1.Differential Acute Abdomen:
-Perforation: sudden onset, pain is constant, generalized, and very severe; classic peritonitis signs-- no movement, rebound, guarding. Examples: perforated gastric ulcer, perforated bowel.
-Obstruction: sudden onset, colicky pain, location and radiation indicates its source; patient is moving all over the table, can't get comfortable. If there is a bowel obstruction, there may also be distention, nausea, vomiting, anorexia. Examples: biliary colic, nephrolithiasis, small bowel obstruction
-Inflammation: gradual onset (gradual buildup over 6-12 hours), pain is constant, starts generalized and localizes. Peritoneal signs are found where the process is occurring, usually there are systemic signs of fever/leukocytosis except pancreatitis. Examples: appendicitis, pancreatitis
-Ischemia: gradual onset, severe pain out of proportion to exam, blood in the gut (the only process that combines acute abdomen with GI bleed). Get a lactate.
2. When facing an acute abdomen, first rule out everything that is not surgically managed, then go for an ex-lap to find and fix the problem.
-Lower-lobe pneumonia: CXR
-MI: EKG, enzymes
-PE: d-dimer
-Primary peritonitis (i.e. infection of extant ascites: treat with abx)
-Pancreatitis: amylase, lipase
-Nephrolithiasis: KUB or CT
-Diverticulitis: CT (manage with IVF, NPO, antibiotics, go the OR if things worsen)
3. Jaundice may be hemolytic, hepatic, or obstructive:
-Hemolytic: bilirubin high but not very high (<10 not >30), indirect fraction elevated. Next step: labs to figure out the cause of the hemolysis (haptoglobin, autoimmune workup, pregnancy test, genetic workup for G6PD, LDH deficiency, thalassemia)
-Hepatic: both indirect and direct bilirubin elevated, AST/ALT often very high, alk phos not very high. Next step: labs to determine the cause of the hepatitis (viral serologies, labs for wilson's, tylenol levels)
-Obstructive: direct bilirubin elevated, alk phos through the roof. Next step: ultrasound to look for dilated bile ducts, examine gallbladder for stones and for thickness; stones in CBD are rarely seen. Thick gallbladder full of stones, think choledocolithiasis: do ERCP to remove stone, do sphincterotomy, schedule later cholecystectomy. Thin gallbladder: think cancer, do CT scan to look for cancer (head of pancreas, cholangio, duodenal ampulla). If the CT scan is positive for a mass, do a percutaneous biopsy; if it's negative, do an ERCP/EUS to get a closer look, as they can see smaller masses that would be missed on CT.
4. Cancers leading to obstructive jaundice:
-Head of Pancreas, poor prognosis even with whipple;
-Ampullary (obstructive jaundice + GI bleed), good cure rate with whipple
-Cholangiocarcinoma: very high alk phos, good prognosis if extra-hepatic or small
5. Range of cholestatic processes:
-Acute Biliary Colic: stones that temporarily impact cystic duct, pain attacks that last 10-30 minutes. Triggered by fatty meals, accompanied by nausea and vomiting but no systemic signs. Treat with anticholinergics. Diagnosed by visualizing stones on u/s. Schedule elective cholescystectomy.
-Acute Cholecystitis: stones in the cystic duct that remain lodged until an inflammatory process develops in the gallbladder. Pain progresses to constant, modest systemic signs, modest peritoneal signs. No LFTs, u/s shows thickened gallbladder, pericholecystic fluid, stones in GB. Treat with bowel rest- NG, NPO, IV fluids, antibiotics. If things improve, schedule elective cholecystectomy. If they do not improve, do emergency cholecystectomy or percutaneous transhepatic cholecystostomy for those who cannot tolerate surgery.
-Acute ascending cholangitis: stones have reached CBD, are partially obstructing, and there is an ascending infection. Strong systemic signs of infection-- fevers to 105, chills, high leukocytosis, sepsis-like picture. Labs show elevated bilirubin and very elevated alk phos. Treat with IV antibiotics and emergent CBD decompression-- ERCP or percutaneous transhepatic cholangiogram (to put in a drain), schedule cholecystectomy soon.
6. Range of pancreatic processes:
-Acute edematous pancreatitis: occurs after heavy meal or bout of pancreatitis, constant pain radiating to back, with n/v, mild peritoneal signs over epigastric region, elevated serum amylase/lipase, elevated hematocrit. Treat with bowel rest, will resolve in ddays
-Acute hemorrhagic pancreatitis: begins with edematous form, but with a lower hematocrit, + other Ranson's criteria (elevated WBC, low Ca, elevated glucose, and then sepsis-like picture with pre-renal labs, metabolic acidosis, hypoxia). Finally multiple abscesses develop.
-Acute suppurative pancreatitis (pancreatic abscess): develop fever and leukocytosis ~10 days after the onset of symptoms, treat with percutaneous drainage.
-Pancreatic pseudocyst: occurs 5 weeks after acute pancreatic incident (pancreatitis, trauma). Collection of pancreatic fluid in cyst, compressive symptoms of stomach (early satiety, mass on deep palpation, vague discomfort), diagnose with CT. For cysts that are <6cm or <6 weeks old, can be observed. For larger or older cysts, manage with drainage (percutaneous, endoscopic) or surgical removal.
7. Causes of surgical hypertension:
-Primary aldosteronism: either adrenal cortical adenoma or hyperplasia. Key to diagnosis: hypokalemia and hypertension in someone not on diuretics; mild hypernatremia, metabolic alkalosis. Hyperplasia will respond appropriately to position, adenoma will not. Renin is low in both.
-Pheochromocytoma: diagnose with 24 hour urine VMA or metanephrines, or octreotide/MBIG scan.
-Renal artery narrowing (fibromuscular dysplasia in the young, bad PAD in old): stent in young, may not be worth operative risk in old.
-Aortic coarctation: correct when there is a >50mmHg gradient, or signs of angina, syncope, CHF.
8. Post-op low urine output: in the face of good perfusion (ie. not shock) it's either inadequate volume or intrinsic renal failure. Test with 500mL or 1L fluid bolus-- if the UOP goes up, it was inadequate volume. If it doesn't change, it may be renal failure. Also can test with FeNa
9. Electrolytes:
-Hypernatremia: due to loss of free water. Replenish with D5 half NS if it was grandual onset, D5W if it was fast-onset.
-Hyponatremia: too much water. Either too much ADH in the context of normal volume, or loss of volume (diarrhea) without replenishing isotonically. In the former, fluid-restrict; in the latter, infuse isotonic fluid- LR, NS.
10. Lung lesions;
-Coin lesion on x-ray, in someone >50 has an 80% chance of being malignant. First step: compare with previous CXR. Next step: CT (chest + liver) & sputum cytology + maybe PET. After this you start getting into invasive tests, so you have to decide if the tumor is operable (mets to mediastinum/carina/liver/other lung) and if the person could survive treatment (FEV1, then determine % lung contribution with vent-perfusion scan, if FEV1 remaining <800, don't do surgery). Then, next step: percutaneous biopsy (peripheral) or bronchoscopic biopsy (central). Next step: thoracotomy/wedge resection.
