Pre-Op Evaluation

• Contraindications to surgery
– Absolute? Diabetic Coma, DKA
High Yield Surgery
– Poor nutrition? albumin <3, transferrin <200,
weight loss <20%.
Shelf Exam Review
– Severe liver failure? bili >2, PT >16, ammonia > 150
Emma Holliday Ramahi or encephalopathy
– Smoker? stop smoking 8wks prior to surgery
If a CO2 retainer, go easy on the O2 in the post-op
period. Can suppress respiratory drive.
Tells you who is at Aspirin, NSAIDs, vit E (2wks)
• Goldman’s Index greatest risk for surgery • Meds to stop:
Warfarin (5 days) – drop INR to
– #1 = CHF
<1.5 (can use vit K)
• What should you check? EF. If <35%, no surg.
Take ½ the morning dose of
– #2 = MI w/in 6mo
EKG stress test insulin, if diabetic
• What should you check? cardiac cath revasc. • If CKD on dialysis: Dialyze 24 hours pre-op
– #3 = arrhythmia
• Why do we check the BUN and Creatinine?
– #4 = Old (age >70)
– What is the worry if BUN > 100?
– #5 = Surgery is emergent
There is an increased risk of post-op bleeding 2/2
– #6 = AS, poor medical condition, surg in chest/abd
uremic platelet dysfunction.
• What should you check?
Listen for murmur of AS- – What would you expect on coag pannel?
Late systolic, crescendo-decrescendo murmur that radiates Normal platelets but prolonged bleeding time
to carotids. ↑ with squatting, ↓ with decr preload
 Vent Settings You have a patient on a vent…
set TV and rate but if pt takes a
• Assist-control breath, vent gives the volume.
• Best test to evaluate management? ABG
• Pressure support pt rules rate but a boost of • If PaO2 is low? increase FiO2
*Important for weaning.* pressure is given (8-20). • If PaO2 is high? decrease FiO2
• If PaCO2 is low (pH is high)? Decr rate or TV
• CPAP pt must breathe on own but + pressure • If PaCO2 is high (pH is low)? Incr rate or TV
given all the time.
• Which is more efficient? TV is more efficient to
change.
• PEEP pressure given at the end of
*Remember minute
*Used in ARDS or CHF* cycle to keep alveoli open ventilation equation
(5-20).
& dead space*
Acid Base Disorders Sodium Abnormalities
• ↓Na = Gain of water
• Check pH if <7.4 = acidotic.
– Check osm, then check volume status.
• Next Check HCO3 and pCO2:
– ↑volume ↓Na: CHF, nephrotic, cirrotic
– If HCO2 is high and pCO2 is high? Respiratory Acidosis
– If HCO2 is low and pCO2 is low? Metabolic Acidosis – ↑volume ↓ Na: diuretics or vomiting + free water
• Next Check anion gap (Na – [Cl + HCO3]), normal? 8-12 – Nl volume ↓Na: SIADH, Addisons, hypothyroidism.
• Gap acidosis = MUDPILES – Treatment? Fluid restriction & diruetics
• Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV)
– If hypovolemic? Normal Saline
• Check pH if >7.4 = alkalotic. – When to use 3% saline? Symptomatic (Seizures), < 110
• Next Check HCO3 and pCO2: – What would you worry about? Central Pontine Myolinolysis.
– If HCO3 is low and pCO2 is low Respiratory Alkalosis
– If HCO3 is high and pCO2 is high
• ↑Na = Loss of water
Metabolic Alkalosis
• Next Check urine [Cl] – Treatment? Replace w/ D5W or hypotonic fluid
• If [Cl] < 20 Vomiting/NG,
antactids, diuretics – What would you worry about? cerebral
• If [Cl] > 20 edema.
Conn’s, Bartter’s Gittleman’s.
 Other Electrolyte Abnormalities Fluid and Nutrition
• Numbness, Chvostek or Troussaeu, prolonged • Maintenance IVFs D51/2NS + 20KCl (if peeing)
QT interval. ↓Ca – Up to 10kg s 100mL/kg/day
• Bones, stones, groans, psycho. Shortened QT – Next 10 kgs 50mL/kg/day
interval. ↑Ca – All above 20 20mL/kg/day
• Paralysis, ileus, ST depression, U waves.↓K • Enteral Feeds are best keep gut mucosa in tact
and prevent bacterial translocation.
