstones and alcohol induced so i've read books where one or the other is listed as number one i'm not sure what the right answer is i think it depends on your patient population here it's probably gallstones um so how do we diagnose pancreatitis what's the test of choice so ct is the best imaging test we can take a look at the amylase and lipase levels because those will both be elevated and the treatment for pancreatitis is mainly supportive so ng suction if they're nauseous npo to give them bowel rest iv hydration and just watching them bad prognostic factors are things that we look for upon admission and then 40 out 48 hours later and you can see those listed on the slide the questions that i think are the most difficult about pancreatitis are the complications so what are some common complications of pancreatitis huh pseudocyst sure what else third spacing of fluid sure that counts to hemorrhage and abscess absolutely so pseudocyst remember because it's pseudo it doesn't have any cells if you see cells on a cyst on the pancreas it's probably cancer hemorrhage and abscess third spacing which can progress to ards is another complication so chronic pancreatitis really these patients usually present with malabsorptive symptoms and what i want you guys to remember about it is that chronic pancreatitis can predispose to splenic vein thrombosis which then leads to what gastric varices good um so cancer of the pancreas adenocarcinoma is the most common um and these are sad cases because they usually don't present with symptoms until it's pretty advanced and really you have the best chance of getting caught early if this if the tumor is in the head of the pancreas because you might have some obstructive symptoms so uh some random vocab words to remember kovacier's sign so how you say that c word what's that sign palpable non-tender gallbladder and it also might be associated with obstructive symptoms itching in jaundice what's true so's sign um no this this one's migratory thrombophlebitis there may be a different truth or so but the truso sign associated with pancreatic cancer is thrombophlebitis in different vessels that migrates around so we diagnose pancreatic cancer with an endoscopic ultrasound nfa we always want to get a tissue diagnosis and for you guys what's important is when do we do surgery or i should say when is surgery not contraindicated when is a pancreatic tumor deemed resectable mainly it can't be invading into important stuff so we don't want to have mets outside the abdomen because the whipple won't be curative we don't want extension into the sma or the portal vein um or mets into the liver or elsewhere so resectable lesions are really pretty well confined to the pancreas and the immediately surrounding areas like the duodenum okay so endocrine pancreas insulinoma usually diagnosed clinically with whipple's triad what's that oh you guys are getting sleepy i'll tell you so symptoms like sweating being shaky hungry even seizures from hypoglycemia low blood glucose level and then the symptoms that get better after we give glu glucose so on labs how we can tell it from a big faker is their insulin levels are high but their c-peptide levels are high and their pro-insulin levels are also high so those second two lab tests are really how we can tell the real deal from the surreptitious insulin administrators so a glucagonoma then is an endocrine tumor that makes glucagon and the symptoms there are hyperglycemia diarrhea and weight loss and you probably won't see this picture but glucagonoma has a characteristic rash does anyone remember the name of it it's on this this guy's butt cheeks right here i think that's his butt i'm not sure so it's called necrolytic migratory erythema so in case you see it in a clinical vignette on a super hard question at least you've heard it once so somatostatinoma these are the worst tumors to have because they're more commonly malignant and they present basically with malabsorptive symptoms and then a vip oma the symptoms are kind of like carcinoid syndrome watery diarrhea flushing and then hypokalemia and dehydration from the diarrhea so the treatment there is like with carcinoid syndrome we give octreotide so gallbladder you saw lots of gallbladder pathology on your general surgery rotation the characteristic symptoms of right upper quadrant pain goes to the shoulder or the back nausea vomiting fever after you eat some mcdonald's what's that usually what gallbladder problem is that is it cholecystitis or is it symptomatic gallstones and fever fever really can can help us make that determination a white blood cell count would also be helpful because you're more likely to see leukocytosis and cholecystitis but fever can also give you that clue so the best first test is an ultrasound that's what i've got shown to the side and we treat it by taking the gallbladder out sure you guys saw a lot of those so the only time you put a percutaneous cholecystostomy is if the if the patient is too unstable to go to surgery so in a patient with right upper quadrant pain high bilirubin and alkaphos what are we thinking of there so it's obstructive symptoms right with the