Friday, November 29, 2013
Wednesday, November 27, 2013
1. Most missed injuries in abdominal survey during trauma:
-G-E junction
-Ureters
-Ligament of treitz
-Mesenteric borders of small bowel
-Posterior wall of transverse colon
-Extraperitoneal rectum
2. "Bail out injuries": i.e. injuries such that if you see these intra-op, do not attempt to completely fix everything in one go. Convert to damage control surgery. Depending on how stable they are, either fix the most life-threatening injuries, or just pack it and get out. Either way, leave the abdomen open and go the ICU. Resuscitate, wait until they are more stable, then go back to the OR to fix things.
-Significant vascular injury plus hollow viscus injury
-Penetrating injury to aorta or IVC
-High grade liver injury
-Pelvic fracture with expanding hematoma
-Injuries requiring simultaneous surgery elsewhere-- thorax, head, neck.
3. Trauma triad of death: hypothermia, coagulopathy, acidosis. These signs are an extremely poor prognosis. If you wait for these to come on before you decide to close and go to the ICU, it will be too late.
4. Intraoperative cues of impending hostile physiology (i.e. precursors to trauma triad of death): if you see these signs, stop operating as quickly as possible, get to the ICU.
-Diffuse oozing
-Bowel mucosa edema
-Midgut distention
-Dusky serosa
-Noncompliant, swollen abdominal wall
5. Options for bleeding vessel control:
-sutures
-packing
-packing + hemostasis agents (surgicel, floseal, thrombin)
-if is a big vessel, you can insert a foley catheter into it, blow up the cuff and pull up
6. If you're operating a long time on an extremity and doing vascular surgery, consider a presumptive fasciotomy to stave off compartment syndrome.
7. Postop fever etiology mnemonic
-POD 1-2 wind (pneumonia)
-POD 3-4 water (UTI)
-POD 4-5 walking (DVT/PE)
-POD 5-7 wound
-POD 7+ wonder drugs (drug fever - esp anticonvulsants & bactrim)
8. On the pupillary light reflex: {source}
"Because of the different paths these two nerve supplies take, brain and brainstem
trauma interrupt the sympathetic and parasympathetic tracts in different patterns.
Consequently, the pupillary reflex can be a valuable assessment tool. For example,
damage to the hypothalamus destroys only the sympathetic branch allowing the
parasympathetic to predominate. Parasympathetic nerve supply causes constriction with
reaction to light. In the lower brainstem (pons and medulla), damage causes a similar
response, but more exaggerated. In this case, the pupils are tightly constricted
(“pinpoint”) and unreactive or “fixed.” Notice that midbrain, mesencephalon, damage
disrupts both the sympathetic and the parasympathetic pathways resulting in pupils being
midposition and “fixed.”
In usual situations, both pupils respond similarly (bilaterally). However, if the
parasympathetic occulomotor nerve is damaged outside the brain and at some point along
its course to the eye, parasympathetic supply is disrupted only to that one eye. In the affected eye sympathetic predominates and the pupil dilates while the other eye remains
normal. This condition is common with temporal lobe herniation as the protruding lobe
of the brain presses on the occulomotor nerve on the herniated side. Thus, the dilated
(“blown”) pupil indicates the side of herniation."
-G-E junction
-Ureters
-Ligament of treitz
-Mesenteric borders of small bowel
-Posterior wall of transverse colon
-Extraperitoneal rectum
2. "Bail out injuries": i.e. injuries such that if you see these intra-op, do not attempt to completely fix everything in one go. Convert to damage control surgery. Depending on how stable they are, either fix the most life-threatening injuries, or just pack it and get out. Either way, leave the abdomen open and go the ICU. Resuscitate, wait until they are more stable, then go back to the OR to fix things.
-Significant vascular injury plus hollow viscus injury
-Penetrating injury to aorta or IVC
-High grade liver injury
-Pelvic fracture with expanding hematoma
-Injuries requiring simultaneous surgery elsewhere-- thorax, head, neck.
3. Trauma triad of death: hypothermia, coagulopathy, acidosis. These signs are an extremely poor prognosis. If you wait for these to come on before you decide to close and go to the ICU, it will be too late.
4. Intraoperative cues of impending hostile physiology (i.e. precursors to trauma triad of death): if you see these signs, stop operating as quickly as possible, get to the ICU.
-Diffuse oozing
-Bowel mucosa edema
-Midgut distention
-Dusky serosa
-Noncompliant, swollen abdominal wall
5. Options for bleeding vessel control:
-sutures
-packing
-packing + hemostasis agents (surgicel, floseal, thrombin)
-if is a big vessel, you can insert a foley catheter into it, blow up the cuff and pull up
6. If you're operating a long time on an extremity and doing vascular surgery, consider a presumptive fasciotomy to stave off compartment syndrome.
7. Postop fever etiology mnemonic
-POD 1-2 wind (pneumonia)
-POD 3-4 water (UTI)
-POD 4-5 walking (DVT/PE)
-POD 5-7 wound
-POD 7+ wonder drugs (drug fever - esp anticonvulsants & bactrim)
8. On the pupillary light reflex: {source}
"Because of the different paths these two nerve supplies take, brain and brainstem
trauma interrupt the sympathetic and parasympathetic tracts in different patterns.
Consequently, the pupillary reflex can be a valuable assessment tool. For example,
damage to the hypothalamus destroys only the sympathetic branch allowing the
parasympathetic to predominate. Parasympathetic nerve supply causes constriction with
reaction to light. In the lower brainstem (pons and medulla), damage causes a similar
response, but more exaggerated. In this case, the pupils are tightly constricted
(“pinpoint”) and unreactive or “fixed.” Notice that midbrain, mesencephalon, damage
disrupts both the sympathetic and the parasympathetic pathways resulting in pupils being
midposition and “fixed.”
In usual situations, both pupils respond similarly (bilaterally). However, if the
parasympathetic occulomotor nerve is damaged outside the brain and at some point along
its course to the eye, parasympathetic supply is disrupted only to that one eye. In the affected eye sympathetic predominates and the pupil dilates while the other eye remains
normal. This condition is common with temporal lobe herniation as the protruding lobe
of the brain presses on the occulomotor nerve on the herniated side. Thus, the dilated
(“blown”) pupil indicates the side of herniation."
9. Fixed, dilated pupils are possibly due to brainstem ischemia, as well as to cranial nerve III compression by uncal hernation. {Neurosurgery, 162 patients GCS<8 underwent xenon CT scans to determine blood flow, found significantly higher brainstem blood flow among those with fixed, dilated pupils vs reactive pupils; pupil reactivity/size did not correlate with ICP or the presence of a brainstem lesion}
10. Uretopelvic junction obstruction: able to tolerate normal urine outflow without trouble, but fails when there is a large diuresis-- hence the adolescent presenting symptomatically (with colicky flank pain) after their first binge-drinking session
Tuesday, November 26, 2013
1. Preparing for trauma surgery:
-2 large bore (18 g) peripheral IVs is better for resuscitation than a central line. In a trauma situation, if you got 2 big peripheral IVs, don't waste time getting in a central line for the purposes of getting in fluids. You don't need it.
