Kaplan SurgeryIntial survey - Airway If patient is conscious and fully normal, normal voice, does not need airway Patient with hematoma but normal voice, still needs an airway because of the expanding hematoma. Use laryngoscope, with anesthesia Pt with subcute air (emphesyma) needs an airway, means injury to trachea or major bronchus. Cant put a tube blindly, might lead to perforation etc... Fibrotic bronchoscope (with visualization) so we can advance beyond injury. Pt is uncons, but breathing spontaneously, but makes noise/gurgles when he breaths. So indication for airway. Also trauma pt who is uncons needs airway even if he is breathing spontaneously. Pt unable to move ext, then became unconscious. First thing we do is take care of airway, but we know he has cervical spine injury so we cant hyperextend neck. Use fiberobtic through endotracheal tube. Patient alert, with facial fractures drowing in his own blood normal anatomic pathways not available, so we go through the neck. Do cricothyroidotomy, or percutaneous tracheostomy. BreathingTrauma Patient in shock Is chest involved? If chest is not involved, then we know the patient is in schock because he is bleeding When Chest is involved Are neck veins distended, or CVP high? No = patient is bleeding Yes = either pericardial tamponade or pneumothorax Is it hard to breathe? YES = pneumothorax NO = pericardial tamponade Must stop bleeding and replace bleeding If patient is in ER, and we know where he is bleeding, then stop the bleeding first. Pt in shock, shot in abdomen - near emerg surg center, take him to OR for laparotomy If you see the bleeding, stop it with direct pressure, and start IV fluids. MVA spont breathing, JVD not distended, hypotensive. We know shock is from bleeding Patient gets intubated. If we dont know where he is bleeding from, first start fluid resuscitation. 2-3 large iv bores. If you think its pericardial tamponade but not sure, do ultrasound. Treatment for pericardial tamponade Pericardiocentesis, tube or window, or mediostenotomy.

Head Trauma Penetrating injury to skull, must go to OR. Foreign body should be removed in OR Linear fracture can be fixed in ER, comminuted must be fixed in OR Pt was unconscious at site of accident, but awake in ER and he is acting normal/neuro exam normal, still needs CT of head. Any pt with lucid interval needs CT of head Signs of skull fracture at base Racoon eyes Fluid dripping from ear, or nose This means theres big trauma, might have cervical/spincal cord injury Needs ct of head and neck. Pt trauma to head, loses conscious, lucid interval, goes unconscious again, now patient has dilated fixed pupil Acute epidural or acute subdural hematoma Lens shapped hematoma on ct Epidural if completely normal Subdural is bigger trauma and usually sicker Crescent shaped hematoma/semilunar. If patient has subdural on ct and small, and no focal neuro signs, then observe in hospital, check ICP if elevated treat medically diuretics, mannitol, hyperventilation to decrease icp. Can reduce o2 demand or brain also by sedation or hypothermia. Patient with signs of alzheimers within weeks, patient has chronic subdural hematoma. Ct scan, evacuate hematoma. Neck Trauma Gunshot wounds: Patient has wound to neck, spitting/coughing blood, expanding hematoma near area of thyroid cartilage. Indications for surgical exploration Gunshots wounds between mandible and above cricoid cartilage (middle of neck) Spitting/coughing blood means injury to larynx/pharynx Expanding hematoma Exceptions Patient with gunshot wound above the mandible Needs angiogram/angiographic assessment of vascular tree and embolization Patient with gunshot above clavicle but below cricoid Angiogram, esophagogram, bronchoscopy Blunt trauma to neck Stable, lacerations to face, tenderness in posterior neck midline Think cervical spine/spinal cord injury If theres pain, even if neuro is normal we need CT scan

Surgical exploration of neck Vital signs are deterioration Expanding hematoma Spitting/vomiting blood Gunshot wounds to middle zone of neck If above angle of mandible Arteriographic dx and tx If below cricoid cartilage Arteriogram, esophagram, esophagoscopy, bronchoscopySpinal cord injuries Hemisection Loss of pain/temp on one side, paralysis and loss of vibration/propiro on the other distal to lesion Anterior cord syndrome (anterior spinal artery) Loss of pain/temp, paralysis on both sides, and preservation of vibratory/position. (dcml posterior) Central cord syndrome Hyperextension of neck Upper extremity issues but lower ext spared. Need to do MRI for any of these Steroids as soon as diagnosis