high bilirubin and alkaline phosphatase so yeah kolidoko so that's where the stone is so we've got a blockage of the common bile duct and we can usually see this stone on ultrasound and treatment is similar we can take the stone out so if your patient in your clinical vignette has this pin tad of right upper quadrant pain fever jaundice hypotension and altered mental status it's a complication of choledocolithiasis where it gets infected ascending cholangitis good so we've got to treat them with antibiotics to cure the infection and then we also have to take this stone out with ercp so for colidocosis you if you had some experience with pd surge you might have seen some of this there's a whole spectrum of types but i would really remember type 1 and type 4 because the treatments are very different so type 1 is the most mild kind it's just where you have fusiform dilation of the common bile duct and we treat it with just excision of that cyst done early in life by a pediatric surgeon type 4 is the most bad it's the most complicated it's also called carroll's disease and that's where the cysts are far into the liver into the intra-hepatic ducts so for those we can't just excise them because they're in the liver we need a total liver transplant and cholangiocarcinoma is pretty rare the risk factors are primary sclerosing cholangitis which is associated with ulcerative colitis and then some other random things and that cancer like most cancers in the gi tract it's treated with surgery and maybe we add radiation afterwards okay so if we order some lfts and we see our ast is twice our alt what's causing that hepatitis alcohol absolutely um and what if they oh just kidding supposed to be alt greater of an ast but they're both super high like in the thousands so reverse that little crocodile mouth alt is higher but they're both in the thousands it's not alcohol it's a virus so viral hepatitis has higher levels of your liver enzymes and the alt is usually higher so if they're both really high but it's after hemorrhage or surgery particularly cardiovascular surgery what might be causing the elevated liver enzymes heard of shock liver so hypotension can cause liver and injury which leads to elevated liver enzymes as well so in terms of cirrhosis that can lead to portal hypertension and cause problems for our patients medical treatment is usually tried first somatostatin is the one of the medications of choice and those vasoconstrict to decrease the portal pressure again we talked about esophageal varices already and that you don't need to treat them prophylactically and tips is a surgical procedure that can be done that's really good at relieving portal hypotension but what complication can it cause so it makes the portal hypertension worse i mean better what does it make worse associated with cirrhosis what encephalopathy good it worsens encephalopathy because it prevents the clearance of ammonia so we'll have higher ammonia levels which worsens the hepatic encephalopathy and what do we treat hepatic encephalopathy with flaculos so we poop it out or the patients poop it out when they take blactulis some risk factors to remember for hepatocellular carcinoma the main one is if you're a chronic hepatitis b carrier hepatitis c carries a risk to a smaller extent and then cirrhosis for any reason can predispose you for hcc afp is the tumor marker to remember for hepatocellular carcinoma and diagnosis is typically with a ct or mri and the treatment depends on if there's one lesion or multiple if there's one it's easier to take it out surgically if there are multiple then we've got to look at some other options okay so some random liver stuff if you're a woman on ocps either got a palpable abdominal mass or spontaneous rupture and hypotension what might that be from hepatic adenoma hepatic angioma is the most common benign lesion in the liver but this um sudden rupture and the associated with association with oral contraceptives should make us think hepatic adenoma in this case so typically we diagnose it either with ultrasound or mri and the treatment stop the ocps so surgery really isn't needed unless it's super large or the woman wants to become pregnant his pregnancy can increase estrogen as well and estrogen is what makes these tumors grow so the other benign liver tumor that's also more common in women but less likely to provide a problem when it ruptures is what it's like hepatic adenoma but different in that it's less dangerous less likely to rupture that's focus focal nodular hyperplasia so that's the second most common benign liver tumor okay so let's talk about bugs a bacterial abscess is most commonly caused by what bacteria okay so the big three are e coli bacterioides and enterococcus this is an example of something that's in surgical recall that actually might be on your shelf so that's good to know we treat this by drainage and iv antibiotics so contrast that with this next patient who has pain in the right upper quadrant around the liver profuse sweating hard-core chills their liver is enlarged and palpable this isn't a bacterial abscess but an amoebic one so this is an amoebic abscess so really