-Get an A-line.
-Prep and drape before you induce anesthesia; induction can drop perfusion, and you want to be ready to go immediately if you start losing vital signs.
-For emergency ex-laps in an abdominal trauma situation, prep chin to knees: you may need to enter thorax, you may need to harvest vein grafts from the legs.
2. Emergency surgery on a traumatic abdomen:
-Get in fast: 3 passes of the knife and in. Don't waste time getting in clean and slow with the bovie.
-Above the umbilicus, the pre-peritoneal fat is really thin, so you can just push your finger through it, and then lift up the peritoneum with your hand and bovie between your fingers.
-As soon as you get in, pull out all the bowels so you can see what's bleeding.
3. How to pack a bleeding liver: pack above, below, and anywhere inside (i.e. if there is an avulsion) where it's bleeding
4. Retroperitoneal bleeding: when to surgically explore vs medically manage
-Zone 1 (central abdomen): explore
-Zone 2 (lateral abdomen): explore if the patient is unstable, the hematoma is expanding, the injury mechanism is penetrating, or there is obvious injury to a vessel or the colon. Otherwise, in blunt trauma, leave it.
-Zone 3 (pelvis): explore if there was penetrating injury. For blunt injury, better go to IR.
-2 large bore (18 g) peripheral IVs is better for resuscitation than a central line. In a trauma situation, if you got 2 big peripheral IVs, don't waste time getting in a central line for the purposes of getting in fluids. You don't need it.
-Get an A-line.
-Prep and drape before you induce anesthesia; induction can drop perfusion, and you want to be ready to go immediately if you start losing vital signs.
-For emergency ex-laps in an abdominal trauma situation, prep chin to knees: you may need to enter thorax, you may need to harvest vein grafts from the legs.
2. Emergency surgery on a traumatic abdomen:
-Get in fast: 3 passes of the knife and in. Don't waste time getting in clean and slow with the bovie.
-Above the umbilicus, the pre-peritoneal fat is really thin, so you can just push your finger through it, and then lift up the peritoneum with your hand and bovie between your fingers.
-As soon as you get in, pull out all the bowels so you can see what's bleeding.
3. How to pack a bleeding liver: pack above, below, and anywhere inside (i.e. if there is an avulsion) where it's bleeding
4. Retroperitoneal bleeding: when to surgically explore vs medically manage
-Zone 1 (central abdomen): explore
-Zone 2 (lateral abdomen): explore if the patient is unstable, the hematoma is expanding, the injury mechanism is penetrating, or there is obvious injury to a vessel or the colon. Otherwise, in blunt trauma, leave it.
-Zone 3 (pelvis): explore if there was penetrating injury. For blunt injury, better go to IR.
5. Pringle Maneuver: clamp across hepaticoduodenal ligament/portal triad, controls liver hemorrhage. Maximum time debated, around 30-45 minutes.
6. Kocher Maneuver: incise the bloodless plane to the R of the duodenal C-curve, that will allow you to flip the duodenum and head of pancreas to the L and expose the aorta and IVC, SMA/SMV, gonadal and renal vessels.
7. Mattox Maneuver: incise the white line of toldt lateral to the descending colon, flip up the colon to the opposite side, rotate up the spleen, either leave kidney in place (if its damaged and/or surgical target) or flip kidney out of the surgical field if its intact, you gain access to IVC/aorta and L renal vessel.
-Pitfalls during mattox maneuver: you can injure the kidney or spleen in your manipulations, or you can injure L lumbar vv (comes off L renal)
8. Cattell-Braasch Maneuver: similar to Mattox, but on the R side, and slightly more involved. You have to do the Kocher maneuver, then incise the white line of toldt on the right side, then connect the two together. Then, importantly, you have to extend the incision from the bottom of the white line of toldt across the mesentery of the small bowel, diagonally towards the ligament of treitz. Do not cut any mesenteric vessels while you do this. Then you can lift the whole thing over to the L and have exposure to the great vessels.
-Pitfalls: do not cut R gonadal vein or SMV.
9. Maneuver to get to thoracic aorta for cross-clamping when all else fails and you can't control the hemorrhage: incise through hepatogastric ligament, along the lesser curve of the stomach to enter lesser sac. Retract the stomach down and lateral, you should now be able to get behind stomach and esophagus and see the aorta coming out of the aortic hiatus, with the diaphragmatic crus on either side. Cut through the crus (they will be soft) to get maximally high on the aorta, and cross-clamp. Note, this is only for massive hemorrhage that is leading to impending crash despite your best efforts at packing.
10. Retroperitoneal bleeding can track between the fascial planes, around the kidney, down into the pelvis, up into the upper abdomen.
Saturday, November 23, 2013
1. Principles of damage control resuscitation:
(applied to trauma patients in hemorrhagic shock)
-Permissive hypovolaemia (hypotension): sacrifice perfusion for hemorrhage control. Titrate pressures (with 250mL boluses) to mental status in awake patients, or to palpable radial pulses, or to systolic > 70-80 in penetrating and >90 in blunt trauma. Too much volume, esp with non-FFP, leads to worsening of hemorrhage, dilution of coag factors and loosening of platelet plugs, also increases ICP.
-Haemostatic transfusion (resuscitation): 1:1:1 of FFP, pRBC, platelets + tranexamic acid if you can give it within 3 hours (PROPPR trial currently underway to eval 1:1:1 vs 2:1:1 ffp/rbc/platelets). Avoidance of crystalloids (NS, Hartmann’s, LR) and colloids (gelofusion, haemaccel, or volulyte), they dilute out clotting factors and hemoglobin and worsen hypothermia.
-NO PRESSORS: early vasopressor use is independently associated with an increased risk of death with published HR's ranging from 2 to 17(!!); that means that they are associated with increased mortality after adjusting for severity of injury and volume status. Use only if cardiovascular collapse is imminent and all attempts to resuscitate with fluids have failed (i.e. patient not fluid responsive)
-Damage control surgery or angiography to treat the cause of bleeding
-Once hemostasis is achieved, restore organ perfusion and oxygen delivery with definitive resuscitation
source: {BMJ Review Paper}
2. Optimal volume status:
-A&O x3
-UOP 0.5-2.0
-CVP<15
In adults, optimal fluid access is 2 peripheral 16 gauge IVs. If unavailable, go to femoral central line (fastest, easiest to insert line; only CI is if you suspect massive IVC injury, in which case you'll have to go for IJ or subclavian) or saphenous vein cut-down. In children <4, IO (prox tibia) is second choice.