– Treatment? give K (kidneys!), max 40mEq/hr
• TPN is indicated if gut can’t absorb nutrients 2/2
• Peaked T waves, prolonged PR and QRS, sine physical or fxnal loss.
waves. ↑K – Risks = *acalculus cholecystitis*, hyperglycemia, liver
– Treatment? Give Ca-gluconate then insulin + glc, dysfxn, *zinc deficiency*, other ‘lyte probs
kayexalate, albuterol and sodium
bicarb. Last resort = dialysis
Burn Clotting & Bleeding
• Clotting-
– In old people? Think cancer
www.readykor.com/docs/burns_files/burns9.jpg
http://emedicine.medscape.com/arti
– Edema, HTN, & foamy pee? Nephrotic syndrome
1st degree
http://en.wikipedia.org/wiki
/Burn
cle/769193-media
– In young person w/ +FH Factor V Leiden
2nd degree 3rd degree
– What’s special about ATIII def? Heparin won’t work
– Young woman w/ mult. SABs? Lupus Anticoagulant
• Circumferential burns? Consider escharotomy – Post op, ↓plts, clots HIT! (If heparin w/in 5-14 days
• Look for singed nose hairs, wheezing, soot in • What do you treat w/?
Leparudin or agatroban
mouth/nose? Low threshold for intubation • Bleeding
• Patient w/ confusion, HA, cherry red skin? – Isolated decr in plts? ITP
– Normal plts but incr bleeding time & PTT? vWD
– Best test? Check carboxyHb (pulse ox = worthless) – Low plts, Incr PT, PTT, BT, low fibrinogen, high Ddimer
– Treatment? 100% O2 (hyperbaric if CO-Hb is ↑↑↑ and schistocytes? DIC!! Caused by gram – sepsis,
carcinomatosis, OB stuff
 Burn Work up and Tx Other Burn Stuff
• Rule of 9s – Parkland formula- • Chemical burn, what to do? Irrigate >30min prior to ER
• Adults- Kg x % BSA x 3-4 • Electrical Burn, best 1st step? EKG!
Give ½ over the • • If abnormal? 48 hours of telemetry (also if LOC)
1st 8hrs and the • Kiddos- Kg x % BSA x 2-4 • If urine dipstick + for blood but microscopic exam
rest over next •
Ringers lactate or is negative for RBCs? Myoglobinuria ATN
16hrs •
normal saline • Then what do you check? K+! (When cells break)
• NO PO or IV abx. Give topical.
http://img.tfd.com/dorland/thumbs/rule_of-nines.jpg
• If affected extremity is extremley tender, numb,
Silver white, cold with barely dopplerable pulses?
• Doesn’t penetrate eschar and can cause
Sulfadiazine Compartment syndrome!!
leukopenia?
• Penetrates eschar but hurts like hell? Mafenide – Criteria? 5 Ps or compartment pressure >30mmHg
• Doesn’t penetrate eschar and causes hypoK and – Treatment? May require fasciotomy. (at bedside!)
HypoNa? Silver Nitrate
Trauma Drama
• Airway-
• Breathing-
– If trauma patient comes in unconscious? Intubate!
– So you intubated your patient… next best step?
– If GCS < 8? Intubate!
Check bilateral breath sounds
– If guy stung by a bee, developing stridor and
– If decr on the left?
tripod posturing? Intubate!
– If guy stabbed in the neck, GCS = 15, expanding Means you intubated the right mainstem bronchus
mass in lateral neck? Intubate! – What to do? Pull back your ET tube
– If guy stabbed in the neck, crackly sounds w/ – Next step? Check pulse ox, keep it >90%
palpating anterior neck tissues? fiberoptic
broncoscope
– If huge facial trauma, blood obscures oral and
nasal airway, & GCS of 7? cricothyroidotomy
 Chest Trauma
• A patient has inward mvmt of the right ribcage
upon inspiration.
– Dx? Flail chest. >3 consec rib fractures
www.imagingpathways.health.wa.gov.au/.../cxr.jpg www.daviddarling.info/images/pneumothorax_rad... – Tx? O2 and pain control. With what?*
Traumatic Aortic Injury Pneumothorax • A patient has confusion, petechial rash in chest,
img.medscape.com/.../424545-425518-718tn.jpg
upload.wikimedia.org/.../Pulmonary_contusion.jpg
axilla and neck and acute SOB.
