Pestana Review Surgery Head Trauma: - Epidural hematoma, good prognosis if emergent craniotomy w/in first few hours, fatal otherwise. o Sx = trauma, initial LOC, lucid interval, gradual coma, fixed dilated pupil on IL side, CL hemiparesis - Subdural hematoma may present similarly to epidural, but have more severe trauma mechanism o Check CT scan, head + spine b/c of severity of injury. Needs emergent craniotomy if midline shift but poor prognosis, otherwise medical MGMT of ICP - Chronic subdural – have trauma several weeks prior, gradual decline of MS, elderly b/c of increased space and tension on bridging veins o Tx is surgical decompression w/ craniotomy – good improvement post - Basilar skull fx = rhinorrhea, otorhhea, battle’s sign, raccoon sign o CT scan of head and C-spine, neurosurgery, abx Shock: - Neuro bleeding cannot cause shock - Abd GSW and shock – try to do ex lap immediately for control of bleeding + concurrent IVF and blood administration - Someone w/ GSW to abd + chest + shock could be hypovolemic b/c of blood loss in GSW but also tamponade or tension PTX given chest injury, look for CVP (high in last + resp findings of PTX) - Tamponade is clinical dx – if shock + distended neck veins w/out resp signs/tracheal deviation do pericardial window, no imaging. If + do thoracotomy. o If location of wound really suggests tamponade may do thoractomy right away - No CXR for tension PTX – do needle decompression then CT - CP + distended neck veins + shock w/out trauma suggests cardiogenic shock - no fluid resuscitation - Vasomotor shock = anaphylaxis or spinal anesthesia/transection get low CVP but warm and flushed patient o Tx w/ vasoconstrictors, fluids OK too Chest Trauma: - Simple traumatic PTX if HDS can get CXR before CT placement - For HTX, if HDS and not a massive amount of blood (1500 initiall, 600ml in 6 hours) then don’t need surgery, just CT, low pressure lung parenchymal bleed will stop on its own o If large amount of initial blood or a lot in the preceeding hours then could be arterial bleed from IC vessels – do thoracotomy to ligate. - Hemo-pneumothorax: dull to percussion at base, hyperresonat at apex, airfluid level on CXR o Tx is CT, sx only if large amount of blood - Tension PTX no CXR – CT right away (needle decompression first), later CXR to r/out widened mediastinum. - Flail chest suggests high risk for other injuries o MGMT is for pulm contusion – fluid restriction, diuretics, colloid rather than crystalloid fluids, resp support (intubation, PEEP)
Pulm contusion may show up later (day 2), see white on out imaging + resp deterioration o If other injuries mean they require OR/resp/intubation should place b/l CT due to high risk of developing tension PTX during PP breathing - Sternal fracture means high risk for myocardial contustion or aortic rupture o Contustion: EKG, enzymes o Aorta: CTA, TEE - Diaphragmatic rupture – get decreased breath sounds on one side but no tympanic changes, would see bowel in chest o Always on left o Treatment is surgical repair from the abdomen - Aortic rupture: hidden injury, may initially be stable as hematoma is forming, be suspicious if have fx of hard-to-break bone like 1 st rib, sternum, or scapula o See widened mediastinum on CXR o Dx is arteriogram o Tx is surgery - Traumatic rupture of the trachea of major bronchus – subQ air, CXR shows air in tissues, confirm dx and level of injury w/ bronchoscopy, then surgical repair Abdominal Trauma: - Patient w/ HDIS but no scalp lac, normal CXR, normal pelvis – think blood in belly o Shock is loss of 25-30%, approx 1.5 L, would see in neck, CXR, pelvis, or long bones if fx o If suspect abd bleeding and stable – CT o If suspect abd bleeding and unstable – FAST or peritoneal lavage o CT w/ ruptured spleen – if stable serial exam and CT, if unstable – exlap - All abd GSW go to surgery for exlap, even if stable o Prep for surgery – bladder catheter, big bore venous line, broad spectrum abx o Belly begins at nipple but chest does not end at nipple So if patient with GSW below nipple line needs w/u for penetrating chest wound (CXR, CT) + exlap - Most bleeding in abd comes from liver, most clinically significant bleeding site comes from the spleen o Think if lower rib fx on left + shocky VS o Diagnostics: if stable/responds to fluids then CT, may follow w/ serial CT/exams o if still unstable then FAST/lavage If + FAST/lavage then exlap Always try to save spleen before removing If remove, need vaccinations - Unstable + peritoneal signs = exlap o Peritoneal signs can be from blood (VS) or hollow viscera contents Urologic Trauma - Hallmark is blood in urine – gross hematuria in setting of trauma needs to be worked up o Microhematuria only needs w/u in peds b/c could be congenital (incidental, not due to trauma)