3. Shock diagnosis:
-Hypotensive, low CVP: either hemorrhagic/hypovolemic (pancreatitis, burns, peritonitis, diarrhea) or vasomotor (i.e. anaphylaxis). Fluids will help in both, but the former will be much more responsive to fluids. Pressors will worsen things in the former, ameliorate in the latter.
-Hypotensive, high CVP: tamponade (u/s to r/o) vs tension pneumo (listen to lungs) vs cardiogenic failure from massive MI. In these cases, don't push fluids.
4. Cranial trauma:
-Linear fractures: if closed, leave to heal. If open (have wound over it) go to OR to close wound; if comminuted or depressed, go to OR to fix fracture.
-Skull base fractures: observation, no antibiotics unless indicated for some other reason, CT c-spine to evaluate for damage.
-LOC in the context of a head injury-- always get a CT to r/o bleed.
-Neurological damage from trauma comes from 3 places: initial blow, bleeding that causes midline shifts (manage surgically) and increased ICP later (manage medically).
5. Acute brain bleeds:
-Epidural: ends with fixed dilated pupil on ipsilateral side, decerebrate on opposite side. Emergency craniotomy leads to impressive recovery.
-Subdural: usually really bad trauma, really sick patient; if there is a midline shift go for craniotomy, if not, put something in to follow ICP (i.e. IVC) and manage medically to prevent more ICP: hyperventilation, fluid underload, mannitol/lasix, head of bed > 30 deg, sedation/hypothermia to decrease O2 need. Try not to drop systemic pressures so low that you start losing other organs, but realize that the brain takes priority. Prognosis is poor.
-Diffuse axonal injury: surgery only if there is hemorrhage. Otherwise maintain ICP medically.
-Chronic subdural: surgical evacuation provides rapid cure.
6. Penetrating neck trauma:
-Go to surgery only if there are signs of expanding hematoma, deteriorating vital signs, or obvious signs of esophageal/tracheal injury (coughing up blood). For GSW to upper neck, do angiograms; for lower neck, angiograms, gastrografin then barium swallow if gastrografin shows no leak, scopes of trachea and esophagus. Knife wounds: watch.
-CT c-spine for everyone
7. Spine injury:
-Transection (nothing below), Brown Sequard (lose pain/temp contra, feeling/motor ipsi): clean cut
-Anterior cord (lose STT/CST, fine DCML = no pain or temp or movement, OK positional and vibratory senses): vertebral burst fractures
-Central cord (lose STT/CST = so burning pain and paralysis in limbs): forced neck hyperextension in old people, i.e. getting rear-ended.
-MRI to evaluate, steroids (don't help if it was transected)
8. Chest injury facts:
-Rib fracture can lead to pain, atelectasis and eventually pneumonia
-Pneumothorax: chest tube anterior, superior
-Hemothorax: chest tube posterior. Lung is low pressure, bleed usually stops on its own. If > 1.5 L evacuated at beginning or >100-200 cc/hour afterwards for 4-6 hours, then a systemic vessel was probably hit (intercostal, or internal mammary), thoracotomy will be indicated.
-Sucking chest wound: occlusive dressing (taped 3 sides), chest tube
-In bad trauma, screen for internal injuries, pulm or card contusion or aortic transection/rupture in bad trauma.
-Pulm contusion: can happen immediately or 48 hours out, monitor with ABG and CXR (white out lungs). Sensitive to fluids, can get pulm edema easily, so restrict fluids, give colloids, diuretics, fluid restriction, vent support if needed.
-Cardiac contusion: suspect if you see a sternal fracture; monitor with EKG, cardiac enzymes (troponins are sensitive, send for them anytime you see sternal fracture). Watch out for arrhythmias.
-Aortic rupture: no symptoms until the adventitia ruptures, killing the patient. Suspicion must be very high. Anytime there is a big deceleration injury, injuries of hard to break bones (scapula, first rib, sternum), get a CXR. If you don't see mediastinal widening, only non-invasive tests indicated (spiral CT is fastest, can also do transesophageal echo, MRI angio). If you see mediastinal widening, still try the noninvasive tests first but aortogram is indicated if the others are inconclusive.
-Rupture of trachea/bronchus: persistent air leak in chest tube, subQ emphysema (esp upper chest/neck), dx with CXR, find lesion with bronchoscopy, intubate and go to OR. Other causes of subQ emphysema- esophageal rupture, usually in setting of endoscopy.
-Fat embolism: long bone trauma, DIC-picture: respiratory distress, petechiae (axilla/neck), fever, tachycardia, platelet consumption. Tx with respiratory support
9. X-ray will not diagnose acute osteomyeltis: even early changes like swelling or periosteal elevation may not be obvious for several days, and bone destruction will not be visible for weeks. use bone scan: "Radionuclide scanning (ie, bone scan) sensitivity: (84 to 100 percent) specificity: (70 to 96 percent) for the diagnosis of osteomyelitis in children. In addition, scintigraphy is helpful early in the course, usually readily available, relatively inexpensive, and it may not require as much sedation as MRI in young children. However, it may not perform as well in neonates or in patients with community-associated methicillin-resistant S. aureus infections, and will not reveal foci of purulence within and near bone (eg, intramedullary abscesses or muscular phlegmon) Scintigraphy is useful when: MRI is not available and imaging other than plain radiography is needed to confirm a diagnosis of osteomyelitis, The area of suspected infection cannot be localized, or Multiple areas of involvement are suspected" (from uptodate)
(applied to trauma patients in hemorrhagic shock)
-Permissive hypovolaemia (hypotension): sacrifice perfusion for hemorrhage control. Titrate pressures (with 250mL boluses) to mental status in awake patients, or to palpable radial pulses, or to systolic > 70-80 in penetrating and >90 in blunt trauma. Too much volume, esp with non-FFP, leads to worsening of hemorrhage, dilution of coag factors and loosening of platelet plugs, also increases ICP.
-Haemostatic transfusion (resuscitation): 1:1:1 of FFP, pRBC, platelets + tranexamic acid if you can give it within 3 hours (PROPPR trial currently underway to eval 1:1:1 vs 2:1:1 ffp/rbc/platelets). Avoidance of crystalloids (NS, Hartmann’s, LR) and colloids (gelofusion, haemaccel, or volulyte), they dilute out clotting factors and hemoglobin and worsen hypothermia.
-NO PRESSORS: early vasopressor use is independently associated with an increased risk of death with published HR's ranging from 2 to 17(!!); that means that they are associated with increased mortality after adjusting for severity of injury and volume status. Use only if cardiovascular collapse is imminent and all attempts to resuscitate with fluids have failed (i.e. patient not fluid responsive)
-Damage control surgery or angiography to treat the cause of bleeding
-Once hemostasis is achieved, restore organ perfusion and oxygen delivery with definitive resuscitation
source: {BMJ Review Paper}
2. Optimal volume status:
-A&O x3
-UOP 0.5-2.0
-CVP<15
In adults, optimal fluid access is 2 peripheral 16 gauge IVs. If unavailable, go to femoral central line (fastest, easiest to insert line; only CI is if you suspect massive IVC injury, in which case you'll have to go for IJ or subclavian) or saphenous vein cut-down. In children <4, IO (prox tibia) is second choice.