madeChest Trauma Blunt trauma and penetrating is the same in chest due to broken ribs that leads to penetration Rib fracture Rx topical anesthetic so they can breath normal Tension pneumo dont do CXR, normal pneumo do XRAy, then chest tube in upper part of chest Hemothorax bleeding usually stops on its own, have to get rid of blood with chest tube in bottom part of chest Once we see drain only drains a little bit we know were doing good and bleeding has stopped In the case that drain recovers a ton of bleeding, that means systemic vessel usually intercostal, means bleeding not stopping, so we need surgical intervention thoracotomy. Flail chest chest tubes, diuretics, fluid restriction. Follow with CXR and EKG she might have contusions lung/heart also in cases of deceleration injuries. May even eventually lead to aortic dissection (slowly) If CXR shows wide mediastinum do spiral CT if they match, do surgery. If they dont match then we do arteriogram Diaphgragmatic rupture Bowel sounds in chest, multiple air levels in chest, more common in left. Gastric tube goes up into chest Thoracic subcutaneous emphesyma Caused by: Transection of esophagus during endoscopy Tension pneumothorax (patient will be in shock) Transactional injury to trachea need to do fiberoptic bronchoscopy to see injury and for intubationAbdominal Trauma Blunt trauma: Anyone with acute abdomen/signs of peritoneal irritation needs exploratory laparotomy Bleeding or not Anyone in bleeding dont know where (low cvp.) Cant be head, not enough room If neck not distended like crazy not bleeding in neck Do CXR (normal), means they arent bleeding in the chest Pelvic fracture check by pelvic exam Femur fracture check by pelvic exam Abdomen if none of the other places bleeding, bleeding most be in abdomen. We dont do exploratory laparotomy unless were sure. Do CT scan first (if they are hemodynamically stable) If not stable focus abdominal ultrasound/diagnostic peritoneal lavage If high cvp think pericardial tamponadePelvic Fractures If patient is hemodynamically stable In women in pelvic fracture: need proctosigmoidscopy exam, pelvic exam (to check for injury to vagina), and retrograde cystogram. In men: in men we have to check injury to rectum and urethra (retrograde urethrogram first) before we rule out bladder damage (then do retrograde cystogram) Case where woman is bleeding to death into pelvis (shock not responding to fluids) Check that patient is nto bleeding into abdomen FAST or DPL Surgery not best answer Usually bleeding from venous plexus so arteriograms are no good Best thing to do is XFIX Blood in urine In case of blunt trauma need to know about associated bony injuries 1. Shot point blank above pubis blood in urine bladder injury Need surgical exploration 2. Blunt trauma Multiple injuries including pelvic flacture, then blood in urine If rib fracture its kidney If not evaluate urethra then evaluate bladder 3. Pelvic fracture, blood in meautus, wants to urinate cant, high riding prostate Urethral injury do regrograde urethragram 4. Male with pelvic fracture, but no blood, and urethral catheter wont go stop there is injury to urethra 5. In bladder cystogram need 2 pics full and empty (if injury is at trigone wont see injury when bladder is full, need to take pics with bladder empty to see extravasation in trigone) 6. Blunt trauma, blood in urine, rib fracture kidney injury do CT scan, dont usually need surgery but CT scan will tell you 7. Pt mva, rib fracture, abdominal contusion, hematuria. Ct scan shows renal injuries dont need surgery. Then 6 weeks later develops SOB, and flank bruit. Renal artery and vein have formed AV fistula leads to CHF Can also have pt develop hypertension months later and that would be due to Renal artery stenosis 8. In child with small trauma and hematuria might mean congenital anomaly, need urological eval, with u/s 9. Child with injury to pelvis, no blood in urine or meatus, but has swollen scrotum Do u/s, might tell us about testicular rupture 10. Large penile shaft hematoma If penis was erect fracture history important (pt might lie) Need emergent repairExtremity fractures Bullet wound in anterolateral thigh, wound embedded. No need for further evaluation. Clean, tetanus, thats it no major arteries Bullet in anteromedial Normal pulses, no hematoma This is anatomical proximity, and needs to be evaluated. Do Doppler studies for integrity of vessels Bullet anteriomedial thigh, except posterial lateral, with large expanding hematoma Eveidence of arterial injury (could also be lack of pulses) Need surgical exploration for dx,tx. Patient has bullet