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