– Dx? Fat embolism
– When to suspect it? After long bone fx (esp femur)
• A patient dies suddenly after a 3rd year medical
student removes a central line.
– Dx? Air embolism
– When else to suspect it? Lung trauma, vent use, during
Hemothorax Pulmonary Contusion heart vessel surgery.
• Cardiovascular- Shock
Worry about shock
– If hypotensive, tachycardic?
Types of Shock Causes Physical Exam Swan-Ganz Treatment
Catheter
Hypovolemic/ Hypovolemic Loss of circulating blood volume (whole Hypotensive, tachycardic, RAP/ PCWP↓ Crystalloid
– If flat neck veins and normal CVP? Hemorrhagic blood from hemorrhage or interstitial from diaphoretic, cool, clammy
bowel obstruction, excessive vomiting or extremities
SVR↑
resuscitation
– Next best step? 2 large bore periph IV- 2L NS or LR over Vasogenic
diarrhea, polyuria or burn)
Decreased resistance w/in capacitance Altered mental status,
CO↓
RAP/PCWP↓ Fluid resuscitation
20min followed by blood.
– If muffled <3 sounds, JVD, electrical alternans,
vessels, seen in sepsis (LPS) and hypotension warm, dry (may cause edema)
SVR↓
anaphylaxis (histamine) extremities (early), Late and tx offending
looks like hypovolemic CO↑ (EF↓) organism
pulsus paradoxus? Pericardial Tamponade Neurogenic A form of vasogenic shock where spinal Hypotensive, bradycardic, RAP/PCWP↓ In adrenal insuff, tx
• Confirmatory test? FAST scan cord injury, spinal anesthesia, or adrenal
insufficiency (suspect in pts on steroids
warm, dry extremities,
absent reflexes and flaccid
SVR↓
w/ dexamethasone
and taper over
encountering a stressor) causes an acute tone. Adrenal insuf will several weeks.
• Treatment? Needle decompression, pericardial window or loss of sympathetic vascular tone have hypoNa, hyperK
CO↑
median sternotomy Cardio- Cardiac tamponade or other processes Hypotensive, tachycardic, U/S shows fluid Pericardio-centesis
– If decr BS on one side, tracheal deviation AWAY compressive exerting pressure on the heart so it cannot JVD, decreased heart
fulfill its role as a pump sounds, normal breath
in the pericardial performed by
space inserting needle to
from collapsed lung? Tension Pneumothorax Cardiogenic Failure of the heart as a pump, as in
sounds, pulsus paradoxus
SOB, clammy extremities, RAP/PCWP↑
pericardial space
give diuretics up
• Next best step? Needle decompression, followed by arrhythmias or acute heart failure rales bilaterially, S3,
pleural effusion, decr
SVR↑
front, tx the HR to
60-100, then address
a chest tube. breath sounds, ascites, CO↓ rhythm. Next give
periph edema, vasopressor support
DON’T do a CXR!!! if nec.
 Head Trauma Neck Trauma
• GCS eyes 4, motor 6, verbal 5
Penetrating Trauma GSW
or stab wound
Zone 3 = ↑ angle of mandible
tumj.tums.ac.ir
prep4usmle.com
uiowa.edu
w/u? Aortography and triple
Epidural Acute subdural Chronic subdural endoscopy.
Hematoma, edema, tumor can cause increased ICP Zone 2 = angle of mandible-cricoid
w/u? 2D doppler +/- exploratory
Symptoms? Headache, vomiting, altered mental status surgery.
Treatment? Elevate HOB, hyperventillate to pCO2 28-32, Zone 1 = ↓ cricoid
give mannitol (watch renal fxn) w/u? Aortography
Surgical intervention?
Ventriculostomy
Penetrating Abdominal Trauma Blunt Abdominal Trauma
• If GSW to the abdomen? If unstable? Ex-lap.
Ex-lap. (plus tetanus prophylaxis)
If stable? Abdominal CT
• If stab wound & pt is unstable, Spleen or
– If lower rib fx plus bleeding into abdomen liver lac.
with rebound tenderness &
– If lower rib fx plus hematuria Kidney lac.
rigidity, or w/ evisceration? Diaphragm
Ex-lap. (plus tetanus prophylaxis) – If Kehr sign & viscera in thorax on CXR
rupture.