wound in arm Has hematoma, nerve damage, bony damage Stabilize bone, fix artery, then do nerve repair. This can lead to comportantment syndrome due to delay of arterial fix and then reperfusion, may need fasciotomy In low velocity bullet wounds damage is just trajectory of bullet High velocity (high power rifles) big exit wound damage is beyond trajectory Need extensive debriment, and amputation due to extensive damage to tissues Crush injury Check potassium, myoglobin in urine, also compartment syndrome may happenBurns Max is 50%, if burn greater than 50% use 50 anyways Head is 9%, arms are 9% total each (4.5 each side), legs are 9% on each surface and thorax is 18% on each side Formula kg * percent * 4 Half in first 8 hrs, 2nd hal fin the last 16 hrs Add 2L of D5W 2nd day get half as much, third day should be fine and will see massive diuresis Other thing people are doing 1 L/hr and adjust based on urinary outputDisorders of Children Developmental dysplasia of hip/congenital dislocation of hip Uneven gluteal folds, one hip dislocated with jerk and click. Do ultrasound Treat with abduction splinting, pavlik harness Leg perves disease/avascular necrosis of capital fermur epiphysis 8 year old, knee pain, limping, gait issues, guarded motion Could be knee or hip pain in children with hip pathology Dx with xray Tx unclear Slipped capital femoral epiphysis 13 year old obese, pain In groin, limping, sole of foot pointing to other foot. Hip cant be rotated internally Orthopedic emergency/surgical emergency Septic hip Toddler has had flu (febrile illness), walking around fine, now refuses ot move leg Slight abduction and external rotation Cant move it txL aspirate and drain (emergency) acute hematogneous osteomyeleitis febrile illness, no trauma, persistent pain in bone do bone scan since xray wont show anything yet treat with antibiotics bow leg (genu varum) normal until 3 genu valgum (knocked knee) normal until 8 Osteochondrosis of tibial tubercle (osgoode schlatter) 14 year old injured knee, pain over tibial tubercle, no swelling if theres no swelling of knee theres nothing wrong with knee in immobilization ofknee for 6 weeks in cast club foot (palathesic genuvarus) baby born with both feet turned inward plantar flexion ankle, eversion of foot, adduction of forefoot and internal rotation of tibia child would be walking on his toes on the top of foot treated with serial casts, fixing deformities from distal to proximal before age of 1 or 2 supracondylar fracture of humerus can lead to vascular compromise of forarm have to keep checking pulses/Doppler studiesTumors in children osteogenic sarcoma (MC tumor) sunburst pattern, 2-3 months of bone pain 2nd most common large fuisiform tumor/onion skin ewing sarcoma (in diaphysis of bones)Adult ortho injuries Anterior dislocation of shoulder Hold arm near body, externally rotated Damage to axillary nerve Posterior dislocation Happens when there is uncoordinated contractions (electrical burns, seizures) Xray wont show it Holds arm normal position across bodyPre-Op assesment Cant do surgery if EF < 0.35 Goldmans criteria Age, bed ridden, emergency operation, enter body cavity, MI recently, arrhythmia, CHF. JVD in a non trauma patient means CHF operation is very high risk. First getting him out of CHF then do surgery (bblocks, diuretics etc) Wait 6 months after MI. Can sometimes do revascularization first in patients with unstable angina before doing other surgeries Patient with lung disease first check PFT esp FEV1 (if abnormal) then check PCO2. If abnormal ask patient to quit something for 8 weeks, improve fev1 and pco2 medically until FEV1 improves then surgery. If liver diseae/liver failure CI to do surgery Also need to check nutritional deficiency if severely malnourished can do hyper alim for 5 days or so and should be enough. (intensive nutritional support delivered to GI tract)Post Op Complications Malignant hyperthermia Oxygen, fluids, cool person down, dantrolene, alkalinize urine to prevent myoglobuniria Post op fever 1. Wind - day 1 -- atelectasis 2. Water - day 3 - UTI 3. Walking day 5 DVT Blood gasses that we see after PE = hypoxemia with hypocapnia (low po2 and low pc02) in pulmonary failure we see low po2 and high pco2. Do spiral CT scan of chest. 