ABSITE Review ConferenceTopic Month

Head and Neck / Breast August 09

Alimentary Sept 09

Alimentary / Abdomen Oct 09

Abdomen / Endocrine Nov 09

Vascular / Pediatric Surgery Dec 09

Surgical Physiology + Critical Care

Jan 10

TBD Feb 10

Trauma / Orthopedics Mar 10

Trauma / Anesthesia Apr 10

Oncology / Skin + Soft Tissue/ Transplant Immunology

May 10

Thoracic Surgery/ Gynecology/Urology

June 10

Trauma/ Anesthesia

You start to perform your Kocher maneuver in the above patient and find that the 1st and 2nd portions of the duodenum are completely blown out proximal to the common bile duct. The most appropriate next step is:

a) Whipple

b) Oversew proximal and distal portions of the duodenum, then gastrojejunostomy

c) Proximal duodenojejunstomy and distal duodenojejunostomy

d) Place drains

Trauma/ Anesthesia

Answer B.

For an injury that is proximal to the ampulla of Vater, you can staple off the proximal and distal ends of the duodenal injury and perform a gastrojejunostomy. You can do this because the ampulla of Vater is not involved and will still drain distally. Food will pass via the gastrojejunsotomy.

Remember to widely drain.

If the injury involves the duodenum distal to the ampulla of Vater, a duodenojejunostomy is needed to control biliary flow. If the ampulla itself is destroyed (functional Whipple), you can place drains initially if the patient is unstable but the patient will need to return for a formal Whipple.

Trauma/ Anesthesia

All of the following are indications for angiogram of an extremity except:

a) Injury to anatomically related nerve

b) History of large severe blood loss from the injury

c) Large hematoma

d) Active hemorrhage

Trauma/ Anesthesia

Answer D. Active hemorrhage is an indication to go to the OR, not get an angiogram.Major (Hard) signs of vascular injury

Active hemorrhage present

Pulse deficit

Expanding or pulsatile hematoma

Distal ischemia

Bruit or thrill present

Treatment for any of the above is to go to OR for exploration.

Minor (Soft) signs of vascular injury

History of hemorrhage at the scene

Anatomically related nerve deficit

A large stable hematoma

Injury close to a major artery (GSW to the medial thigh)

ABI < 0.9

Unequal pulses

Diagnosis for any of the above is to go to angiography.

Trauma/ Anesthesia

You perform a DPL on a patient involved in a motor vehicle accident which is positive. The patient has remained hypotensive despite blood resuscitation. The patient has a blown pupil on the right. The most appropriate next step is:

a) Head CT

b) Abdominal CT

c) Head and Abdominal CT

d) OR

Trauma/ Anesthesia

Answer D.

A positive DPL in a hypotensive patient mandates operative exploration. In the ABC’s scheme, C (circulation) must be addressed before addressing the head injury.

Trauma/ Anesthesia

While in the OR, this patient should undergo:

a) Laparotomy only

b) Laparotomy followed by head CT

c) Laparotomy and Burr hole placement

d) Burr hole placement only

Trauma/ Anesthesia

Answer C.

While in the OR, you should place a Burr hole to decompress the side with the blown pupil. This is placed 5 cm anterior and 5 cm superior to the external auditory canal (frontal bone).

Another option would be to place an ICP bolt and check the pressure, with placement of a Burr hole is the pressure is elevated (although just doing the Burr hole is probably the best treatment).

WHERE TO MAKE THE FIRST BURR HOLE?• If fracture crosses a vessel, make the hole there.• If patient has an obvious scalp injury, start in the center.• If there is no fracture line or obvious scalp injury, make the first hole in the

classical position.• If the first hole is negative, make the next one in the parietal region, and

then one in the frontal region. • If this too is negative, repeat the same three holes in the same order on

the other side.

• Occasionally, you will have to make six holes; only if all six are negative can you be sure that there is no clot above a patient’s tentorium- “woodpecker method”

• Only when you have reached the dura will you see if the bleeding is epidural or subdural.

• Do NOT make a burr hole over a major sinus.

Trauma/ Anesthesia

A 25 year old man in a MVA will open his eyes only to painful stimuli, does not form words but mumbles, and withdraws to pain. The patients Glasgow Coma Scale is:

a) 10

b) 8

c) 6

d) 4

Trauma/ Anesthesia

Answer B.