3. Shock diagnosis:
-Hypotensive, low CVP: either hemorrhagic/hypovolemic (pancreatitis, burns, peritonitis, diarrhea) or vasomotor (i.e. anaphylaxis). Fluids will help in both, but the former will be much more responsive to fluids. Pressors will worsen things in the former, ameliorate in the latter.
-Hypotensive, high CVP: tamponade (u/s to r/o) vs tension pneumo (listen to lungs) vs cardiogenic failure from massive MI. In these cases, don't push fluids.
4. Cranial trauma:
-Linear fractures: if closed, leave to heal. If open (have wound over it) go to OR to close wound; if comminuted or depressed, go to OR to fix fracture.
-Skull base fractures: observation, no antibiotics unless indicated for some other reason, CT c-spine to evaluate for damage.
-LOC in the context of a head injury-- always get a CT to r/o bleed.
-Neurological damage from trauma comes from 3 places: initial blow, bleeding that causes midline shifts (manage surgically) and increased ICP later (manage medically).
5. Acute brain bleeds:
-Epidural: ends with fixed dilated pupil on ipsilateral side, decerebrate on opposite side. Emergency craniotomy leads to impressive recovery.
-Subdural: usually really bad trauma, really sick patient; if there is a midline shift go for craniotomy, if not, put something in to follow ICP (i.e. IVC) and manage medically to prevent more ICP: hyperventilation, fluid underload, mannitol/lasix, head of bed > 30 deg, sedation/hypothermia to decrease O2 need. Try not to drop systemic pressures so low that you start losing other organs, but realize that the brain takes priority. Prognosis is poor.
-Diffuse axonal injury: surgery only if there is hemorrhage. Otherwise maintain ICP medically.
-Chronic subdural: surgical evacuation provides rapid cure.
6. Penetrating neck trauma:
-Go to surgery only if there are signs of expanding hematoma, deteriorating vital signs, or obvious signs of esophageal/tracheal injury (coughing up blood). For GSW to upper neck, do angiograms; for lower neck, angiograms, gastrografin then barium swallow if gastrografin shows no leak, scopes of trachea and esophagus. Knife wounds: watch.
-CT c-spine for everyone
7. Spine injury:
-Transection (nothing below), Brown Sequard (lose pain/temp contra, feeling/motor ipsi): clean cut
-Anterior cord (lose STT/CST, fine DCML = no pain or temp or movement, OK positional and vibratory senses): vertebral burst fractures
-Central cord (lose STT/CST = so burning pain and paralysis in limbs): forced neck hyperextension in old people, i.e. getting rear-ended.
-MRI to evaluate, steroids (don't help if it was transected)
8. Chest injury facts:
-Rib fracture can lead to pain, atelectasis and eventually pneumonia
-Pneumothorax: chest tube anterior, superior
-Hemothorax: chest tube posterior. Lung is low pressure, bleed usually stops on its own. If > 1.5 L evacuated at beginning or >100-200 cc/hour afterwards for 4-6 hours, then a systemic vessel was probably hit (intercostal, or internal mammary), thoracotomy will be indicated.
-Sucking chest wound: occlusive dressing (taped 3 sides), chest tube
-In bad trauma, screen for internal injuries, pulm or card contusion or aortic transection/rupture in bad trauma.
-Pulm contusion: can happen immediately or 48 hours out, monitor with ABG and CXR (white out lungs). Sensitive to fluids, can get pulm edema easily, so restrict fluids, give colloids, diuretics, fluid restriction, vent support if needed.
-Cardiac contusion: suspect if you see a sternal fracture; monitor with EKG, cardiac enzymes (troponins are sensitive, send for them anytime you see sternal fracture). Watch out for arrhythmias.
-Aortic rupture: no symptoms until the adventitia ruptures, killing the patient. Suspicion must be very high. Anytime there is a big deceleration injury, injuries of hard to break bones (scapula, first rib, sternum), get a CXR. If you don't see mediastinal widening, only non-invasive tests indicated (spiral CT is fastest, can also do transesophageal echo, MRI angio). If you see mediastinal widening, still try the noninvasive tests first but aortogram is indicated if the others are inconclusive.
-Rupture of trachea/bronchus: persistent air leak in chest tube, subQ emphysema (esp upper chest/neck), dx with CXR, find lesion with bronchoscopy, intubate and go to OR. Other causes of subQ emphysema- esophageal rupture, usually in setting of endoscopy.
-Fat embolism: long bone trauma, DIC-picture: respiratory distress, petechiae (axilla/neck), fever, tachycardia, platelet consumption. Tx with respiratory support
9. X-ray will not diagnose acute osteomyeltis: even early changes like swelling or periosteal elevation may not be obvious for several days, and bone destruction will not be visible for weeks. use bone scan: "Radionuclide scanning (ie, bone scan) sensitivity: (84 to 100 percent) specificity: (70 to 96 percent) for the diagnosis of osteomyelitis in children. In addition, scintigraphy is helpful early in the course, usually readily available, relatively inexpensive, and it may not require as much sedation as MRI in young children. However, it may not perform as well in neonates or in patients with community-associated methicillin-resistant S. aureus infections, and will not reveal foci of purulence within and near bone (eg, intramedullary abscesses or muscular phlegmon) Scintigraphy is useful when: MRI is not available and imaging other than plain radiography is needed to confirm a diagnosis of osteomyelitis, The area of suspected infection cannot be localized, or Multiple areas of involvement are suspected" (from uptodate)
10. Pathologic fracture in an adult means tumor, usually mets. Bone scan, whole body PET to look for mets and primary-- in women, breast; men, prostate; smokers, lung.
Friday, November 22, 2013
1. Billroth I:
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis: end-to-end, duodenum to stomach edge.
-pros: somewhat physiologic-- maintains somewhat normal flow of fluids, no backleak of alkaline fluids into stomach/esophagus
-cons: may be more tension on the anastomosis, since you have to pull the duodenum all the way up to the mid-gastric region.
2. Billroth II:
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis: end-to-side, jejunum to stomach. The cut end of the duodenum is stapled shut into a blind loop, with the pancreatic and gallbladder drainage intact.
-pros: low-tension anastomosis
-cons: since pancreatic/biliary secretions are now upstream of gastric contents, there can be efflux of bicarb and/or bile into the stomach and up the esophagus. This can be prevented by making an Omega loop, aka Braun entero-enterostomy, where you make a connection between the jejunum proximal to and distal to the stomach anastomosis, providing an alternate path for the alkaline secretions to go directly through rather than into stomach. The omega loop must be at least 40cm in diameter for the fluids to effectively bypass. Additional disadvantages of the billroth II: afferent or efferent obstruction, causing swelling of duodenal loop, and finally mucous ulcer formation from stomach contents moving directly across to unprotected duodenum.