profound fevers and chills they're sicker than somebody with just a bacterial liver access and how do we treat these do we drain it no so this is the second abscess in the body that's not preferentially treated by drainage the first was the lung abscess the second is an amoebic liver abscess so treatment of choice is metronidazole don't drain it first okay the last one i always miss this one on the q bank it's usually a patient from mexico or um or somewhere else in south america or somewhere in south america and they come in with right upper quadrant pain and lots of liver cysts on an ultrasound yes so this is in kind of conca in kinda caucus and the mode of transmission here how do people get it i think it's dog poo but i'm not sure could be fish also it could be fish also so that's that's where um i read that the cysts come from it's from dog feces the laboratory findings that are uh characteristic here you see eosinophilia because it is a parasite and there's something called the cassone skin test that's positive just because of the high amounts of ige in the eosinophils from the reaction to the parasite so the treatment is important surgery or no surgery 50 50. we do do surgery so we give albendazole for for medication and we have to be very careful during surgery because if one of these little cysts opens or breaks during removal it can cause an anaphylactic reaction and even death for the patient so we do do surgery but we have to be very careful to remove this cyst in one piece all right so some spleen stuff remember after a splenectomy you want to make sure to check the platelets they can be high after splenectomy it's not a huge deal you just have to give aspirin for um for preventing clots and prophylactic penicillin is important for people after a splenectomy because of its role in immune function also remember the big three vaccines we need to give a patient after we've removed their spleen itp we talked about this a little bit already the buzzwords you look for in the clinical vignette is that only the platelets are low everything else is fine coags are fine isolated decrease in platelets usually means itp hereditary spirocytosis you can also have splenomegaly because those abnormally round red blood cells are being taken up by the spleen so the treatment there is going to be splenectomy as well a little bit on trauma traumatic splenic rupture we talked about this already a little bit we want to consider it if there's a left lower rib fracture and intra-abdominal bleeding and curse sign we already talked about that's left shoulder pain because of irritation in the left hemidiaphragm all right so we'll probably get to talk about the appendix and then it will be nine o'clock but i will have all the rest of these slides posted if you guys want to take a look at them later because i know nobody's brain can work after nine if the review is supposed to go from seven to nine so we'll talk about the appendix and then we'll stop okay so what if we have a pain a patient with pain that starts kind of periphilically and then moves to the right lower quadrant and becomes more sharp what's that softball right that's appendicitis good so when do we go to surgery in a patient with appendicitis not a trick question if if we if we think they have appendicitis yeah if they have a strong clinical picture we really don't technically need imaging um at uh they typically get a ct uh anyway but really you don't need it to to justify surgery how would your management change if the appendix were either perforated or had an abscess exactly so we want to make sure we drain the abscess and give antibiotics first particularly antibiotics that are going to cover e coli and bacterioides because those are the most common bugs and then we'll do an appendectomy after they've been stabilized so stabilize first and then take out the appendix so carcinoid tumor anyone know the number one site for carcinoid tumor appendix good so uh conveniently placed on this slide and what are the symptoms for carcinoid syndrome flushing diarrhea that's pretty much it some wheezing too wheezing so when do they happen what has to happen to the carcinoid tumor before we get carcinoid syndrome it's metastatic already to the liver or beyond right because serotonin is metabolized by the liver on first pass metabolism so if it's just in the gi tract the serotonin would be denatured before it gets out so what else are we looking for in a patient with carcinoid syndrome there's a particular nutritional deficit that patients with carcinoid syndrome often have it's a vitamin that they become deficient in niacin very good why yes close serotonin and niacin are both made from tryptophan good so yes so if all of our tryptophan is being used to make serotonin there's none left to make niacin and high five for that at almost nine o'clock very good um and remember from way back in the day the cardinal symptoms of niacin deficiency are diarrhea dementia and dermatitis so that's another sneaky medicine thing that they can throw into your surgery shelf okay so if our carcinoid tumor is bigger than two centimeters at the base of the appendix or with positive