Opens eyes (2), Incomprehensible sounds(2), Withdraws from pain (4)Eye opening

4 Spontaneous

3 Opens to command

2 Opens eyes to pain

1 No response

Verbal response

5 Appropriate and oriented

4 Confused but responds

3 Inappropriate words with speech

2 Incomprehensible sounds

1 No response

Motor function

6 Follows commands

5 Localizes to pain site

4 Withdraws from pain

3 Flexion with painful stimuli (decorticate)

2 Extension with painful stimuli (decerebrate)

1 No response to painful stimuli

Trauma/ Anesthesia

The above patient is having difficulty maintaining his airway so you intubate him. Head CT shows loss of sulci and compression of cisterns so you place an ICP monitoring catheter. All of the following are true of cerebral perfusion except:

a) In general, a cerebral perfusion pressure of 70 is sufficient

b) Cerebral perfusion pressure = Mean arterial pressure – intracranial pressure

c) Mannitol can help lower ICP

d) Hypoventilation benefits these patients

Trauma/ Anesthesia

Answer D.

In general, a CPP > 60 is sufficient. Mannitol helps increase cerebral perfusion bu drawing water from the brain thereby decreasing ICP. Mild hyperventilation (pCO2 30-35) helps by causing mild cerebral vascocontriction which limits brain edema.

Trauma/ Anesthesia

A 27 year old man is in the ICU 6 hours after splenectomy following a MVA. The patient has a prolonged transport time and received 20 units of blood prior to arrival. Currently, his peak airway pressures are 65 (plateaus 50), his abdomen is distended, he is not making any urine, and his bladder pressure is 40. His CVP is 18. The most appropriate maneuver in this patient is:

a) Increase PEEP

b) Volume resuscitation

c) Decompressive laparotomy

d) CT scan

Trauma/ Anesthesia

Answer C.

The patient has classic signs of abdominal compartment syndrome. Objectively, a bladder pressure > 25-30 suggests abdominal compartment syndrome. Decreased urine output from IVC compression results in decreased cardiac output. Elevated ventilatory pressures are coexistent. Treatment of abdominal compartment syndrome is decompressive laparotomy.

Trauma/ Anesthesia

Trauma/ Anesthesia

Malignant hyperthermia is most commonly related to a defective receptor (ryanodine receptor) on the sarcoplasmic reticulum that controls calcium release. The 1st sign of malignant hyperthermia after receiving succinylcholine in the intubated patient is:

a) Fever

b) Rigors

c) Increase in end tidal CO2

d) Tachycardia

Trauma/ Anesthesia

Answer C.

Trauma/ Anesthesia

The most appropriate step in the treatment of malignant hyperthermia is:

a) Dantrolene

b) Dopamine

c) Dobutamine

d) Lasix and potassium

Trauma/ Anesthesia

Answer A.

Malignant hyperthermia can be triggered by either volatile gaseous inhalation anesthetics (sevoflurane, isoflurane, halothane, enflurane, etc.) or succinylcholine.

The defect is in calcium metabolism which causes a prolonged muscle excitation- contraction syndrome.

In an intubated patient, the first sign is a rise in the end tidal CO2. Other signs include tachycardia, fever, rigidity, acidosis, and hyperkalemia.

Treatment includes stopping the precipitating anesthetic or paralytic, dantrolene (which decouples the excitation complex), cooling blankets, HCO3- (alkalinize), glucose, and oxygen.

Trauma/ Anesthesia

Drop in end tidal CO2

Disconnection from the ventilator

Pulmonary embolus

CO2 embolus

Trauma/ Anesthesia

Rise in end tidal CO2

Most common cause is alveolar hypoventilation (atelectasis). Others include lung injury, absorption of CO2 with laparoscopy, shivering, hyperthermia, catecholamine release, thyroid storm, inadequate fresh gas flow, exhausted soda lime

Hypoventilation, which may result from increased resistance to air flow in external anesthesia equipment (rebreathing of CO2), the tracheal tube (kinking, obstruction with secretions, and herniated or ruptured cuff), or the tracheobronchial tree (laryngospasm or bronchospasm)

Trauma/ Anesthesia

Cis-atracurium (Nimbex) is metabolized by:

a) Liver

b) Kidney

c) Plasma cholinesterase

d) Hoffman degradation

Trauma/ Anesthesia

Answer D.

