Discuss Dx for Acute Cholecystitis

RUQ pain; first US look for gallstones, GBW>3mm thick;

Pericholecystic fluid, US Murphy's sign. If US equivocal do HIDA
scan. If complications such as perf, abscess or cancer suspected
do CT

Acute cholecystitis presenting signs and symptoms?

RUQ pain may radiate to R flank and back; sharp, stabbing,
unremitting. N/V/F/C

DDx for acute cholecystitis

GERD; Peptic ulcer perforation; acute pancreatitis; cholangitis;
choledocholithiasis; acute hepatitis; hepatic abscess;
nephrolithiasis; pyelonephritis; RLL pneumonia.

Treatment plan for cholecystitis?

During first 5-7 days of sx, operative management perferred.
After 7 days tx w/ fluids & antibiotics and readmit for surgery in
6 weeks. Surgery must decide lap vs. open. Open indicated in
severe inflammation of Calot's triangle or difficult antomy, risk
of CBD high, malignant possibility.

Acute cholecystitis?
Inflammation of gallbladder of sudden onset 2/2 obstruction.
90% due to GS lodged in neck or cystic duct. ONly 10-20% of
those w/ GS will get acute cholecystitis. Mortality <5% due to
extremes of age, gangrenous or acalculous cholecystitis.

Differential Dx of Anterior Mediastinal mass?

6 Ts: Thymoma, thyroid, teratoma, testicular tumors, "Terrible"
Lymphoma, paraThyroid tumor.

Thymoma
Dx byCXR and CT. 25% malignant, dx by invasion at surgery;
Ass'd w/ Myasthenia gravis. Role of surgery is treatment +/-
diagnostic.

Signs and sx of anterior mediastinal mass?

Cough; dyspnea; dysphagia; hoarseness; facial swelling (SVC
syndrome)

How do you dx a substernal goiter?

Symptoms; CXR; CT scan; functional scans such as Iodine 131
uptake.

Teratoma?
Tumor of brachial cleft cells: endoderm, ectoderm, mesoderm.
15% malignant. Surgery is diagnostic/tx

Seminoma/non-seminoma?
Usually large bulky mass, symptomatic. Tx: chemo/rad. Surgery
is diagnostic

Lymphoma?
Can create mass anywhere in mediastinum. Sx: cough, fever,
chest pain, wt. loss, SVC syndrome, chylothorax. Dx by CXR, CT,
mediastinoscopy w/ node biopsy. Tx w/ chemo +/-rad. surg is
diagnostic.

Mediastinal parathyroid?
Primary hyperparathyroidism. Will p/w increased PTH, serum
Ca2+ and 24hr urine Ca2+. parathyroidectomy is tx.

Differential Dx when considering choledocholithiasis?

Choledocho; Mirizzi's syndrome (physical obstruction of
common hepatic ducts), pre-ampullary pancreatic mass (cancer,
pseudocyst, duodenal diverticulum), gangrenous cholecystitis,
liver abscess or hepatitis, Gilbert's, gallstone panc, choledochol
cyst, Ascaris (worm) infection

Management when suspecting choledocholithiasis?

Keep NPO, serial labs, Biliary imaging: MRCP, ERCP, lap/open
chole +/- intraoperative cholangiogram

Surgical options for choledocholithiasis?

1) ERCP followed by elective lap-chole; 2) Lap chole w/ CBD
exploration

Signs/sx of choledocholithiasis?
Many asymptomatic, RUQ pain/biliary colic; N/V,
jaundice/scleral icterus, dark urine/clay-colored stools,
increased LFTs. pain worse w/ food, radiates to back

Diagnosis of choledocholithiasis?
RUQ US; ERCP, MRCP, intraoperative cholangiogram
What will you find on US for choledocho?
Gallstones; 20-30% of CBD stones visualized, bile duct dilatation
>8mm or 10% of age

ERCP vs MRCP for choledocho?

ERCP: dx & tx, sphincterotomy, 85-95% stones removed, 2-10%
morbidity, 1%mortality. Comp: pancreatitis, bleeding,
cholangitis, duodenal perf, stone recurrence. MRCP: >95%
accurate for dx of choledocholithiasis, used if choledocho is
unlikely but must be r/o

Lap CBD exploration?

Performed during lap chole, either trancystic duct approach or
lap choledochotomy. T-tube placement.

Diagnosis of inguinal hernia?

Protuberant groin mass, manually reducible or may
spontaneously reduce; pain, "pops out", Perform physical
upright and supine, exam w/ valsalva. Labs nonspecific, but if
strangulated: leukocytosis, increased base deficit and lactate

Reduction of incarcerated inguinal hernias?

icepack; trendelenberg, relax the pt, gentle continuous pressure.
Contraindications: erythema, induration, significant tenderness,
leukocytosis

Surgical repair of inguinal hernia?