4. Wound day 7 wound infection 5. Wonder - day 10 drugs, deep abscess, what did we do Get a ct scan if fever on day 10 MIs happen either during operation or after 1-2 days. If patient has alarming chest pain think of either MI or PE depends on timing. Before day 5 its MI Post surgery patient cant get clot busters, can give anticoag (heparin) but not thrombolytics Changes in ekg are first changes seen in post op or during operation for an MI Aspiration of gastric contants do bronchoscopy to wash out and remove particles Steroids not helpful after the factPost op disorientation If nothing is wrong, but patient is confused do blood gases lack of o2 to brain ARDS Patient has already been very sick Low Po2 with lots of oxygen Patchy infiltrates Tx: PEEP, dont use high volume, check for other signs of infection/sepsisAbdominal distention Paralytic ileus occurs in the first few days post op. Abdominal distention, no passing gas, absent bowel sounds Prolonged by hypokalemia Early SBO mechanical Due to adhesions Usually after paralytic ileus not resolving after 5-6 days Xray Dilated loops of SB, and air fluid levels Confirmed with CT scan shows transiotion point b/w proximal dilated and distal collapsed bowel at site of obstruction Need surgeryFluid and electrolytes Hypernatremia Lost water (or hypotonic fluids), became hypertonic. Every 3 meq/L that serum sodium is above 140, means 1L of water lost Tx: D5 1/2NS If hypernatremia happens fast, and produces CNS sx, can correct quicker with D5W or D51/3 NS Hyponatremia Water has been retained. 1. Patient starts with normal fluid volume, and retains water due to ADH Correction via fluid restriction 2. Patient is losing lots of isotonic fluids (usually from GI), forced to retain water if he has not had enough fluid replacement Restore volume with isotonic fluids NS or LR. If it occurs quickly, have to fix with 3% or 5% NS If it occurs slowly (from SIADH), correction is via fluid restriction Hypokalemia Happens slowly due to K+ lost from the GI or in urine Can happen quickly when K+ moves into the cells (seen when DKA is corrected) Rx: K+ replacement IV no more than 10 meq/h Hyperkalemia Happens slowly when kidney cant excrete K+ (kidney failure or aldosterone antagonists) Rapidly if K+ is being dumped from the cells (crush injuries or dead tissue/acidosis) Rx: hemodyliasis is ultimate treatment Before that use 50% dextrose and insulin to push K+ into cells Can also do NG suction IV calcium (fastest correction)Diseases of Gi System Esophagus GER If Dx is uncertain, do pH monitoring with correlation to sx. In long standing GERD, do endoscopy and bx to check for barretts esophagus If long standing, cant be controlled with PPI/meds, then we do surgery. Imperative if ulcers/stenosis/ or if there are severe dysplastic changes In dysplastic changes resection is needed, otherwise do laparascopic nissen fundoplication Cancer Progression of dysphagia Weight loss always seen Sq Cell Ca, in smokers. Adenocarcinoma in long standing GERD Dx: endoscopy and bx, first do barium swallow before endoscopy to prevent perforation CT scan assess operability Tx: usually palliative surgery Mallory weis tear After prolonged foreceful vomiting Bright red blood comes up. Endoscopy establishes the Dx Tx: photocoagulation Boerhaave syndrome Prolonged, forceful vomiting leads to esophageal perforation Continuous, severe, wrenching epigastric and low sternal pain that is sudden Fever, leukocytosis, SICK pt. Dx: Contrast swallow (gastrografin/water soluble first, and then barium if gastrografin is negative) Tx: need emergency surgical repair Stomach Gastric adenocarcinoma Seen in elderly. Anorexia, weight loss, and vague epigastric distress Dx: endoscopy and bx. CT can help. Tx: surgery is best tx Gastric lymphoma Similar to gastric adenomcarcinoma Tx: based on chemo or radioation. Surgery is done if possibility of perforation as tumor cells die. MALTOMA can be reversed by eradication of H. pylori. Mid and lower GI Small bowel Mechianical obstruction Due to adhesions. Colicky ab pain, protrated vomiting, progressive distention, no passage of gas/feces. First will have high pitched bowel sounds. Xray Distended loops of SB, air fluid levels TX: NPO, NG suction, IV fluids Surgery is done if conservative mgmt. fails w.in 24 hrs if complete, a few days if partial. Strangulated obstruction Starts as mechanical obstruction, then patient gets septic (fever, wbc, pain, peritoneal irritation, sepsis etc) EMERGENCY SURGERY Carcinoid syndrome Small bowel carcinoid tumor with liver mets Flushing of face, diarrhea, wheezing, RH valve damage (JVD) 24 hours urine for 5Hydroxyindolacetic acid (5HIAA) GI bleeding MC from upper gi which is from nose to ligament of treitz. Only 25% are from colon or rectum, and minority occur in jej or ileum. GI bleeding from colon is due to angiodusplasia, polyps, diverticulosis or cancer When young person has GI bleed most commonly its from upper GI or hemmorhoids