Blood at meatus – urthreal injury, needs retrograde urethrogram, don’t insert foley! Posterior urethral injury may have high riding prostate and sensation to void but unable Tx is to get suprapubic and delay repair x 6 months Anterior urethral injury needs repair right away o Blood in urine – bladder or kidney Bladder dx with retrograde cystogram Extraperitoneal – place foley Intraperitoneal – surgical repair + suprapubic foley Kidney almost always no surgery Rare sequalae is AV fistula leading to CHF - Scrotal hematoma – needs surgery only if testicle is ruptured (sonogram) - Penile fracture occurs only when penis is erect – get fx of tunica albuginea or corpora cavernosa –needs emergency sx Burns - Chemical (alkaline worse than acid) needs massive amounts of irrigation started ASAP - High voltage electrical burns – always worse than looks, may need massive debridement/amputation o Concern for myoglobinuria + RF – TONs of fluids, osm diuretics, alkalinization of urine - Concern for resp burns if soot around mouth or in mouth, concern if flame/chemical in enclosed space o Dx w/ bronch + blood gases o Tx w/ resp support - Circumfrential burns – bad b/c cut off blood supply when develop edema o MGMT w/ serial monitoring of pulses o If s/s of compromised circulation due escharotomies - Scalding burns in children think abuse - Third degree burns: o White/leathery in adults o Bright red in children - Extent of burns – rule of 9s o Arms and head are 9 each, trunk is 4 9s, each leg is 2 9s o Babies have big heads, get 2 9s for head and 3 b/t both legs - Fluid requirement in burns o 4 cc/kg/% burned – mL of LR, want ½ in first 8 hours o Really are just adjusting to desired UOP and CVP UOP want 1-2 ml/kg/hour Keep CVP below 15-20 o Will see lot’s o UOP day 3 after burn edema reabsorbed and massive dieresis o For babies 20 ml/kg/h if >20% burn - Other burn: o Tetanus o Silver sulfadizine or mafenide acetate for deper o Triple abx for near eyes/face b/c silver irritating o
NG suction first 1-2 days then intense nutritional support (high cal, high N2) o If no regeneration in 2-3 weeks then graft Early excision and grafting if 3rd degree and localized (under 20%) o
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*Human bites (cut on knuckle) need specialized orthopedic car including surgical exploration Pediatric Orthopedics - Hip disorders: o Developmental dysplasia: uneven gluteal folds, easy post dislocation w/ jerk +click then snapping relocation Tx is abduction splinting (no xray) o Legg-Calve-Perthes disease: age 6, avascular necrosis of capital femoraly epiphysis, get gradual limping + hip/knee pain + decreased ROM Dx w/ XRAY Tx is contain femoral head w/in the acetabulum by casting and crutches o Slipped capital femoral epiphysis: chubby teen, groin/knee pain, limping, foot turns towards other when dangling Dx w/ XRAY Needs ortho sx o Septic hip – toddler w/ recent febrile illness who then refuses to move the hip - Acute heme OM: febrile illness then localized bone pain w/o hx of trauma – won’t see on XRAY for 2 weeks– need MRI + abx - Genu varum – bowlegs, is nml up to age 3, then blunt dz - Genu valgus – knock knee, nml b/t 4-8 - Osgood-Schlatter dz – teens w/ pain over tibial tubercle worse w/ contraction of quads – RICE tx, if no response then ortho for casting - Club foot – casting then sx at 9-12 months if no improvement - Scoliosis is adolescent girls – T spine – tx if severe or issues w/ pulm function. May progress until skeletal maturity is reached – 80% at onset of menses - Kids remodel super fast, may not need same degree of angulation you require w/ adults - Supracondylar fractures of the humerus from hyperextension when falling on hand w/ arm extended – issue is vascular and nerve injuries leading to Volkmann contracture – need to monitor – median nerve and brachial artery - Growth plate fractures – can close reduction if fx does not cross the epiphyses or growth plate and does not involve the joint – if does then need precise aligment w/ open reduction and internal fixation Tumors: - Primary malignant bone tumors seen in young persons while older it is metastatic disease - Osteogenic sarcoma is most common, seen in 10-25 y/o, subburst pattern on XRAY - Ewing sarcoma in younger children age 5-15 – see onion skinning