– If handlebar sign Pancreatic rupture.
If you see this? • If stab wound but pt is stable?
FAST exam. DPL if FAST is equivocal. – If stable w/ epigastric pain?
Do not pass go, go Ex-lap if either are positive. • Best test? Abdominal CT.
directly to • If blunt abdominal trauma pt • If retroperitoneal fluid is found? Consider duodenal
exploratory with hypotension/tachycardia: rupture.
laparotomy. Ex-lap.
 Pelvic Trauma Ortho Trauma
FAST and DPL to r/o bleeding in
• If hypotensive, tachycardic abdominal cavity.
• Can bleed out into pelvis stop bleeding by fixing fx
• Fractures that go to the OR-
– Depressed skull fx
internal if stable, external if not.
– Severely displaced or angulated fx
• If blood at the urethral meatus and a high riding prostate? – Any open fx (sticking out bone needs cleaning)
Consider pelvic fracture w/ urethral or bladder injury. – Femoral neck or intertrochanteric fx
• Next best test? Retrograde urethrogram (NOT FOLEY!) • Common fractures-
• If normal? Retrograde cystogram to evaluate bladder – Shoulder pain s/p seizure or electrical shock Post. shoulder dislocation
– Arm outwardly rotated, & numbness over deltoid. Ant. shoulder dislocation
• What are you looking for? Check for extravasation of dye. Take
– old lady FOOSH, distal radius displaced. Colle’s fracture
2 views to ID trigone injury. – young person FOOSH, anatomic snuff box tender. Scaphoid fracture
If extraperitoneal extravasation? – “I swear I just punched a wall…” Metacarpal neck fracture “Boxer’s
Bed rest + foley fracture”. May need K wire
If intraperitoneal extravasation? – Clavicle most commonly broken where? Between middle and distal 1/3s.
Ex-lap and surgical repair Need figure of 8 device
Ortho Trauma X-rays • Fever on POD #1-
– Most common cause, low fever (<101) and non
productive cough? Atalectasis
• Dx? CXR- see bilateral lower lobe fluffy infiltrates
• Tx? Mobilization and incentive spirometry.
– High fever (to 104!!), very ill appearing. Nec Fasc
Depressed skull fx
mksforum.net
Colle’s fx
xraypedia.com/files/images/fxapcolles.jpg
Scaphoid fx • Pattern of spread? In subQ along Scarpa’s fascia.
• Common bugs? GABHS or clostridium perfringens
orthoinfo.aaos.org/figures/A00012F04.jpg
• Tx? IV PCN, Go to OR and debride skin until it bleeds
– High fever (>104!!) muscle rigidity. Malignant
• Caused by? Succ or Halothane Hyperthermia
• Genetic defect? Ryanodine receptor gene defect
Clavicle fx Femoral neck fx
en.academic.ru
gentili.net Intertrochanteric fx • Treatment? Dantrolene Na (blockes RYR and decr
download.imaging.consult.com/.../gr5-
intracellular calcium.
midi.jpg
 • Fever > POD 7-
Central line infection
• Fever on POD #3-5- – Pain & tenderness at IV site
• Tx? Do blood cx from the line. Pull it. Abx to cover staph.
– Fever, productive cough, diaphoresis
Pneumonia – Pain @ incision site, edema, induration Cellulits
acutemed.co.uk
but no drainage.
• Tx? Check sputum sample for culture, cover w/ moxi
• Tx? Do blood cx and start antibiotics Simple
etc to cover strep pneumo in the mean time.
– Pain @ incision site, induration WITH drainage.Wound
– Fever, dysuria, frequency, urgency, particularly in a • Tx? Open wound and repack. No abx necessary Infection
patient w/ a foley. – Pain w/ salmon colored fluid from incision. Dehiscence
UTI • Tx? Surgical emergency! Go to OR, IV abx, primary closure of fascia
• Next best test? UA (nitritie and LE) and culture. – Unexplained fever Abdominal Abscess
• Tx? Change foley and treat w/ wide-spec abx until • Dx? CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
culture returns. • Tx? Drain it! Percutaneously, IR-guided, or surgically.
– Random thyrotoxicosis, thrombophlebitis, adrenal
insufficiency, lymphangitis, sepsis.