if present In old person it could be from anywhere Vomiting blood Bleed from upper GI. Same if its blood recovered by NG tube in a patient who has rectal bleeding (upper gi again) Then we do GI endoscopy. Check mouth and nose first Melena Indicates digested blood and usually upper GI. Start with upper GI endoscopy RBPR Can be from anywhere in GI First if patient is actively bleeding pass NG tube and aspirate gastric contents If there is blood it must be upper GI bleed If no blood is retrieved (fluid is white/no bile, then theres no bleeding from nose to pylorus. Then follow with upper GI If no blood retrieved and fluid is green (bile) then entire upper GI is excluded. If there is still active bleeding and weve exluded upper GI Check hemorrhoids (anoscopy) first Colonoscopy not helpful during heavy active bleeding If heavy bleeding do angiogram If small bleeding do tagged red cell study. Tagged blood will pool somewhere, then we can do angiogram. Patients with recent hx of bleeding with no active In young pts start with endoscopy In older do both endoscopy and colonscopy In child think meckels, start with technetium scan (for ectopic gastric mucosa)Acute Abdomen Perforation Sudden onste, constant, generalized, severe. Signs of peritoneal irritation (tenderness, guarding, rebound) Free air under diagphragm in upright xray confirms EMERGENT SURGERY Obstruction Could be due to duct obstruction ureter, cystic, or common duct Onset of colicky pain Patient moves constantly to find comfort Ischemic process Combines severe ab pain with blood in the lumen of gut Primary peritonitis Suspect in child with nephrosis and ascites or adult with ascites who has mild generalized acute abdomen Will also have fever, wbc. Cultures of ascetic fild yield single organism. Tx: antibiotics (NOT SURGERY) Generalized acute abdomen Tx is exploratory laparotomy if its not primary peritonitis Rule out things that mimic acute abdomen first MI (ecg), lower lobe pneu (cxr), PE, or things that dont require surgery (pancreatitis) Acute pancreatitis In alcoholic with upper acute abdomen Rapid onset of inflammatory process, pain is constant, epigastric, radiates to back, n/v/retching. Dx: serum/urinary amylase, lipase. CT if dx not clear. Tx: npo, ngt, iv fluids. Biliary tract dz Fat women, forties, five children, right upper quadrant ab pain. Acute diveriticulitis Acute ab pain in LLQ. Middle age or older Fever, wbc, physical findings of peritoneal irritation in LLQ. Dx: CT scan is dianogstic TX: npo, iv, antibiotics. Most cool down, if they do not, will require emergent surgery. Radiologically guided percutaneous draingge of abscess may precede resection. Elective surgery for those who have had at least >2 attacks Volvulus of sigmoid In old people. Signs of intestinal obstruction, severe ab distention Dx: XRAY is diagnostic Shows airfluid levels in small bowe, distdend colon, huge air filled loop in RUQ that tapers down toward LQ parrots beak. Tx: proctosigmoidscopic exam resolves acute problem. Rectal tube is left in Recurrent cases need elective sigmoid resection Mesenteric ischemia In old. Develop acute abdomen in person with afib or recent MI Dx is late because old people dont have impressive acute abs (minimal sx) Source is usually clot that breaks off and lodges in the SMA Usually dx is late when there is blood in lumen and acidosis sepsis has developed. In early cases arteriogram and embolectomy save the dayHepatobiliary The liver Primary hepatoma Only in people with cirrhosis Develop vague RUQ pain, weight loss. Marker = alpha-fetoprotein. CT scan will show location/extent Resection if possible Met to liver More common than primary. Found by CT while treating primary, or if CEA rising in those with colon cancer If met is confined to one lobe, and slow growing can do lobe resection. Hepaticadenomas Complication of OCP. Tendency to rupture and bleed massively in abdomen CT is dx, and emergent surgery needed Pyogenic liver abscess Complication of biliary tract dz, esp acute ascending cholangitis. Fever, wbc, tender liver Dx: CT scan. Tx: Percutaneous drainage. Amebic abscess MEXICO Similar to pyogenic Tx: metronidazole Can begin empiric tx in those clinically suspected, if they improve its continued, if it does not improve then drainage is done. Jaundice Hemolytic Jaundice Unconjugated (indirect) only. No bile in urine. Workup to determine what is killing RBCs Hepatocellular jaundice Elevation of both bilis. High LFTs, and small increase in Alk P MC hepatitis Do serologies to determine cause of hepatitis first Obstructive jaundice Elevations of both, increase in LFTs, very