Lichtenstein: tension free mesh w/ low recurrence and risk of
infection of 1%. Laparascopic: preperitoneal or transperitoneal.
More serious complications (vascular or bladder)

Post operative complications of inguinal hernia repair?

Scrotal hematoma, bleeding, difficulty voiding, scrotal swelling,
neuroma/neuritis, infection

Direct inguinal hernia?

Passes through Hasselbach's triangle. medial to the inferior
epigastric artery. Etiology: acquired weakness in floor of
Hasselbach's triangle.

Indirect inguinal hernia?

Sac lies anteromedial to cord. Exits through internal ring laternal
to the inferior epigastric artery. Congenital patency of processus
vaginalis. herniation through internal ring facilitated by weak
inguinal floor.

Risk fx of inguinal hernias

Obesity, COPD, Pregnancy, Constipation, BPH, ascites. Males:
females 7:1

DDx of GERD
Cholelithiasis: biliary colic or chronic cholecystitis; PUD;
coronary artery disease; Diffuse esophageal spasm; zenker's;
Esophageal motor disorder; cacner; chronic panc.

Pathophysiology of GERD
LES fails either 1) chronically weak and hypotensive or 2) it
opens too readily (transient LES relaxations). Manometry may
ID resting dysf. showing pressure <6mm or short LES length. pH
probe most accurate measurement. DeMeester score >14.72

Types of hiatal hernia:

type 1) sliding hernia may be reducible when upright
2)paraesophageal herniation of stomach w/ GE jnct at normal
position 3) Paraesophageal herniation of stomach w/ GE jnct
above normal 4) paraesophageal herniation of stomach and
other abdominal contents, GE jnct above normal

Complications of GERD
Esophagitis: erosions or penetrating ulcer; barrett's; esophageal
stricture (or peptic); adenocarcinoma from Barrett's; recurrent
pneumonia, asthma; laryngitis, subglottic stricutre; esophageal
perf. Incarceration can call gastric obstruction, chronic iron
deficiency anemia, gastic pouch ulcer, space occupation/dyspnea

Management of GERD
Lifestyle: elevate HOB (4-6in), sleep on L side; wt loss; avoid
bedtime snacks, chocolate, fatty food, cigs, EtOH. Med mgmt:
PPIs, prokinetic agents

Indications for urgent surgery in GERD

Obstruction, Gastric necrosis; malignancy. Relative indications:
paraesophageal hiatal hernia, complications of reflux (ulcerative
peptic esophatitis, stricture, chornic ulcer), disabling sx
(uncomplicated)

What is the gold standard surgery for GERD?

Nissen fundoplication. Most effective antireflux but highest risk
of side effects. Other surgical options: Posterior partial wrap
(Toupet), anterior partial wrap (Dor), Linx procedures w/
magnests around the GEJ, mucosal ablation for barrett's

Signs/sx of Necrotizing fasciitis

Fever, tachycardia, hypotension, edema (outside involved area),
pain out of proportion, blisters/bullae, crepitus/gas,
leukocytosis, marked hyperglycemia, acidosis, "wooden" tissue.
Can do finger test + frozen section: 2cm incision w/ local, lack of
bleeding, dishwater fluid, probe along deep fascia. Section will
show obliterative vasculitis, subQ necrosis

Imaging findings for nec fasc

CT: gas in tissues, fluid collections; MRI: soft tissue contrast,
high sensitivity to detect soft tissue fluid. but don't delay surgery
for tests

Surgical tx of nec fasc

prompt and aggressive surgical debridement. All necrotic tissue
should be radically debrided at initial surgery. Excise all tissue
that gives way to moderate digital probing. Inpsect deep fascia
and muscle w/ fluid and tissue for immediate gram stain and cx.
2nd look <24hrs later

What ABX do you use for nec fasc?

Gram (+): PCN or extended sepcturm PCN; Gram (-):
aminoglycoside, carbapenam, cephalosporin; Anaerobe:
Clindamycin. MRSA: Vancomycin. Cont. for 3 days after sx
resolve. Also note that mortality is 100% w/ ABX tx alone.. must
have surgery

How does clindamycin tx anaerobic nec fasc?

Inhibits bact. protein (toxin) synthesis. Efficacy not affected by
innoculum size orstage of bact. growth. Facilitates phagocytosis.
Suppresses synthesis of TNF-alpha.

Types of nec fasc?

Type 1: Mixed infection of aerobic + anaerobic; multibacterial
symbiosis; ass'd w/ surgery, trauma, diabetes, peripheral
vascular dz; Type 2: monobacterial usually GAS, MRSA,
clostridium, otherwise healthy w/ h/o trauma.