Pressure Ulcers Thoracic
• Caused by impaired blood flow ischemia
– Don’t culture will just get skin flora. Check CBC and blood cultures. • Pleural Effusions see fluid >1cm on lat decu
Can mean bacteremia or osteomyelitis. thoracentesis!
– Can do tissue biopsy to rule out Marjolin’s ulcer
– Best prevention is turning q2hrs – If transudative, likely CHF, nephrotic, cirrhotic
• If low pleural glucose? Rheumatoid Arthritis
– Stage 1 = skin intact but red. Blanches w/ pressure judy-
waterlow.co. • If high lymphocytes? Tuburculosis
uk
• If bloody? Malignant or Pulmonary Embolus
– Stage 2 = blister or break in the dermis
qondio.com – If exudative, likely parapneumonic, cancer, etc.
– Stage 3 = SubQ destruction into the muscle – If complicated (+ gram or cx, pH < 7.2, glc < 60):
– Stage 4 = involvement of joint or bone. gndmoh.com seejanenurse.wordpress.com
• Insert chest tube for drainage.
– Light’s Criteria transudative if:
• Stage 1-2 get special mattress, barrier protection LDH < 200
• Stage 3-4 get flap reconstruction surgery LDH eff/serum < 0.6
– Before surgery, albumen must be >3.5 and bacterial load must be Protein eff/serum < 0.5
<100K
ncbi.nlm.nih.gov
 • Spontaneous Pneumothorax subpleural bleb
ruptures lung collapse. Work up of a Solitary Lung Nodule
– Suspect in tall, thin young men w/ sudden dyspnea (or
asthma or COPD-emphysema)
• 1st step = Find an old CXR to compare!
– Dx w/ CXR, Tx w/ chest tube placement
– Indications for surgery = ipsi or contra recurrence, • Characteristics of benign nodules:
bilateral, incomplete lung expansion, pilot, scuba, live – Popcorn calcification = hamartoma (most common)
in remote area VATS, pleurodesis (bleo, iodine or
talc) – Concentric calcification = old granuloma
• Lung Abscess usually 2/2 aspiration (drunk, – Pt < 40, <3cm, well circumscribed
elderly, enteral feeds) – Tx? CXR or CT scans q2mo to look for growth
– Most often in post upper or sup lower lobes
• Characteristics of malignant nodules:
http://emedicine.medscape.com/
article/356271-media
– Tx initially w/ abx IV PCN or clinda
– Indications for surgery = abx fail, – If pt has risk factors (smoker, old), If >3cm, if eccentric
abscess >6cm, or if empyema is present. calcification
– Tx? Remove the nodule (w/ bronc if central,
www.meddean.luc.edu open lung biopsy if peripheral. http://emedicine.medscape.com/ar
ticle/358433-media
A patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated pnia or lung ARDS
collapse.
• MC cancer in non-smokers? Adenocarcinoma. Occurs in scars of old pnia
• Pathophys: inflammation impaired www.ispub.com/.../ards3_thumbnail.gif
• Location and mets? Peripheral cancer. Mets to liver, bone, brain and adrenals
• Characteristics of effusion? Exudative with high hyaluronidase
gas xchange, inflam mediator release,
• Patient with kidney stones, hypoxemia
Squamous cell carcinoma.
constipation and malaise low PTH +Paraneoplastic syndrome 2/2 secretion • Causes:
central lung mass? of PTH-rP. Low PO4, High Ca
• Patient with shoulder pain, ptosis, Superior Sulcus Syndrome from Small
– Sepsis, gastric aspiration, trauma, low perfusion,
constricted pupil, and facial edema? cell carcinoma. Also a central cancer. pancreatitis.
• Patient with ptosis better after 1 Lambert Eaton Syndrome from small • Diagnosis: 1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
minute of upward gaze? cell carcinoma. Ab to pre-syn Ca chan 2.) Bilateral alveolar infiltrates on CXR
• Old smoker presenting w/ Na = 125, SIADH from small cell carcinoma. 3.) PCWP is <18 (means pulmonary edema is non-cardio
moist mucus membranes, no JVD? Produces Euvolemic hyponatremia.