high Alk P. First U/S for dilatation of biliary ducts If caused by stones (the stone obstructing the duct is not usually seen) but stones are seen in GB In malignant obstruction Large, thin walled, distended gb is seen (Courvoisier terrier sign) Obstructive jaundice by stones Fat Female Forty fertile High alk phosph, dilated cuts on u/s, non dilated GB full of stones. Do ERCP to confirm dx, do sphincterotomy to remove CBD stone Follow with cholecystectomy Obs jaundice by tumor Usually adenocarcinoma of head of pancreas, adenocarcinoma of ampulla of vater or cholangiocarcinoma from CBD itself. If suspected tumor on U/S then do CT scan. Follow with percutaneous bx If CT is negative Then do ERCP (ampulla cancers cause obstruction when they are small and not seen on CT, but can be seen on ERCP, and cholangiogram will show intrinscit tumors from the duct or any pancreatic tumors not seen in CT. Gallbladder Asymptomatic Gallstones are left alone Biliary colic When stone temp occludes cystic duct Colicky pain in RUQ, rads to R shoulder, and beltlike to the back. Triggered by ingestion of fatty food + N/V NO signs of peritoneal irritation or systemic signs. Self limited - 10-30 min Dx: U/S establishes dx of gallstones and elective cholecystectomy is indicated Acute cholecystitis Starts as biliary colic but stone stays in cystic duct and then inflamm obstructs GB. Pain is constant, fever, WBC, with signs of peritoneal irritation in RUQ. Dx: U/S (gallstones, thick walled gb, pericholecystic fluid Tx: NG suction, NPO, IV, antibiotics cool down most cases then do elective cholecystectomy. If they do not respond/cant cool down, then we need to do emergent cholecystectomy. If pt is very sick might need to do percutaneous transhepatic cholecystostomy temporarily. Ascending cholangitis Stones reached common duct producting partial obstruction and ascending infection Much sicker temp 104-105, chils, high WBC, SEPSIS VERY HIGH ALK PHOSPH TX: IV antibiotics, emergency decompression of common duct by ERCP or percutaneous through liver (PTC) Then must do cholecystectomy Biliary pancreatitis When stones become impacted distally in the ampulla Obstructing both pancreatic and biliary ducts. Stones pass spontaneously, get mild and transitory episode of cholangitis Get manifestations of pancreatitis (elevated amylase/lipase.) u/s shows gallstones in gb TX: Npo, ng, iv fluids. Followed by cholecystectomy May need ercp and sphncterotomy to dislodge stone Pancreas Acute pancreatitis Complication of gallstones, or alcoholics. Acute edematous pancreatitis In alcohlic or pt with gallstones. Epigastric midab pain starts after heavy meal or heavy drinking Constant, radiates to the back, N/V, and continued retching after stomach is empty Elevated amylase/lipase diagnostic. Key finding to establish edematous nature is elevated hematocrit. Tx: Pancreatic rest Npo, ng, iv fluids Acute hemorrhagic pancreatitis Begins edematous, but low hematocrit. WbC, increased blood glucose, and low serum calcium. Next morning hematocrit is evne lower, serum calcium stays low even with replacement, BUN increases and we have metabolic acidosis develop. May die, due to multiple pancreatic abscesses and bleeding. Daily CT scans and drain abscess Tx: IV imipenem if signs of infection Pancreatic abscess Some one not getting CT scanned, and has persistent fever, WBC about 10 days after pancreatitis. Imaging will then reveal collections of pus Have to drain percutaneous and tx with imipenem/meropemen. Psuedocyst Late sequel of acute pancreatitis or abdominal trauma 5 weeks after initial problem. Collection of pancreatic juice outside pancreatic duct and pressure sx. DX: CT or U/S Tx: If 6 cm or smaller or present for les sthan 6 weeks can be observed If larger than 6 cm or older than 6 weeks they might rupture/bleed Treat with drainage of cyst percutanously or endoscopic Chronic pancreatitis Repeated episodes of pancreatitis (usually alcoholic) Develop calcified pancreas Leads to steatorrhea, diabtes, constant epigastric pain. Tx: Insulin, pancreatic enzymes Pain is resistant ERCP may helpBreast Mammography started at age 40 Earlier if FHx, but not before age 20 Fibroadenomas Seen in young women, firm, rubbery mass, moves easily. Dx: Either FNA or sonogram Removal is optional if symptomatic Giant juvenile fibroadenomas In young adolescents. Rapid growth, need to remove to avoid deformity CYstosarcoma phyllodes In late 20s, grow over many years, become large and can distort breast. Benign but can become malignant sarcomas. CNB or incisional bx is needed (FNA not enough) MUST REMOVE Fibrocystic