Simple model to differentiate between necrotizing and non-

necrotizing soft tissue infection.
WBC>15; Na<135: 90% sensitivity, 76% specificity.

Physiology and etiology of compartment syndrome?

Phys: increased pressure w/i an anatomical compartment -->
decreased cap perfusion (~25-30cmH20). Etiology: fx, trauma,
vascular injuries, hematoma, contusions, burns, tight
dressings/casts, massive fluid resuscitation.

Sx of compartment syndrome
6 Ps: pain, pressure, paresthesias, paralysis, pale (pink)
pulseless. If altererd: high level of suspicion warrants routine
compartment pressure monitoring. Dx is clinical, but can measre
intracompartment pressure w/ Wick/Slit catheter.

Tx of compartment sx?
Address cause; administer mannitol; fasciotomy and
decompression: double anterolateral & posteromedial or single
lateral. 11-15% mortality; 11-21% amputation; Nerve damage,
bleeding, infection, dysfunction

Airway in penetrating trauma to neck:

10% w/ penetrating neck trauma present w/ airway loss,
laryngotracheal injury, hematoma status, endotracheal
intubation over bronchoscope best approach and ensures
definitive airway. Avoid paralyzing agents that can lose muscle
tone and worsened obstruction. Always be prepared for
cricothyroidotomy.

Breathing and circulation in penetrating trauma to neck

Decompress any pneumothorax, control bleeding w/ digital
pressure, balloon tamponade if necessary and IV fluids. Issues:
airway may be compromised if large hematoma or extensive
laryngotracheal injury, always prep for cricothyroidotomy,
external compression and trendelenburg position to reduce risk
of air embolism, spinal cord/CNS injuries.

Work-up of penetrating trauma to neck:

CT to evaluate for C-spine injuries; FAST-cardiac tamponade; CT
only after hemodynamically stable; color flow doppler and
angiogram.

What are the criteria for emergency operation for penetrating

trauma to neck?
Hard signs: severe hypovolemic shock, active bleeding, pulsatile
or growing hematoma, bubbling of air through wounds, mental
status change, dyspnea, decreased peripheral pulse. Soft signs:
pain on swallowing, small amount of hematemesis, hoarseness,
slight hemoptysis, subQ emphysema in absense of
pneumothorax. Note only 20% of penetrating neck injuries
require surgery.

What are common mistakes in treating penetrating neck

injury?
Sitting pt up --> air emboli, phramacological paralysis for eT
intubation in pt w/ large hematoma, failure to evaluate for other
injuries, missed spinal injury.

Indications of ABG?
Eval of ventilation by measuring partial pressures of O2 and Co2
and pH of arterial blood to assess pulm. function. Indicates
status of gas exchange b/t lungs and blood. Base deficit is used as
resuscitation endpoint.

Contraindications of ABG(8)?
infection of radial artery; negative Allen test; coagulation defects
hemophilia; hx of clotting disorder; hx of arterial spasms
following previous punctures; severe PVD; arterial grafts;
arterial-venous shunts.

Complications of ABG (7)?

Discomfort; infection; hematoma; arteriospasm; thrombus
formation; air or clotted blood emboli; anaphylaxis form local
anesthetic.

Problems w/ integrity of ABG and possible erroneous results

(3)?
1) Air bubbles; 2) Delay in cooling causing blood cells to continue
to consume oxygen; 3) venous blood mixed in ABG sample.

What are abcesses?

localized infection of tissue marked by collection of pus
surrounded by inflamed tissue. Strep, staph, enteric bact. or
combination usually cause. Hot, tender and red and may rupture
and spread if untreated --> bacteremia.

Contraindications of I&D outside of OR?

Extremely large abscesses, deep abscesses in sensitive areas,
palmar space or deep plantar spaces are more likely to develop
complications, nasolabial folds, pts at risk for endocarditis (need
ABX)
Local anesthesia technique?
Cleanse skin; anesthesize top of wound by inserting 25 gauge
needle under skin, draw back to ensure not in vessel and inject
anesthetic into intradermal tissues.

Key points to I&D technique?

Make sure to anesthesize. Make incision (along skin tension
lines) w/ scalpel over abscess. Take culture w/ swab. Irrigate
wound w/ normal saline until effluent is clear. Pack w/ firm
gauze. Skin margins must remain open until wound granulates
from in to out. ABX usually not necessary, remove packing 2-3
days.

Indications of IV catheter insertion?

Administer IV fluids and/or meds

Contratidincation of IV catheter insertion?

Don't use an extremity if there's a fistula, shunt, amputation or
past surgical procedure (i.e. mastectomy)

What are the common sites fo IV catheter insertion?