3. Roux-en-y
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis:
(1) resect distal jejunum, bring up to end-to-side with stomach (limb must be > 40cm long to avoid alkaline reflux.
(2) anastomose original duodenal limb with gastro-jejunal limb with continuing jejunum in a "Y" shape
-pros: fewer problems with efferent/afferent limb obstruction
-cons: erosive ulcer formation still occurs.
9. Be careful of doing sternotomies in people with previous sternotomy scars and incomplete surgical history-- if they had a previous CABG with the RIMA, you may cut the RIMA on entry and give them an MI intraop. Poor form.
10. When putting in a central line in someone with an IVC filter, do not push the guidewire in too far, or it may get tangled with the IVC filter and require a trip to IR to bail you out.
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis: end-to-end, duodenum to stomach edge.
-pros: somewhat physiologic-- maintains somewhat normal flow of fluids, no backleak of alkaline fluids into stomach/esophagus
-cons: may be more tension on the anastomosis, since you have to pull the duodenum all the way up to the mid-gastric region.
2. Billroth II:
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis: end-to-side, jejunum to stomach. The cut end of the duodenum is stapled shut into a blind loop, with the pancreatic and gallbladder drainage intact.
-pros: low-tension anastomosis
-cons: since pancreatic/biliary secretions are now upstream of gastric contents, there can be efflux of bicarb and/or bile into the stomach and up the esophagus. This can be prevented by making an Omega loop, aka Braun entero-enterostomy, where you make a connection between the jejunum proximal to and distal to the stomach anastomosis, providing an alternate path for the alkaline secretions to go directly through rather than into stomach. The omega loop must be at least 40cm in diameter for the fluids to effectively bypass. Additional disadvantages of the billroth II: afferent or efferent obstruction, causing swelling of duodenal loop, and finally mucous ulcer formation from stomach contents moving directly across to unprotected duodenum.
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis:
(1) resect distal jejunum, bring up to end-to-side with stomach (limb must be > 40cm long to avoid alkaline reflux.
(2) anastomose original duodenal limb with gastro-jejunal limb with continuing jejunum in a "Y" shape
-pros: fewer problems with efferent/afferent limb obstruction
-cons: erosive ulcer formation still occurs.
4. Lymph node resection for gastric cancer:
-D1: perigastric lymph nodes. For distal gastric cancer, you have to take the omental nodes, and nodes along distal lesser gastric curve. For proximal gastric cancer, you take the peri-gastric nodes around the proximal part of stomach.
-D2: you take all of the D1 nodes, plus the nodes around the celiac vessels-- common hepatic, proximal GDA, proximal proper hepatic, proximal L gastric, all the ones around the splenic vessels to the spleen. In a Japanese D2, you take the spleen and the pancreas as well.
5. D1 vs D2 lymph node resections landmark trials:
-Cuschieri, RCT n=400, randomized to D1 vs Japanese D2 resection, no difference in death from gastric cancer, OS, PFS. Removal of spleen and pancreas independently associated with survival.
-Bonenkamp, RCT n=711 randomized to D1 vs Japanese D2, similar 5-year OS rates, but more complications (43 vs 25%), longer hospitalizations, and most postop deaths in D2 resection.
6. FOLFIRINOX is associated with significantly longer OS/PFS compared to gemcitabine, but also higher complication rates, when treating metastatic pancreatic adenocarcinoma:
From the abstract, {NEJM, RCT, n=342}
"The median overall survival was 11.1 months in the FOLFIRINOX group as compared with 6.8 months in the gemcitabine group (hazard ratio for death, 0.57; 95% confidence interval [CI], 0.45 to 0.73; P<0.001). Median progression-free survival was 6.4 months in the FOLFIRINOX group and 3.3 months in the gemcitabine group (hazard ratio for disease progression, 0.47; 95% CI, 0.37 to 0.59; P<0.001). The objective response rate was 31.6% in the FOLFIRINOX group versus 9.4% in the gemcitabine group (P<0.001). More adverse events were noted in the FOLFIRINOX group; 5.4% of patients in this group had febrile neutropenia. At 6 months, 31% of the patients in the FOLFIRINOX group had a definitive degradation of the quality of life versus 66% in the gemcitabine group (hazard ratio, 0.47; 95% CI, 0.30 to 0.70; P<0.001)."
(5-FU, leucovorin, irinotecan, oxaliplatin)
7. Post-op bleeding:
-Don't overinterpret post-op Hb drops: being NPO before surgery likely leads to some degree of hemoconcentration, so Hb's measured intraop or immediately before op may be much higher than a Hb measured post-op and s/p many liters of crystalloids.
-Look for vital sign changes and changes in urine OP and mental status if you're worried about a bleed.
-Toradol can make people bleed more, particularly in combination with heparin or lovenox-- if you're worried, hold the anticoagulants for 5-6 hours after you give toradol.
-If someone has a hematoma and they're stable and it's stable, you can drain it with IR. If it's clotted off and won't drain, you may need to go to the OR to scoop it out.
-If they are acutely unstable, go to the OR.
8. Be careful of putting in CABG grafts in people with subclavian stenosis-- if the LIMA is distal to the stenosis, you will get subclavian steal where the distal subclavian is a lower pressure than the coronary system and blood will flow backwards from heart to arm. Consider using RIMA if the stenosis is not bilateral.9. Be careful of doing sternotomies in people with previous sternotomy scars and incomplete surgical history-- if they had a previous CABG with the RIMA, you may cut the RIMA on entry and give them an MI intraop. Poor form.
10. When putting in a central line in someone with an IVC filter, do not push the guidewire in too far, or it may get tangled with the IVC filter and require a trip to IR to bail you out.
Wednesday, November 20, 2013
1. If you find thyroid tissue outside of the thyroid/thyroglossal duct path, its metastatic follicular carcinoma. Do a radiolabeled-iodine scan to find the primary.
2. Hyperaldosterone: if aldo is lower when lying down, and increases upon standing, it's physiologic and more likely to be due to adrenocortical hyperplasia which is treated medically with aldactone (spironolactone, inhibits aldo effect in kidney). If the measurements are the same, or lower when standing, it's more likely to be an adenoma which needs to be treated surgically.
3. Duodenal obstruction in a newborn (bilious vomiting, double bubble)
-Complete: duodenal atresia vs annular pancreas
-Partial: duodenal stenosis vs annular pancreas vs malro (c ladds bands). Malro is a super emergency, diagnose with contrast enema or gastrographin upper GI study.