Cis-atricurium is degraded by Hoffman degradation which makes it ideal for patients with either renal failure or liver failure.

Trauma/ Anesthesia

Two days after a severe inhalational injury, you have trouble oxygenating your patient so you decide to paralyze her with pancuronium. The most common side effect of pancuronium is:

a) Fever

b) Hypotension

c) Increased Intracranial Pressure

d) Tachycardia

Trauma/ Anesthesia

Answer D.

The most common side effect of pancuronium (non-depolarizing muscle relaxant) is tachycardia.

Trauma/ Anesthesia

A 52 year old woman undergoes a routine low anterior resection for colon cancer and has a temperature of 104.0 six hours post-op. you look at her wound and it is purple around the edges and there seems to be some gray drainage. The most appropriate next step is:

a) Cefazolin

b) Ceftriaxone

c) Zosyn

d) Re-exploration

Trauma/ Anesthesia

Answer D.

Trauma/ Anesthesia

The most likely organism in the above scenario is:

a) Staph aureus

b) Clostridum perfringens

c) Enterococcus

d) E. Coli

Trauma/ Anesthesia

Answer B.

Clostridium perfringens wound infection is rare but it needs to be recognized. Patients who have high fever immediately post-op need to have their dressing removed and their wound inspected. If wound drainage appears or there is surrounding skin changes, the patient should immediately be taken back to the OR for wide debridement. The patient is at high risk for developing necrotizing fascitis and/or myonecrosis.

Beta-hemolytic group A strep is also a potential source of early invasive wound infection early post-op.

Penicillin is the classic treatment of choice for both clostridium perfringens and beta-hemolyttic group A strep but in reality you would start a broad spectrum antibiotic until you knew what the organism was.

Trauma/ Anesthesia

The muscles that are the 1st to relax with paralytics are the:

a) Neck muscles and face

b) Diaphragm muscles

c) Extremities

d) Abdominal Wall

Trauma/ Anesthesia

Answer A.

Trauma/ Anesthesia

The muscles that are the last to relax with paralytics and the 1st to recover are the:

a) Neck muscles and face

b) Diaphragm muscles

c) Extremities

d) Abdominal Wall Muscles

Trauma/ Anesthesia

Answer B.

The muscles of the neck and face are the 1st to relax with paralytics and the last to recover. The diaphragm muscles are the last to relax and the 1st to recover.

Trauma/ Anesthesia

The various inhaled anesthetics have different biological characteristics. A low minimum alveolar concentration (MAC) of an inhaled anesthetic indicates:

a) A less potent anesthetic

b) A more lipid soluble anesthetic

c) A very fast onset

d) A large amount of anesthetic is required for induction

Trauma/ Anesthesia

Answer B.

The minimum alveolar concentration of an inhaled anesthetic is the amount of anesthetic for which only 50% of patients will move with incision.

A low MAC = more lipid soluble = more potent anesthetic.

Speed of induction is inversely proportional to solubility.

A high alveloar concentration = less lipid soluble = less potent = faster onset.

Nitrous oxide is the fastest working inhaled anesthetic but also has a high MAC.

Trauma/ Anesthesia

Severe hallucinations are a common side effect of:

a) Ketamine

b) Etomidate

c) Propofol

d) Sodium thiopental

Trauma/ Anesthesia

Answer A.

Severe hallucinations are a side effect of ketamine.

Trauma/ Anesthesia

Non-depolarizing paralytics can be reversed with:

a) Beta-blocker

b) Alpha blocker

c) Calcium

d) Neostigmine

Trauma/ Anesthesia

Answer D.

Non-depolarizing paralytics competitively block acetylcholine receptors. If you block acetylcholinesterase, you get build up of acetylcholine which will compete against the non-depolarizing paralytic.

Neostigmine is an inhibitor of acetylcholinesterase.