changes, cystic mastitis 30s-40s. goes away with menopause Bilateraly tenderness related to menstrual cycle. Multiple lumps that come and go. Mammogram is theonly thing needed if no persistant or dominant mass If theres a mass need to do aspiration If fluid is clear and mass goes away, thats it If mass persists or recurs need bx, If bloody fluid, must send to cytology Intraductal papilloma In young women (30s) bloody nipple discharge Need to do mammogram, but papillomas will not show up too small. Galactogram may guide resection Infiltrating ductal carcinoma MC breast cancer. DCIS Cannot metastazie (no axillary sampling needed) but high incidence of recurrence. Need only local excision If many lesions can do total simple mastectomyEndocrine System Thyroid Thyroid nodules In euthyroid pts think of cancer. Dx: FNA If benign do notintervene If malignant or indeterminate must do thyroid lobectomy. Total thyroidectomy should be done in follicular cancers In hyperthyroid patients Almost never cancer but might reason for hyperthyroid Do labs TSH (low), T4 (high) Nuclear scan will show if nodule is the source Treated with radioactive iodine or if they have a hot adenoma can be treated with surgical excision of affected lobe Hyperparathyroidism Usually due to finding high calcium in labs Repeact calcium and check for low phosphorus and rule out bone cancer (mets) If findings persist do PTH determination Elective intervention is justified even if asymptomatic 90% have single adenoma removal is curative. Cushing Hairy face, buffalo hump, obesity, stria, thin weak extremeties. Osteoporosis, DM, HTN, mental instability. Dx: Start with overnight low dose dexamethasone supprestion (suppression at low levels rules out disease) If theres no suppression do 24 hour urine-free cortisol. If elevated due high dose suppression Suppresion at high doses means its pituitary adenoma No suppression at high doses means adrenal adenoma or paraneoplastic syndrome (ectopic acth) Then do imaging studies (MRI for pit, CT scan for adrenal) Tx: removal of tumorSurgical Hypertension Primary hyperaldosternoism Can be due to adenoma or hyperplasia Findings: hypokalemia in a hypertensive pt not on diuretics Hypernatremia, metabolic alkalosis. High aldo, and low levels of renin If appropriate response to postural changes (increase in aldo when standing) suggest hyperplasia If no response then its an adenoma Adrenal CT scan localizes, and then do surgical removal Pheochromocytoma Thin, hyperactive women, attacks of headache, perspiration, palpitations, pallor When pts are seen attack has subsided and pressure might be normal Start with 24 hour urinary vanillulmandelic acid (VMA), metanephrines or free urinary catecholamines Follow with CT of adrenal glands/readionuclide studies for extaadrenal sites Surgery requires prep with alpha blockers Coarctation of aorta Seen in MC in young pts, HTN in arms, normal pressure/low pressure in legs. CXR scalloping of ribs Spiral CT can with IV dye (CTA) is diagnostic Surgical correction is curative Renovascular HTN 2 groups, both are resistant to usual medications, have faint bruit over fnlank or upper abdomen DX: Duplex scan of renal vessels and CTA 1. Young women with fibromuscular dysplasia TX: balloon dilatation and stending 2. Old men with arteriosclerotic occlusive disease Tx is controversial due systemic disease from atherosclerosisPediatric First 24 hours Esophageal atresia Shows up shortly after birth when first feeding is attempted. NG tube is passed, will coil up in upper chest on xrays. MC I sblind pouch in the upper esophagus and a fistula beween LE and tracheobronchial tree. Check for VACTER Tx: Surgical repair, if it needs to be delayed do gastrostomy to protect lungs from acid Imperforate anus Noted on physical exam, part of VACTER anomlies If no fistula present need to do colostomy if its a high pouch. If pouch close to anus can do primary repair right away. Double bubble and green vomit Large air fluid level in the stomach, and a smaller one to its right in first part of duodenum Duodenal atresia, annular pancreas or malrotation Malrotation is emergency Dx with contrast enema or upper GI. Intestinal atresia Shows up with green vomit NEGATIVE double bubble but has multiple air fluid levels in abdomenFew days old to 2 months old Necrotizing enterocolitis In premature infants when they are first fed Feeding intolerance, ab distention, rapidly dropping platelet count Tx: stop feeding, broad spectrum antibioitics, iv fluids and nutrition Need surgery if they develop: abdominal wall erythema, air in the portal vein, intesintal pneumatosis