• CXR showing peripheral cavitation andFluid restrict +/- 3% saline in <112 • Treatment: Mechanical ventilation w/ PEEP
CT showing distant mets? Large Cell Carcinoma
 Murmur Buzzwords More Murmurs
• SEM cresc/decresc, louder w/ • Holosystolic murmur w/ late
Aortic Stenosis VSD
squatting, softer w/ valsalva. + diastolic rumble in kiddos
parvus et tardus • Continuous machine like PDA
• SEM louder w/ valsalva, softer HOCM murmur-
w/ squatting or handgrip. • Wide fixed and split S2- ASD
• Late systolic murmur w/ click Mitral Valve Prolapse
• Rumbling diastolic murmur Mitral Stenosis
louder w/ valsalva and with an opening snap, LAE and
handgrip, softer w/ squatting A-fib
• Holosystolic murmur radiates Mitral Regurgitation • Blowing diastolic murmur with Aortic Regurgitation
to axilla w/ LAE widened pulse pressure and
eponym parade.
• Bad breath & snacks in Zenker’s diverticulum. If hematemesis (blood occurs If gross hematemesis If progressive
Tx w/ surgery after vomiting, w/ subQ unprovoked in a cirrhotic dysphagia/wgt loss.
the AM. emphysema). Can see pleural w/ pHTN. Esophageal Carcinoma
• True or false? False. Only contains mucosa effusion w/ ↑amylase Gastric Varices Squamous cell in
• Dysphagia to liquids & solids. Dysphagia worse w/ hot & Boerhaave’s If in hypovolemic shock? smoker/drinkers in the
Esophageal Rupture middle 1/3.
Achalasia. cold liquids + chest pain that do ABCs, NG lavage, Adeno in ppl with long
Tx w/ CCB, nitrates, feels like MI w/ NO regurg Next best test? medical tx w/ octreotide standing GERD in the
botox, or heller CXR, gastrograffin or SS. Balloon
sxs. Diffuse esphogeal spasm. distal 1/3.
myotomy esophagram. NO tamponade only if you
Assoc w/ Chagas dz Tx w/ CCB or nitrates edoscopy need to stablize for
jykang.co.uk
Best 1st test?
and esophageal transport
Tx? barium swallow, then
cancer.
surgical repair if full Tx of choice? endoscopy w/ bx, then
ajronline.org
thickness staging CT.
• Epigastric pain worse after GERD. Most sensitive test is 24-hr pH Endoscopic
sclerotherapy or
eating or when laying down monitoring. Do endoscopy ifst“danger signs” banding
present. Tx w/ behav mod 1 , then antacids,
cough, wheeze, hoarse. *Don’t prophylactically
H2 block, PPI.
band asymptomatic
• Indications for surgery? bleeding, stricture, Barrett’s, incompetent LES, varices. Give BB. img.medscape.com
max dose PPI w/ still sxs, or no want meds. /pi/emed/ckb/onco
logy/276262
 Stomach Duodenum
http://emedicine.medscape.c
om/article/175765-media
• MEG pain better w/ eating Duodenal Ulcers
• Acid reflux pain after eating, when laying down- Hiatal Hernia – 95% assoc w/ H. pylori
– Type 1 = Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs. – Healthy pts < 45y/o can do trial of H2 block or PPI
– Type 2 =Paraesophageal. Abd pain, obstruction, strangulation needs surgery. – Dx? blood, stool or breath test for H. pylori but endoscopy w/
• MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids- Gastric Ulcers biopsy (CLO test) is best b/c it can also exclude cancer.
Double-contrast barium swallow- punched out lesion w/ reg margins. PPI, clarithromycin & amoxicillin for 2wks. Breath or stool
– Work up = – Tx?
EGD w/ bx can tell H. pylori, malign, benign. test can be test of cure.
– Surgery if-
Lesion persists after 12wks of treatment.
• Gastric Cancer- Adeno most common. Esp in Japan • What to suspect if MEG pain/ulcers don’t resolve? ZE Syndrome
– Krukenberg Gastric CA ovaries Blummer’s Shelf Mets felt on DRE – Best test? Secretin Stim Test (find inapprop high gastrin)
Virchow’s node L supraclav fossa Sister Mary Joseph Umbilical node – Tx? Surgical resection of pancreatic/duodenal tumor
– Lymphoma- HIV MALT-lymphoma- H. pylori – What else to look for? Pituitary and Parathyroid problems.
• Randoms- • A patient has bilious vomiting and post-prandial pain.
– Mentriers = protein losing enteropathy, enlarged rugae. Recently lost 200lbs on “Biggest Loser”. SMA Syndrome
– Gastric Varices = – Pathophys- 3rd part of duodenum compressed by AA and SMA
splenic vein thrombosis.