4. Peds surg:
-Exstophy of the bladder has better outcomes if its fixed within 48 hours of birth
-Nec enterocolitis: IV fluids/nutrition, NPO, antibiotics; indications to go to OR: pneumoperitoneum, air in biliary tract, abd wall erythema
5. Barium can induce an inflammatory response (granuloma formation) in the peritoneal or mediastina cavity if it leaks, leading to peritonitis, ileus, etc. If you're trying to rule out an esophageal tear or worried about a bowel leak (i.e. intussuception reduction <1% risk perforation in good hands), use gastrographin instead. However gastrographin can cause damage to the lungs if aspirated, so in someone with a high aspiration risk, barium is better. Barium also has much better bowel mucosa coating ability and is a better diagnostic agent, gastrographin has more false negatives.
6. Ann Arbor staging for lymphoma:
I: in one LN, +/- local surrounding tissues
II: In multiple LN, same side of diaphragm
III: both sides of diaphragm, + spleen
IV: extranodal mets (liver, BM)
Modifiers:
A: no B symptoms
B: B symptoms
E: extranodal
X: disease >10 cm
S: splenic involvement
7. Lymph node location, drainage differential diagnosis {source}
Submandibular-- Tongue, submaxillary gland, lips and mouth, conjunctivae -- Infections of head, neck, sinuses, ears, eyes, scalp, pharynx
Submental -- Lower lip, floor of mouth, tip of tongue, skin of cheek -- Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus, toxoplasmosiss
Jugular -- Tongue, tonsil, pinna, parotid -- Pharyngitis organisms, rubella
Posterior cervical -- Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes
-- Tuberculosis, lymphoma, head and neck malignancy
Suboccipital -- Scalp and head -- Local infection
Postauricular -- External auditory meatus, pinna, scalp -- Local infection
Preauricular -- Eyelids and conjunctivae, temporal region, pinna -- External auditory canal
Right supraclavicular node -- Mediastinum, lungs, esophagus -- Lung, retroperitoneal or gastrointestinal cancer
Left supraclavicular node -- Thorax, abdomen via thoracic duct -- Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection. (Thoracic duct drains directly into L supraclavicular node, at junction of L subclavian and L carotid veins. Thoracic duct drains abdomen, L mediastinum; R mediastinum goes to R side.)
Axillary -- Arm, thoracic wall, breast -- Infections, cat-scratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma
Epitrochlear -- Ulnar aspect of forearm and hand -- Infections, lymphoma, sarcoidosis, tularemia, secondary syphilis
Inguinal -- Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal -- Infections or cancers of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma, pelvic malignancy, bubonic plague
2. Hyperaldosterone: if aldo is lower when lying down, and increases upon standing, it's physiologic and more likely to be due to adrenocortical hyperplasia which is treated medically with aldactone (spironolactone, inhibits aldo effect in kidney). If the measurements are the same, or lower when standing, it's more likely to be an adenoma which needs to be treated surgically.
3. Duodenal obstruction in a newborn (bilious vomiting, double bubble)
-Complete: duodenal atresia vs annular pancreas
-Partial: duodenal stenosis vs annular pancreas vs malro (c ladds bands). Malro is a super emergency, diagnose with contrast enema or gastrographin upper GI study.
4. Peds surg:
-Exstophy of the bladder has better outcomes if its fixed within 48 hours of birth
-Nec enterocolitis: IV fluids/nutrition, NPO, antibiotics; indications to go to OR: pneumoperitoneum, air in biliary tract, abd wall erythema
5. Barium can induce an inflammatory response (granuloma formation) in the peritoneal or mediastina cavity if it leaks, leading to peritonitis, ileus, etc. If you're trying to rule out an esophageal tear or worried about a bowel leak (i.e. intussuception reduction <1% risk perforation in good hands), use gastrographin instead. However gastrographin can cause damage to the lungs if aspirated, so in someone with a high aspiration risk, barium is better. Barium also has much better bowel mucosa coating ability and is a better diagnostic agent, gastrographin has more false negatives.
6. Ann Arbor staging for lymphoma:
I: in one LN, +/- local surrounding tissues
II: In multiple LN, same side of diaphragm
III: both sides of diaphragm, + spleen
IV: extranodal mets (liver, BM)
Modifiers:
A: no B symptoms
B: B symptoms
E: extranodal
X: disease >10 cm
S: splenic involvement
7. Lymph node location, drainage differential diagnosis {source}
Submandibular-- Tongue, submaxillary gland, lips and mouth, conjunctivae -- Infections of head, neck, sinuses, ears, eyes, scalp, pharynx
Submental -- Lower lip, floor of mouth, tip of tongue, skin of cheek -- Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus, toxoplasmosiss
Jugular -- Tongue, tonsil, pinna, parotid -- Pharyngitis organisms, rubella
Posterior cervical -- Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes
-- Tuberculosis, lymphoma, head and neck malignancy
Suboccipital -- Scalp and head -- Local infection
Postauricular -- External auditory meatus, pinna, scalp -- Local infection
Preauricular -- Eyelids and conjunctivae, temporal region, pinna -- External auditory canal
Right supraclavicular node -- Mediastinum, lungs, esophagus -- Lung, retroperitoneal or gastrointestinal cancer
Left supraclavicular node -- Thorax, abdomen via thoracic duct -- Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection. (Thoracic duct drains directly into L supraclavicular node, at junction of L subclavian and L carotid veins. Thoracic duct drains abdomen, L mediastinum; R mediastinum goes to R side.)
Axillary -- Arm, thoracic wall, breast -- Infections, cat-scratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma
Epitrochlear -- Ulnar aspect of forearm and hand -- Infections, lymphoma, sarcoidosis, tularemia, secondary syphilis
Inguinal -- Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal -- Infections or cancers of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma, pelvic malignancy, bubonic plague
8. Nosebleed in a young adult, not anterior: either septal perforation from cocaine abuse or nasopharyngeal angiofibroma
9. You need an FEV1 of at least 800 to have an acceptable pulmonary quality of life (i.e. not dependent on 10L NC oxygen to walk). When considering significant lung resection, like pneumonectomy for central tumor, do a V/Q scan to see how much lung function comes out of what you're about to resect, subtract from FEV1 score. If its much less than 800, it's a no-go for surgery. {chart on normal FEV1 values by age, gender, height}
10. Common ENT problems that are usually bilateral that present unilaterally in a kid: foreign object; in an adult: cancer.
Tuesday, November 19, 2013
1. Three worst kinds of abdominal pain- obstruction of a hollow viscous leading to spasm and intermittent increase in interluminal pressure (as it attempts to push through obstruction): nephrolithiasis, cholelithiasis, labor.
2. Don't forget that abdominal pain can be referred pelvic pain: esp in children, as they can be shy about talking about it, you need to examine GU/pelvic structures to rule out things like testicular torsion. Testicular pain after a sporting event-- likely just local trauma, manage with pain medication and observation, don't miss a torsion, which needs to go emergently to OR. Torsion can happen after sporting events as well, rule it out with a doppler
3. Pain with any movement ("I felt every bump on the ride here") = peritoneal irritation. The logic is that it's caused by passage of some non-sterile, pro-inflammatory contents into the peritoneal cavity; adhesions form quickly to contain the effluent; these adhesions are initially made of fibrin, which needs time to form. The peritoneal process stops GI motility (ileus) and stops the person from moving (severe pain with movement) to buy time for the fibrin to form.