pneumoperitononeum Meconium Ileus Babies who have cystic fibrosis (mother might have it also) Develop feeding intolerance, bilious vomiting Xray shows multiple dilated loops of bowel and ground glass appearance Dx: Gastrografin enema is diagnostic and therapeutic Hypertrophic pyloric stenosis Nonbilious projectile vomiting after each feed. Baby is hungry and wants to eat Palpable olive size mass in ruq If no mass, do u/s Tx: Rehydrate and correct alkalosis Then ramstedt pyloromyotomy or balloon dilatation. Biliary atresia 6-8 week old babies with persistent increasing jaundice Do serologies and sweat test then do HIDA scan If HIDA scan shows up everywhere in biliary tree then its not biliary atresia, but if dye is stuck in liver then he does have it Will need surgery and maybe liver transplant Hirschsprung dz (aganglionic megacolon Chronic constipation Rectal exam may lead to explosive expulsion of stool and flatus and relief of abdominal distention Xrays show distended proximal colon (normal) and normal-looking distal colon (aganglionic part) Dx: full thickness bx of rectal mucosaLater in infancy Intussuception In 6-12 month olds colicky ab pain Lasts 1 min and then kid goes back to normal until another episode Mass on right side, empty RLQ, current jelly stools Tx: barium or air enema diagnostic and therapeutic Meckel diveriticulum Lower gi bleed in kids. Do radioisotope scan for gastric mucosaOphthalmology Children Amblyopia Vision impairment due to interference with the processing of images by brain during first 6 to 7 years of life. Seen in child with strabismus. if its not corrected early on there will be permanent cortical blindness (even though eye is perfectly normal) Strabismus Dx: reflection from a light comes from different areas of the cornea in each eye Should be surgically corrected at dx to prevent amblyopia If it develops later in infancy we will see an exaggerated convergence Then use corrective glasses True strabismus does not resolve on its own White pupil in a baby Is an emergency might be due to retinoblastoma or congenitall cataract Should be attended to to prevent amblyopiaOpth in adults Glaucoma Acute angle Severe eye pain or frontal headache starting in the evenining or when pupils have been dilated for a while Pt may report halos around lights Pupil is mid=dilated and does not react to light Cornea is cloudy with greenish hue Eye feels hard as a rock Tx: Emergency drill hole in iris with laser to provide route for drainage Can also administer carbonic anhydrase inhibitors (Diamox) and topical beta blockers or alpha-2-agonist Mannitol or pilocarpine can also be used Orbital cellulitis Emergency Eyelids are hot, tender, red, pt is febrile. Key finding: eyelids are rpied open and pupil is dilated and fixed with limited motion Pus in orbit Dx: emergency CT and drainage Chemical burns Require massive irrigation After prying it open and washing for an hour transports to ER. Continue irrigation with saline, corrosive particles are removed before patient is sent home and pH is tested to make sure its all gone Retinal detachment Emegerncy Pt reports seeing flashes or having floaters in the eye (more floaters, means its worse) Tx with laser spot welding to protect remaining retina Embolic occlusion of retinal a. Emegerncy but not much can be done Old patient, sudden loss of vision in ONE eye. After 30 min damage is IRREversible Get patient to breathe into paper bag, someone press hard on eye and release Vasodilate and shake the clot to more distal locationNeurosurgery TIA Sudden, transitory loss of neurologic function Usually due to high grade stenosis of the internal carotid Predictors of stroke, need elective carotid endarterectomy Ischemic stroke Sudden onset without headache Neurologic deficits present for more than 24 hours Assessment by CT scan and therapy for rehab Can treat with t-pa if used with 90 min to 3 hours (up to 6 hours?) First do CT scan to rule out exntesive infarcts or hemorrhage. Organ transplant Hyperacute rejection Vascular thrombosis that occurs within minutes due to preformed anitbioties. Prevented by ABO matching and lymphocytotoxic cross motch Not seen clinically Acute rejection After the first 5 days, within 3 months Occur even if pt is on immunosuppression Dx: Signs of organ dysfunction Confirmed with bx In case of liver First rule out biliary obstruction by u/s and vascular thrombosis by Doppler. Tx: First line therapy is bolus of steroids If that doesnt work can use anti-lymphocyte agents but are very toxic Chronic rejection Seen months to years after transplant Gradual loss of function Irreversible