– Dieulafoy’s = massive hematemesis mucosal artery erodes into – Tx? by restoring weight/nutrition. Can do Roux-en-Y
stomach
Exocrine Pancreas Endocrine Pancreas
• MEG pain straight through to the back. Pancreatitis • Insulinoma- sxs (sweat, tremors, hunger, seizures) + BGL <
– Most common etiologies? Gallstones & ETOH – Whipple’s triad? 45 + sxs resolve w/ glc admin
– Dx? Incr amylase & lipase. CT is best imaging test – Labs? insulin ↑, C-peptide ↑, pro-insulin ↑
– Tx? NG suction, NPO, IV rehydration and observation
– Bad prognostic factors- old, WBC>16K, Glc>200, LDH>350, AST>250… • Glucagonoma-
drop in HCT, decr calcium, acidosis, hypox – Sxs? Hyperglycemia, diarrhea, weight-loss
– Complications- pseudocyst (no cells!), hemorrhage, abscess, ARDs
– Characteristic rash? necrolytic migratory erythema
• Chronic Pancreatitis-
– Chronic MEG pain, DM, malabsorption (steatorrhea) • Somatistainoma- img.medscape.com/.../104
– Can cause splenic vein thrombosis which leads to …? Gastric varices! – Commonly malignant. see malabsorption, 8885-1093550-244.jpg
• Adenocarcinoma- steatorrhea, ect from exocrine pancreas malfxn
– Usually don’t have sxs until advanced. If in head of pancreas
Courvoisier’s sign large, nontender GB, itching and jaundice • VIPoma-
– Trousseau’s sign = migratory thrombophlebitis – Sxs? Watery diarrhea, hypokalemia, dehydration, flushing.
– Dx w/ EUS and FNA biopsy – Looks similar to carcinoid syndrome.
– Tx w/ Whipple if: no mets outside abdomen, no extension into SMA or
portal vein, no liver mets, no peritoineal mets.
– Tx? Octreotide can help sxs
 Gallbladder Acute Cholecystitis Liver
• RUQ pain back, n/v, fever, worse s/p fatty foods. • Hepatitis-
– Best 1st test? U/S
– AST = 2x ALT Alcoholic heptatitis (reversible)
– Tx? Cholecystectomy. Perc cholecystostomy if unstable med-ed.virginia.edu
– AST > ALT high (1000s) Viral hepatitis
• RUQ pain, high bili and alk-phos. Choledocolithiasis – AST & ALT high s/p hemorrhage, surg, or sepsis Shock liver
– Dx? U/S will show CBD stone.
• Cirrhosis and Portal HTN-
– Tx? Chole +/- ERCP to remove stone
– Tx- SS and VP vasocontrict to decrease portal pressure, betablockers
• RUQ pain, fever, jaundice, ↓BP, AMS. Ascending Cholangitis also decrease portal pressure.
– Tx? w/ fluids & broad spec abx. ERCP and stone removal. – Don’t need to treat esophageal varices prophyactically, but
• Choledochal cysts- band/burn them once they bleed once.
– Type 1? Fusiform dilation of CBD Tx w/ excision – TIPS relieves portal HTN but… worsens hepatic encephalopahty
– Type 5? Caroli’s Dz. Cysts in intrahepatic ducts needs liver transplant • Treat with: Lactulose. helps rid body of ammonia.
• Cholangiocarcinoma- rare. • Hepatocellular Carcinoma
– Risk factors? – RF- chronic hepB carrier > hepC. Cirrhosis for any
Primary sclerosing cholangitis (UC), liver flukes and
reason, plus aflatoxin or carbon tetrachloride.
thorothrast exposure. Tx w/ surgery +/- radiation.
– Dx w/ high AFP (in 70%), CT/MRI.
– Tx: can surgically remove solitary mass, use rads or cryoablation for
pallation of multiple.
More Liver Spleen
• Post-Splenectomy
*Women on OCP palpable abd mass or spontaneous
– Post op thrombocytosis >1mil give aspirin. img.medscape.com/.../432648-432823-
rupture hemorrhagic shockHepatic Adenoma www.radswiki.net/main/images/thumb/
3/3e/Hepat...
3042.jpg
– Prophylactic PCN + S. pneumo, H. flu and N. meningitidis vaccines.