Antecubital- easy, fast but if pt bends arm solusion may not
infuse. Hand- more painful. Wrist: more painful, mobile area
may need splinting. Wrist to elbow: multiple choices, easy access.

Describe different sizes for IV cannulas/catheters?

Yellow (24G)- used in infants and children. Blue (22G)- in
children and pt w/ small veins (elderly). Pink (20G) Standard
size, useful for most infusions and blood. Green (18G) Better for
blood. Grey (16G) Used for pts in shock- GI bleeds, trauma.

Key points to IV insertion?

Pt's arm on pillow, prepare tubing, tourniquet, gloves. Cleanse
area and allow to dry 30second. Hold catheter hub rotate 360
degrees. Anchor vein below needle at 10 degrees with hand
above, after flashback lower to parallel to skin. Thread catheter
to vein, release tourniquet, apply pressure above, retract needle,
connect tubing. Cover w/ transparent dressing label w/ date
time, gauge and initials on side of dressing.

What are the indications for NG tube placement (5)?

Decompress the stomach (obstruction, ileus), administer
feedings and medications, lavage post toxic ingestion, dx GI
bleeding, diaphragmentic hernias.

What are the contraindications for NG tube placement (4)?

Blunt or penetrating head injury w/ suspected basilar skull
fracture; Facial fractures, suspected esophageal perforation
(Boerhaave's), GI surgery w/ orders contraindicating it.

What size NG tube do you use for adults vs children?

Adults #16-18. Children -Broselow tape.

Key points in NG tube insertion?

Explain procedure, ask about previous nasal surgery and test
nostril patency, get water w/ straw. Have pt sit up or in reverse t-
berg. Measure and mark with tape. Lubricate tip, insert and
instruct pt to take small sips of water and swallow. Observe for
signs of cyanosis. Secure w/ tape to nose. Use syringe to see if
gastric contents come back. Send for CXR to confirm placement

Documentation of NG tube?
Indicate size, color, amount of drainage, complications, epistaxis,
N/V. Daily documentation for feeding, amount, residual volumes
(obtained every 4 hours) and recheck CXR if dislodgement
suspected.

Indications for urinary catheter (4)?

Tx urinary retention and bladder outlet obstruction; For accurate
UOP measurement in critically ill or post-op pt; Obtain urine
specimen in pt who can't void; Measure intra-abdominal
pressures (for abdominal compartment syndrome).

Contraindications to urinary catheter?

Evidence of urethral trauma (Pelvic fx, straddle injuries or
penetrating trauma)- signs and sx: blood at meatus, scrotal or
perineal hematoma, high riding prostate all require retrograde
urethrogram to document urethral integrity prior to insertion.
Rectal and genital exam MUST be done before insertion.

Key points for foley insertion:

Make sure you prepare the sterile field. Take swabs out and
lubricant and make sure tubing is connected. Test balloon. Hold
labia or penis with non-dominant hand and maintain hand there
until preparing to inflate balloon because now it's not sterile. Use
one swab per sweep from anterior to posterior. For males, one
swab per circular motion, hold penis perpendicular to body.
Females insert until you see urine and advance 2 more inches, in
males insert all the way. Inflate balloon, tape catheter.

Types of suturing needles?

Curved: cutting (skin) vs. tapered ("round bodied" w/ shart wtip
and smooth edges that are less traumatic using in deeper tissue).
Straight: can be used w/o instruments.

How long should sutures be left in?

Face: 5-7d; Neck 7d; scalp 10d; trunk and upper extremities 10-
14; lower extremities 14-21d

In what order do you draw blood?

Blood culture must always be first, then electrolyes, lFTs. Thent
he next ones can be in any order: type and cross (pink), CBC
(magenta), Coag (blue) Trops, ammonia (green, ammonia must
be sent on ice).

General principles of Cervical collar placement?

All trauma pts assessed by physician must have spine evaluated.
Clinical clearance by NEXUX low-risk criteria. If not met, pt
must get radiologic evaluation. Moving pts w/ spinal precautions
must be done via log-rolling.

NEXUS criteria for C-collar removal:

"NSAID"- Neurologically intact; Spinal midline cervical
tenderness abscent; Alert (GCS>15) ; not Intoxicated; no
Distracting injuries.

Contraindications to skin stapling?

Never be used on face or any surface that must bear weight or is
subject to pressure.

General principle of wound dressing?

Keep wound tissue moist and surrounding tissue dry. Dressing
functions to protect wound from contamination/trauma, provide
compression if bleeding or swelling, apply medications, absorb
drainage or debrided necrotic tissue, filling or pakcing wound,
protecting skin surrounding wound.

What syringe/catheter should you use for irrigating a wound?

19G catheter to 35mL syringe delivers proper irrigation pressure
and reduces risk of trauma and infection