4. DDx of peritoneal irritation, "rebound, guarding":
-Foregut: perforated gastric ulcer (very classic rebound/guarding exam), pancreatitis, cholecystitis
-Midgut/hindgut: appendicitis +/- rupture, bowel perforation, necrotic bowel, diverticulitis +/- perforation,
-Pelvic: PID, ectopic, ruptured functional (or other) ovarian cyst (can be irritating to peritoneum)
-Systemic: spontaneous bacterial peritonitis, DKA (can cause abdominal pain), familial mediterranean fever (AD, polyserositis-- pleura, peritoneum; diagnosis with peritoneal bx, treat with colchicine)
5. Diagnosing appendicitis, relative constants:
-Anorexia: present in almost all patients. If your patient is hungry, or has eaten recently, they are unlikely to have appendicitis
-Slow onset
-Vomiting/diarrhea not a significant component. If they describe these symptoms as starting first, and the abdominal pain as later, think of other etiologies.
-No history of similar symptoms.
6. Diagnosing appendicitis, what labs/imaging to order:
-CBC, UA (r/o pyelo), pregnancy test (r/o ectopic), amylase/lipase/LFTs (r/o pancreatitis, cholecystitis)
-Gradient ultrasound if they can tolerate it-- many people can't. The u/s can't see through air, and there's often a lot of air in the cecum-- so you have to push pretty hard on the abdomen with the u/s probe to get a good imaging appendix and this is highly uncomfortable.
-CT: you will see the appendix coming off cecum, see if it is enlarged, edematous; look for fat stranding around it (normal CT fat, sort of a greyish ground glass background; fat stranding is when it sort of clumps into grey strands interspersed with grey background.
7. Surgical management of acute abdomen
-You have to weigh the risk of a sitting on an acute abdomen vs the morbidity of a negative ex-lap. Some people wait for signs of systemic infection (elevated white count, fever) in addition to an abdominal exam suggestive of acute abdomen.
-In people who may not be able to tolerate sepsis (sickle cell patients, immunocompromised), it may be worth it to go the OR earlier. People with sickle cell also unfortunately have more complications from big abdominal surgeries-- more susceptible to post-operative hypoxia, for example.
-You can find the appendix because its where the colonic tinea come together, forming a ring of longitudinal muscles around it.
-When you take the appendix, ligate the appendiceal aa in the mesoappendix.
8. Appendicitis in an older person- you have to rule out cancer. Appendicitis has a bimodal distribution: it's high in children (from before preteen years to 20s) with lymphoid follicle proliferation (appendix has prominent lymphoid follicles). It's also high in older adults, but the cause there is usually cancer-- it can be hard to detect intraop because inflammation around the appendix and cecum can lead to induration that hides a tumor to palpation. So remove the appendix, and then make sure to follow up with a colonoscopy weeks later when the inflammation has died down.
9. Hypotension in a young woman is a ruptured ectopic pregnancy until proven otherwise.
10. Group A strep skin infections tend to cause local and systemic symptoms; strep agalactiae (aka GBS) can cause local infection without systemic signs.
2. Don't forget that abdominal pain can be referred pelvic pain: esp in children, as they can be shy about talking about it, you need to examine GU/pelvic structures to rule out things like testicular torsion. Testicular pain after a sporting event-- likely just local trauma, manage with pain medication and observation, don't miss a torsion, which needs to go emergently to OR. Torsion can happen after sporting events as well, rule it out with a doppler
3. Pain with any movement ("I felt every bump on the ride here") = peritoneal irritation. The logic is that it's caused by passage of some non-sterile, pro-inflammatory contents into the peritoneal cavity; adhesions form quickly to contain the effluent; these adhesions are initially made of fibrin, which needs time to form. The peritoneal process stops GI motility (ileus) and stops the person from moving (severe pain with movement) to buy time for the fibrin to form.
4. DDx of peritoneal irritation, "rebound, guarding":
-Foregut: perforated gastric ulcer (very classic rebound/guarding exam), pancreatitis, cholecystitis
-Midgut/hindgut: appendicitis +/- rupture, bowel perforation, necrotic bowel, diverticulitis +/- perforation,
-Pelvic: PID, ectopic, ruptured functional (or other) ovarian cyst (can be irritating to peritoneum)
-Systemic: spontaneous bacterial peritonitis, DKA (can cause abdominal pain), familial mediterranean fever (AD, polyserositis-- pleura, peritoneum; diagnosis with peritoneal bx, treat with colchicine)
5. Diagnosing appendicitis, relative constants:
-Anorexia: present in almost all patients. If your patient is hungry, or has eaten recently, they are unlikely to have appendicitis
-Slow onset
-Vomiting/diarrhea not a significant component. If they describe these symptoms as starting first, and the abdominal pain as later, think of other etiologies.
-No history of similar symptoms.
6. Diagnosing appendicitis, what labs/imaging to order:
-CBC, UA (r/o pyelo), pregnancy test (r/o ectopic), amylase/lipase/LFTs (r/o pancreatitis, cholecystitis)
-Gradient ultrasound if they can tolerate it-- many people can't. The u/s can't see through air, and there's often a lot of air in the cecum-- so you have to push pretty hard on the abdomen with the u/s probe to get a good imaging appendix and this is highly uncomfortable.
-CT: you will see the appendix coming off cecum, see if it is enlarged, edematous; look for fat stranding around it (normal CT fat, sort of a greyish ground glass background; fat stranding is when it sort of clumps into grey strands interspersed with grey background.
7. Surgical management of acute abdomen
-You have to weigh the risk of a sitting on an acute abdomen vs the morbidity of a negative ex-lap. Some people wait for signs of systemic infection (elevated white count, fever) in addition to an abdominal exam suggestive of acute abdomen.
-In people who may not be able to tolerate sepsis (sickle cell patients, immunocompromised), it may be worth it to go the OR earlier. People with sickle cell also unfortunately have more complications from big abdominal surgeries-- more susceptible to post-operative hypoxia, for example.
-You can find the appendix because its where the colonic tinea come together, forming a ring of longitudinal muscles around it.
-When you take the appendix, ligate the appendiceal aa in the mesoappendix.
8. Appendicitis in an older person- you have to rule out cancer. Appendicitis has a bimodal distribution: it's high in children (from before preteen years to 20s) with lymphoid follicle proliferation (appendix has prominent lymphoid follicles). It's also high in older adults, but the cause there is usually cancer-- it can be hard to detect intraop because inflammation around the appendix and cecum can lead to induration that hides a tumor to palpation. So remove the appendix, and then make sure to follow up with a colonoscopy weeks later when the inflammation has died down.
9. Hypotension in a young woman is a ruptured ectopic pregnancy until proven otherwise.
10. Group A strep skin infections tend to cause local and systemic symptoms; strep agalactiae (aka GBS) can cause local infection without systemic signs.
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