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Adults: o Metastatic: lytic is breast, blastic is prostate Path fx may be presentation o MM get punched out lytic lesions + bence jones in urine + Ig in blood o Soft tissue sarcomas are firm + fixed to surrounding structures Mets to lung but not lmph nodes General Adult Orthopedics - Need two views 90 from one antoher + one join above and below - Anterior dislocation of shoulder most common – hold arm close to body but located outwards - Posterior shoulder dislocations from sz w/ massive contractions – hold arm close to body and IR, need axiallary or scapular XRAY views to detect - Colles fracture: old lady, FOOSH, dinner fork, dorsally distplaced and angulated distal radius fractures - Monteggia/nightstick fracture is from blow to ulnar – get diaphyseal fracture of the proximal ulna - Galeazzi fx is mirror of monteggia but of the raidus - Metacrapl neck fx (4/5th) from closed fist hitting wall – tx depends on degree of angulation/displacement – mild do closed reduction w/ ulnar gutter - Hip fracture leg is shortned and ER - Femoral neck fx need replacement of femoral head to prevent avascular necrosis - Intertrochanteric fx less tenuous blood supply – open reduction + internal fixation - Femoral shaft fx need intramedullary rod fixation – high risk for clot b/c of immobilization - Collateral ligament injuries from sideways blow to knee – valgus stress hurts medial, varus stress hurts lateral - ACL more common than PCL – do anterior drawer or Lachmans - Meniscal tears do MRI – get pop/click - May get ACL, MCL, and MM together - Tibial stress fractures – xrays may be normal, do cast and repeat xray in 2 weeks - Leg fx of tibia/fibula concern for compartment syndrome - Rupture of achilles tendon do equinis position casting or sx - Back pain o Lumbar disk herniation – L4/L5 or L5/S1 – vague aching pain then sudden neurogenic pain – worse when coughing, sneezing, defecating, + straight leg raising – tx is bed rest – pain injections – sx if neuro deficits o Cauda equine – bladder retention, flaccid rectal spinchter, perineal saddle anesthesias – needs emergent decompression o Ankylosing spondylitis – young men, chornic back pain and morning stiffiness –wrose w/ rest, better w/ activity – bamboo spine – HLA-b27 o Metastatic malignancy – progressive BP worse at night and unrelieved by rest or positional changes + weight loss – lytic women blastic men - Leg Ulcers: o DM ulcers: pressure points (heel, tips of toes, metatarsal head) , get b/c of neuropathy, fail to heal b/c of microvascular dz
Arterial insuffiency – tip of toes – poor granulation in base – other s/s of AS dz like absent pulses, trophic changes, rest pain, claudication – doppler for pressure gradient (if not is microvascular dz and not surgery) o Venous stasis ulcers from chronically edematous, inducated, and hyperpigmented skin w/ granulating bed – frequent ceulluitis – support stockings, ace bandages, unna boot o Marjoin ulcer is SCC of skin that develops w/in chronic leg ulcer – seen w/ untreated third degree burns or chornic draining sinuses from osteo – get ulcer w/ heaped up dedges – need wide local excision and skin grafting - Foot pain: o Plantar fasciitis – bone spur hurts but lots of us have them w/out pain – heel o Morton neuroma – inflammation of the common digital nerve in the third interspace b/t the 3rd and 4th toes- get palpable and tender spot, can be from high heeled shoes/pointed boots – analgesics and better shoes – surg Orthopedic Emergencies: - Compartment syndrome – most commonly in lower leg and forearm – prolonged ischemia, reperfusion, crush, fracture w/ closed reduction is mst common. Pai w/ passive extension. - Pain under cast should remove cast and inspect - Open fx need OR for cleaning and reduction w/in 6 hours - Posterior dislocation of hip – head on collision w/ knees up – leg is shortned and INTERNALLY rotated – needs emergency reduction b/c of tenuous blood supply of the femoral head + avascular nercosis potential - Gas gangrene see w/ penetrating deep dirty wounds – need debridement and hyperbaric oxygen - NV injuries: o Radial nerve in oblique fractures of the middle to distal thirds of the humerusm – can’t dorsiflex/extend wrist – can resolve w/ reduction, if not entrapped and needs OR o Popliteal injuries w/ posterior dislocation of the knee, if delayed restoration of flow need prophylactic fasciotomy - Think of hidden injuries if: direction of force, fall from height landing on feet (LT spine), head on automobile collisions, facial fractures/closed head think cspine. Hand Probszzz - Carpal tunnel women w/ repetitive hadn motion – numbness in median nerve distribution, particularly at night – clinical dx or XRAY – splint and NSAIDs – if need sx to nerve conduction studies - Trigger finger – also women – flexed finger, painful snap to extend – injections before surgery considered - De Quervain tenosynovitis from forced wrist flexion and thumb extension – pain with fist + ulnar deviation – is radial side of wrist – splint + NSAIDs + steroid injections - Dupuytren contracture – older men of Norwegian descent – get contraction of the palm of hand and palmar fascial nodules can be felt – may need surgery o