lymph nodes in the area what surgery do we do a big one right a hemicholectomy so we're going to take out more than just the appendix if it's smaller than two centimeters in the tip of the appendix and no nodes are positive we can just take out the appendix itself okay what time is it how many slides more can i do probably do one or two more so um in terms of small bowel obstruction i can just point out the highlights here um remember that the symptoms for small bowel obstruction pain constipation obstupation not passing gas and vomiting because nothing's going through and again what you need to remember is when do we do surgery this is a surgery shelf or at least it's supposed to be so surgery is indicated in small bowel obstruction if there are peritoneal signs rigidity rebound tenderness that kind of stuff or if conservative management doesn't cause improvement within 48 hours um differences between post-op ilias and ogilvy syndrome i remember being important for the surgery shelf um radiographically they're different and that post-op ilias has dilated loops of small bowel all the way through with um air fluid levels because it's kind of a general stasis of stuff through your bowel whereas ogilvy's syndrome really the the highest points of dilation or the biggest points of dilation are in the colon or cecum so the thing to remember about ogilvy syndrome is the threshold for treating is greater than 10 centimeters of dilation and you can either decompress from above with an ng tube below with the colonoscope or you can give them neostigmine because that kind of gets stuff moving through the bowel the thing that makes this scary and i had a patient who we gave neostigmine to when i was a third year is that neostigmine can cause bradycardia so you really have to have somebody acls certified standing by the patient's bedside while you're giving that treatment and this is a good slide to end on because you probably will see some kind of chest x-ray or abdominal x-ray on your shelf so i kind of want to point out some of the high-yield stuff that that you might see so what do we have going on in this one can you even tell me what they notice about this first abdominal x-ray so we kind of see some dilated loops here and can you see on this x-ray do these little markings these little segmental markings go all the way through or do they go halfway through all the way and from gross anatomy does that mean it's small bowel or a large vowel small right because the plica go all the way around the the whole diameter circumference of the bowel if we were in large bowel the haustra only go halfway through so this is a small bowel obstruction and we can see um the transition point or the blockage is probably somewhere like right here right because there's poop in the lower part of the intestine there's no air down here but in the small bowel we see the dilated loops up from the point of distention so let's compare that to this picture what do you think we have going on here lots of air right lots of dilation pretty much all the way through right it's pretty uniformly dilated there's air throughout all of the intestine all the way down to the rectum down here air in the rectum so what condition would most likely cause the second picture that we just talked about it's a post-op ilias good um and as a bonus what electrolyte should you check if you see this abdominal x-ray potassium because low potassium can contribute to alias good all right so what about this thing can you see how big this part is right here what part of the intestine do you think this is that's cecum that's a big ginormous cecum so what is this picture this is ogilvies so this is the characteristic abdominal x-ray of oval bees the cecum is really massively dilated i don't have a ruler or anything but i bet it's bigger than 10 centimeters so we would be treating this pseudo obstruction okay so lastly we've seen this picture before does this picture make you nervous down here yes where are we going with this chest x-ray to the or this is free air under the diaphragm so maybe a perforated small bowel obstruction maybe diverticulitis gone awry so something something super bad here and this barium study they might describe it as a bird speak so this is a vulvulis sql or sigmoid sql sql so the bird speak is a sequel vulvulus this coffee bean sign here is a sigmoid bobulus so the kind of crease in the coffee bean can you because this kind of look like coffee bean right this crease here um is the mesenteric artery that's the kind of focal point for the twist so this is a stigmoid vobulus this is a sql volvulus those are kind of the abdominal x-rays at least that you would want to be able to identify correctly on your test and i think that brings us right to nine o'clock so i'm sorry we couldn't get through everything i guess i talk a lot and we couldn't go through all of surgery in two hours but i will post these slides tomorrow morning dr hensey will send you the the link in the file so if you have any questions email me you know i'm a fourth year so i don't have anything to do and thanks for coming and i wish you luck on friday thank you thanks harlingen