Trauma/ Anesthesia

Of the anesthetic agents listed below, the one most likely to case an allergic reaction is:

a) Lidocaine

b) Bupivicaine

c) Mepivicaine

d) Procaine

Trauma/ Anesthesia

Answer D.

Procaine is an ester type anesthetic along with cocaine and tetracaine. They are more likely to cause allergic reactions because of their PABA analogue.

Amide type local anesthetics all have an “i” in the first portion of their names such as lidocaine, bupivicaine, and mepivicaine. These rarely cause allergic reactions.

Trauma/ Anesthesia

All of the following are true of local anesthetics except:

a) These agents work by increasing the action potential threshold in peripheral nerves

b) Work better in acidic environments

c) Can cause seizures

d) Ester based local anesthetics have increased allergic reactions compared to amide based anesthetics

Trauma/ Anesthesia

Answer B.

Local anesthetics work by raising the action potential threshold (makes it harder to have an action potential occur so pain sensation is not tranmitted). Local anesthetics work very poorly in acidic environments (which makes it hard to anesthetize infected wounds).

Trauma/ Anesthesia

Helpful hints to make local anesthetic more comfortable • Use smaller gauge needles (higher numbers)• Elective procedures: 27 to 30 gauge needl• Avoid using anything larger than a 25 gauge needle• Infiltrate skin slowly• Inject through wound edge if possible• Warm Xylocaine to body temperature• Be generous with local anesthetic• Use Buffered Lidocaine (Bicarbonate 1 part to Xylocaine 9 part ratio)• Cool skin before injection (Ice, Liquid Nitrogen, frigiderm)• Consider topical anesthetic use before injection

Trauma/ Anesthesia

Topical pre-anesthetics• Ethyl Chloride Spray: Do not use with electrocautery, 1-2 seconds of anesthesia• Lidocaine-Epinephrine-Tetracaine (LET): Indicated for open wounds• EMLA cream (Eutactic Mixture of Local Anesthetic): Indicated in closed wounds, Apply ointment under Occlusion, Use 90 minutes prior to injection• Iontophoresis: Lidocaine sponges applied to intact skin, DC current applied to electrodes, Onset within 10 minutes and duration of 15 minutes, Penetration depth of 1-2 cm• Lidocaine 4% in liposomal matrix (ELA-Max): Similar application as with EMLA cream• Anesthetic Patch (Lidoderm)

Trauma/ Anesthesia

Amide and Ester anesthetic metabolism and excretion.

Metabolized by liver

Excreted by kidney

Dose calculations

Solution of 0.5%: 5 mg/ml

Solution of 1%: 10 mg/ml

Solution of 2%: 20 mg/ml

Trauma/ Anesthesia

Local Anesthetics: Short acting Amide Anesthetics

Local Lidocaine (Xylocaine) 1% or 2%

Onset: 2 minutes

Duration: 1.5 to 2 hours

Max dose: 4 mg/kg to 280 mg (14 ml 2%, 28 ml 1%)

Mepivacaine (Carbocaine) 1%

Onset: 3 to 5 minutes

Duration: 1.5 to 2 hours

Max dose: 4 mg/kg up to 280 mg (28 ml))

Prilocaine (Citanest) 1%

Onset: 2 minutes

Duration: 1 hour

Max dose: 7 mg/kg up to 500 mg (50 ml)

Trauma/ Anesthesia

Local Anesthetics: Long acting Amide Anesthetics

Lidocaine with Epinephrine 1:100,000 or 1:200,000

Onset: 2 minutes

Duration: 2 to 6 hours

Max dose: 7 mg/kg to 500 mg (25 ml 2%, 50 ml 1%)

Bupivacaine (Marcaine) 0.25%

Onset: 5 minutes

Duration: 2 to 4 hours

Max dose: 2.5 mg/kg up to 175 mg (50 ml)

Etidocaine (Duranest) 0.5% or 1%

Max dose: 4 mg/kg to 280 mg (25 ml 1%, 50 ml 0.5%)

Trauma/ Anesthesia

Histamine release is characteristic of:

a) Demerol

b) Fentanyl

c) Sufentanil

d) Morphine

Trauma/ Anesthesia

Answer D.

Morphine has a characteristic histamine release which can cause hypotension.