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Felon is abscess at pulp of finger tip – fever – throbbing – can lead to tissue necrosis so needs drainage - Gamekeepers thumb is injury of ulnar collateral ligament from forced hyperextension of the thumb – casting - Jersey finger – grab jersey get when flexed finger is forcefully extended splinting - Mallet finger – extended finger is forefully flexed – splinting - Traumatically amputated digits – surgically reattached Pre-Op Assessment: - EF less than 35% - 75-85% periop MI risk - Goldman’s index: JVD, recent MI, PVCs, other than sinus, emergency sx, >70, aortic stenosis, poor medical conditions, surgery w/in the chest or abdomen - JVD indicating CHF is worst, followed by recent MI - Smokng compromised ventilation – measure FEV1 – cessation for 8 weeks and IS therapy prior to surgery - Hepatic: high bili, low albumin, high PT, ascites, and encephalopathy - Severe nutritional depletion : loss of 20% of body weight, serum albumin below 3, anergy to skin antigens, serum transferrin level less than 200 – 2-5 days of TPN helpful - Diabetic risk is absolute CI to sx Post-Op Complications: - Fever: o High fever immediately post op think malignant hyperthermia (also w/ metabolic acidosis and hyperCa do dantrolene and O2) or bacteremia (like if instrumentation in the urinary tract, do blood culures x 3 abx) o Usual 101-103 range: Atelectasis POD 1 PNA POD3 UTI POD3 Deep thrombophlebitis POD 5 Wound infection POD7 Deep abscess POD 10-15 - Chest Pain: o MI: during 2/2 hypotension, 2-3 days post op, much higher mortality risk than non post op MI – can’t use tPA but do angioplasty + stenting o PE: POD 7 – hypoxemia, hypocapneia, resp alkalosis – CTA, JVD, heparin + IVC filter if repeats Prevent by preventing DVT – TEDS on all those w/ LE fx + AC if >40, pelvic or leg fx, venous injury, femoral venous catheter, prolonged anticipated immobilization o Other pulm: aspiration (why NPO, lavage w/ bronchoscopy, bronchodilators and resp support) o IO Tension PTX – difficult to ventilate – can decompress through the diaphragm or anterior chest - Disorientation/Coma: o Hypoxia is first thing to suspect – check abg and give supplemental O2, may be 2/2 sepsis o ARDS – b/l pulm infiltrates w/out evidenve of CHF – tx w/ carefell PEEP o Delirum tremens – give IV 5% ethanol in 5% dextrose or benzos
Hyponatremia if lots of non-isotonic (sodium free like D5W) in post op patient with high ADH levels (triggered 2/2 trauma) – tx w/ ? small amounts of hypertonic saline and osmotic diuretics o Hypernatremia – large, unreplaced H20 loss – sx damage to the post pit w/ unrecognized diabetes insipidus – need to rapidly replace fluid but cushion tonicity w/ D51/2 or 1/3 NS o Ammonium intox in cirrhotic patient Urinary complications: o Post op retention common – do cath in 6 hours, if need to do 3 do indwelling cather o Zero OP – mechanical issue o Low UOP (less than 0.5 ml/kg/hr) Dehydrated – imp w/ bolus challenge, also excretion of Na is low (less than 10-20 or fraction less than 1) RF – no imp w/ bolus challenge – are not conserving Na so see >40 and FeNa>1 Abdominal distension: o Paralyatic ileus – both small and large bowel, bowel sounds absent, first few days post op, mild distension, no pain o Early mechanical SBO – b/c of adhesions, think if paralytic ileus not resolving at 5-7 days, see dilated SB and air fluid w/ no gas in colon, confirm T point with CT, need to sx o Oglive is paralytic ileus of large bowel seen in sedentary patients following non-abd surgery (femur) – get abd distension, and see massively dilated colon. Need to r/o mechanical obs before giving IV Neostigmine. Wound o Dehiscence is seen around POD5 – get pink colored fluid that is from peritoneum – bind and care for it, nonemergent sx later to prevent ventral hernia. o Evisercation – abd contents rush out - em sx o Wound infections POD7 o Fistulas of GI tract – cause sepsis if not draining or if draining then fluid/electrolyte loss, nutritional depletion, and skin erosion and digestion of belly wall Support, should heal if no FETIIDS – FB, epithelization, tumor, infection, IBD, irradiated tissue, distal obstruction, or steroids. Fluids/electrolytes: o Hypernatremia: lots of water loss (or other hypotonic fluids) – I L for every 3 above 140 Slow get adapt and no CNS issues, fast get CNS issues Need to correct volume quickly but NOT tonicity b/c leads to cerebral edema – correct w/ D5 ½ NS o
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