High Yield Surgery Emma Holiday Ramahi PP

After pH, HCO2, and pCO2, check anion gap (Na - [Cl + HCO3]). What is the normal anion gap?

8-12

Best test to evaluate management of pt on vent?

ABG

Parkland formula

Adults: Kg x % BSA x 3-4 Kids: Kg x % BSA x 2-4 Ringers lactate or normal saline Give 1/2 over the first 8 hours and the rest over next 16 hours

Poor nutrition contraindications to surgery

Albumin <3 Transferrin <200 Weight loss <20%

Late systolic, crescendo decrescendo murmur that radiates to carotids Increases with squatting Decreases with decreased preload

Aortic stenosis

Other factors of Goldman's index

Arrhythmia Old >70 Emergent? AS, poor medical condition, surgery in chest/abd

Meds to stop prior to surgery

Aspirin NSAIDs Vitamin E (2 weeks) Warfarin (5 days) - drop INR to <1.5 (can use vit K) Take half the morning dose of insulin if diabetic

Explain CPAP vent

Pt must breath on own but + pressure given all the time

What do do when intubated and decreased lung sounds on left?

Pull back ET tube

Treatment for high sodium

Replace w/D5W or hypotonic fluid

If pH <7.4, and HCO2 is high and pCO2 is high?

Respiratory acidosis

If pH >7.4 and HCO3 is low and pCO2 is low?

Respiratory alkalosis

NL volume Decreased sodium Causes:

SIADH Addisons Hypothyroidism

Explain Assist control vent

Set TV and rate but if pt takes a breath, vent gives the volume

Doesn't penetrate eschar and causes hypoK and hypoNa

Silver nitrate

Which Abx doesn't penetrate eschar and can cause leukopenia

Silver sulfadiazine

Contraindications to the smoker

Stop smoking 8 weeks prior If a CO2 retainer, go easy on the O2 in the post-op period; can suppress respiratory drive

When to use 3% saline in low sodium patients?

Symptomatic (seizures) <110

Which is more efficient to change? Rate or TV?

TV is more efficient to change *Remember minute ventilation equation and dead space

Goldman's index

Tells you who is at greatest risk for surgery

Isolated decrease in platelets DX?

ITP

Explain Pressure support vent

Important for weaning Pt rules rate but a boost of pressure is given

If pt on vent has low PaO2?

Increase FiO2

If PaCO2 is high (pH is low) in pt on vent?

Increase rate or TV

Bones, stones, groans, psycho. Shortened QT interval.

Increased calcium

Peaked T waves, prolonged PR and QRS, sine waves. Cause? Treatment?

Increased potassium Tx: give calcium gluconate then insulin + glucose, kayexalate, albuterol, and sodium bicarbonate Last resort: Dialysis

Why do we check the BUN and Creatinine? What is the worry if BUN >100?

Increased risk of post-op bleeding due to *uremic platelet dysfunction*

TPN indications? Risks?

Indicated if gut can't absorb nutrients 2/2 physical or fxnal loss. *Risks* = *acalculus cholecystitis*, hyperglycemia, liver dysfxn, *zinc deficiency*, other 'lyte probs

If urine dipstick + for blood but microscopic exam is negative for RBCs in burn pt?

Myoglobinuria (ATN) Rhabdo

Clotting with edema, HTN, foamy pee

Nephrotic syndrome

What would you expect on coag panel if BUN>100?

Normal platelets, prolonged bleeding time

Tx for low sodium and hypovolemic?

Normal saline

A patient has inward mvmt of the right ribcage upon inspiration. Dx Fail Chest Tx

O2 and pain control

Explain PEEP vent

Pressure given at the end of each cycle to keep the alveoli open *Used in ARDS and CHF

Physical Exam findings for Pneumothorax

decreased breath sounds on the effected side hyperressonance to percussion If tension pneumo= JVD and tracheal displacement away from effected side

Physical exam findings in hemothorax

decreased breath sounds, dullness to percussion

What type of Antibiotics for burn patients

no PO or IV antibiotics, only topical to avoid resistance

Treatment for Traumatic Aortic Injury

surgery ASAP to perform reconstruction with a clip

Normal platelets but increased bleeding time and PTT Dx?

vWD

Electrical Burn, best 1st step?

EKG

causes and treatment for pulmonary contusion

causes: rib fracture, MVA, trauma Tx: pulmonary toilet and pain management

Criteria for compartment syndrome

5P's or pressure >30mmHg Pain, palor, pulselessness, poikilothermia, parasthesia

Electrical Burn, abnormal EKG or LOC: Next step?

48 hrs of telemetry

Pt with confusion, HA, cherry red skin... Tx?

100% O2 (hyperbaric if CO-Hb really high)

Contraindications to surgery due to severe liver failure

Bili >2 PT >16 Ammonia >150 Encephalopathy

#1 on Goldman index

CHF Check EF. If <35% no surgery

Increased volume Decreased sodium Causes:

CHF Nephrotic Cirrhotic

Clotting in old people Sign of?