Trauma/ Anesthesia

An overdose of Fentanyl is treated with:

a) Flumazenil

b) Narcan

c) Neostigmine

d) Edrophonium

Trauma/ Anesthesia

Answer B.

All narcotic agents (Morphine, Fentanyl, Demerol, Sufentanil) overdoses can be treated with Narcan (naloxone).

Trauma/ Anesthesia

Narcan Dosing•IV is most effective. IM or SC administration may be necessary if the IV route is not available. •An initial dose of 0.4 mg to 2 mg of NARCAN may be administered intravenously. •May be repeated at two- to three-minute intervals. •If no response is observed after 10 mg, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned.

Trauma/ Anesthesia

A severe overdose of Ativan is treated with:

a) Flumazenil

b) Narcan

c) Neostigmine

d) Edrophonium

Trauma/ Anesthesia

Answer A.

Severe overdoses of benzodiazepines (Ativan, Valium, Versed) are treated with Flumazenil.

Trauma/ Anesthesia

Flumazenil Dosing• Recommended initial dose of ROMAZICON is 0.2 mg (2 mL) administered intravenously over 15 seconds. • If the desired level of consciousness is not obtained after waiting an additional 45 seconds, a second dose of 0.2 mg (2 mL) can be injected and repeated at 60-second intervals where necessary (up to a maximum of 4 additional times) to a maximum total dose of 1 mg (10 mL). •The dosage should be individualized based on the patient's response, with most patients responding to doses of 0.6 mg to 1 mg.

Trauma/ Anesthesia

A patient undergoing a left lower lobectomy has an epidural placed containing morphine and bupivicaine. All of the following are true about the epidural except:

a) Respiratory depression is most likely due to the morphine

b) Hypotension and bradycardia are most likely due to the bupivicaine

c) Epidurals are well tolerated in patients with hypertrophic cardiomyopathy

d) Spinal headaches can often be treated with a blood patch

Trauma/ Anesthesia

Answer C.

HCM is a contraindication to epidurals because they cause a decrease in afterload which can be catastrophic in dilated cardiomyopathy (the ventricle collapses at the level of the septum).

Hypotension and bradycardia with epidurals are almost always related to the local anesthetic. (Sympathectomy and decrease venous return)

Trauma/ Anesthesia

Answer C.

Morphine administered by epidural does not cause hypotension. CSF does not contain mast cells that release histamine.

Respiratory depression is related to morphine in epidurals. Many centers place Dilaudid in epidurals to avoid this side effect.

Trauma/ Anesthesia

Prior to performing a lung resection, the anesthesiologist attempts to intubate the patient but is not sure if the tube is in the trachea. The best determinant of esophageal versus tracheal intubation is:

a) Breath sounds

b) Gastric sounds

c) Grade of the view of the vocal cords

d) End tidal CO2

Trauma/ Anesthesia

Answer D.

End tidal CO2 monitoring is the most sensitive test as to whether or not the endotracheal tube is placed correctly.

Observational methods to confirm correct tube placement

Direct visualization of the tube passing through the vocal cords, Clear and equal bilateral breath sounds on auscultation of the chest, Absent sounds on auscultation of the epigastrium, Equal bilateral chest rise with ventilation, Fogging of the tube, An absence of stomach contents in the tube

Instruments to confirm correct tube placement

Colorimetric end tidal CO2 detector, Waveform capnography, Self inflating esophageal bulb, Pulse oximetry- delay in fall of saturation, especially if pre-oxygenated, Esophageal Detection Device (ODD)

Trauma/ Anesthesia

A 65 year old man on dialysis for renal failure undergoes an elective AAA repair. The patients ASA class is:

a) II

b) III

c) IV

d) V

Trauma/ Anesthesia

Answer B.

Class I: Healthy

Class II: Mild disease without limitation (HTN, DM, Obesity, Smoker)

Class III: Severe Disease (Stable angina, previous MI, moderate COPD)

Class IV: Severe Disease with Constant Threat to Life (Unstable Angina, Renal or Liver Failure, Severe COPD)

Class V: Moribund Patient that will not survive without surgery (Ruptured AAA, Saddle Pulmonary Embolus)

Class VI: Organ Donor

Trauma/ Anesthesia

Trauma/ Anesthesia