Cancer

Pt with confusion, HA, cherry red skin... Cause? Best test?

Carbon Monoxide poisoning Check carboxy Hb (pulse ox = worthless)

When replacing with saline, what do you need to worry about?

Central pontine myelinolysis

What would you worry about when replacing sodium

Cerebral edema

So you intubated your patient... next best step?

Check b/l breath sounds

What do do when intubated and decreased lung sounds on left? Next step?

Check pulse ox Keep >90%

If affected extremity is extremely tender, numb, white, cold with barely dopplerable pulses?

Compartment syndrome

If pH>7.4, HCO3 high, pCO2 high, and urine Cl >20 what could cause this?

Conn's (1* hyperaldosteronism. Low Renin, high BP, poor vision, headaches) Bartter's (low K+, alkalosis, hypotension, defect in thick LOH) Gittlemans (Low K+ low Mag, Decreased excretion of Calcium/hypocalciuria)

Tx for circumferential burns

Consider escharotomy

If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7?

Cricothyroidotomy Do not intubate if no clear airway

Maintenance IVFs

D51/2NS + 20KCl (if peeing) - Up to 10kgs: 100mL/kg/day - Next 10 kgs: 50mL/kg/day - All above 20: 20mL/kg/day

Low platelets, increased PT/PTT/BT, low fibrinogen, high D dimer, and schistocytes Dx?

DIC (Caused by gram sepsis, carcinomatosis, OB stuff)

If pt on vent has high PaO2?

Decrease FiO2

If PaCO2 is low (pH is high) in pt on vent?

Decrease rate or TV

Numbness, Chvostek or Troussaeu, prolonged QT interval

Decreased calcium

Paralysis, ileus, ST depression, U waves. Cause? Treatment?

Decreased potassium Tx: give K, max 40mEq/hour

Absolute contraindications to surgery

Diabetic coma DKA

If CKD in dialysis...

Dialyze 24 hours post-op

Increased volume decreased sodium Causes:

Diuretics Vomiting Free weater

Clotting in a young person w/+FH

Factor V leiden

Treatment for compartment syndrome

Fasciotomy at bedside

A patient has confusion, petechial rash in chest, axilla and neck and acute SOB. Dx?

Fat embolism

Enteral feeds

Feeds that keep gut mucosa in tact and prevent bacterial translocation

If guy stabbed in the neck, crackly sounds w/palpating anterior neck tissues? First step?

Fiberoptic bronchoscope Careful intubation

A patient has inward mvmt of the right ribcage upon inspiration. Dx?

Flail chest. >3 consecutive rib fractures

Treatment for low sodium

Fluid restriction and diuretics

Decreased sodium is usually due to ______ water. What do you check?

Gain of water. Check volume status.

Causes of non-gap acidosis

HARD ASS Hyperalimentation, Acetazolamide, RTA, Diarrhea, Diuretic, Addisons, Small bowel Fistula, Spironolactone RTAs (I<II, IV)

Clotting post-op, decreased platelets, clots

HIT (If heparin within 5-14 days)

Whats special about ATIII deficiency?

Heparin wont work

If GCS <8 First step?

Intubate

If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck? First Step?

Intubate

If guy stung by bee, developing stridor and tripod posturing First Step?

Intubate

If trauma pt comes in unconscious First step?

Intubate

If intubated and decreased lung sounds on left?

Intubated right mainstem bronchus Pull back

Chemical burn, what to do?

Irrigate >30 min prior to ER

If urine dipstick + for blood but microscopic exam is negative for RBCs in burn pt? Then what do you check?

K+ (lysis of intracellular contents)

Tx for HIT

Lepirudin, argatroban

Physical cues for low threshold of intubation

Look for singed nose hairs, wheezing, soot in nose/mouth

Increased sodium is due to _____ water

Loss of water

Clotting in woman w/multiple SABs

Lupus anticoagulant

#2 on Goldman index

MI w/in 6 months Check: EKG --> stress test --> cardiac cath --> revasc

Causes of Gap acidosis

MUDPILES Methanol, Uremia, DKA, Paracetamol, Paraldehyde, Isoniazid, Lactic Acidosis, Ethanol, Ethylene glycol, Salicyclates

Which Abx penetrates eschar, but hurts like hell

Mafenide

If pH <7.4 and HCO2 is low and pCO2 is low?

Metabolic acidosis

If pH >7.4 and HCO3 is high and pCO2 is high? What do you check next?

Metabolic alkalosis. Next, check urine [Cl]...

treatment for hemothorax and when to go to OR

Tx: chest tube go to OR if there is high output=>1.5L after chest tube insertion or >200cc/hr in the first 4 hours

If pH>7.4, HCO3 high, pCO2 high, and urine Cl <20 what could cause this?

Vomiting NG Antacids Diuretics