Dx? U/S or MRI • ITP-
Tx? D/c OCPs. Resect if large or pregnancy is desired – Consider in isolated thrombocytopenia (bleeding gums, petechiae,
*2nd MC benign liver tumor. W>M but less likely to rupture. Focal Nodular nosebleeds).
No tx needed. Hyperplasia – Decr plt count, incr megakaryocytes in marrow.
*Bacterial Abscess. – NO splenomegaly.
Most common bugs? E. coli, bacteriodes, enterococcus. – Tx w/ steroids 1st. If relapse splenectomy.
Tx? Surgical drainage and IV abx. • Hereditary Spherocytosis-
RUQ pain, profouse sweating and rigors, palpable liver. Entamoeba histolytica – See sxs of hemolytic anemia (jaundice, incr indir bili, LDH, decr
haptoglobin, elevated retic count) + spherocytes on smear and
Tx? Metronidazole. DON’T drain it. +osmotic frag test. Prone to gallstones.
Patient from Mexico presents w/ RUQ and large liver cysts found – Tx w/ splenectomy (accessory spleen too).
on U/S Enchinococcus. • Traumatic Splenic Rupture- www.ezhemeonc.com/wp-
content/upload
– Mode of transmission? Hydatic cyst paracyte from dog feces. – Consider w/ L lower rib fx and intra abd hemorrhage. Can have Kehr’s
– Lab findings? eosinophilia, +Casoni skin test sign (irritates L diaphragm).
– Tx? albendazole and surgery to remove ENTIRE cyst,
rupture anaphylaxis
 Appendix Bowel Obstruction
• Small Bowel Obstruction-
• pain in umbilical area RLQ, n/v. – Suspect in hernia, prior GI surgery (adhesions), cancer,
intussusception, IBD.
perf. Appendicitis – Sxs are pain, constipation, obstipation, vomiting.
– Go to surgery if: Clinical picture is convincing. – 1st test is upright CXR to look for free air. CT can show point of
obstruction.
– If perforated/abscess? drain, abx (to cover e.coli & bacteriodes), – Tx w/ IVF, NG tube. Do surgery if peritoneal signs, Incr WBC, no
and do interval appendectomy improvement w/in 48hrs.
• Carcinoid Tumor- #1 site: Appendix! • Volvulus- either cecal or sigmoid
– Decompression from below if not strangulated. Otherwise, need
– Carcinoid syndrome sxs? Diarrhea, Wheezing. surgical removal and colostomy.
• Post-Op Ileus-
– When do they happen? When mets to liver. (1st pass metabolism) – Also consider if hypoK (make sure to replete), opiates.
– What else to look out for? Diarrhea, Dementia, Dermatitis – See dilated loops of small bowel w/ air-fluid level.
– Do surgery for perforation. Give lactulose/erythromycin.
– If >2cm, @ base of appendix, or • Ogilvie’s syndrome-
w/ + nodes Hemicolectomy – See massive colonic distension. If >10cm, need decompression w/ NG
tube and neostigmine (watch for bradycardia) or colonoscopic
– Otherwise Appendectomy is good enough decompression.
Abdominal Imaging Hernias
• Umbilical- in kiddos, close spontaneously by age 2. In
adults: 2/2 obesity, ascites or pregnancy.
• Indirect Inguinal- MC through inguinal ring (lat to
epigastric vessles) in spermatic cord. R>L, more often
http://emedicine.medscape.com/article/ http://www.ganfyd.org/index.php?tit http://emedicine.medscape.com/ar
congenital (patent proc vaginals)
374962-overview le=Small_bowel_obstruction ticle/178948-media
• Direct Inguinal- through Hasselbeck’s triangle
(med to epigastric vessles), more often acquired
weakness.
• Femoral- more common in women.
http://emedicine.medscape.com/article/7
http://emedicine.medscape.co
• Tx- emergent surgical repair if incarcerated to
m/article/774045-
74045-diagnlearningradiology.comosis diagnlearningradiology.comosis learningradiology.com
avoid strangulation. Elective if reducible.
 Inflammatory Bowel Disease IBD Images & Complications
• Involves terminal ileum? Crohn’s. Mimics appendicitis. Fe deficiency.
• Continuous involving rectum? UC. Rarely ileal backwash but never higher
• Incr risk for Primary UC. PSC leads to higher risk of cholangioCA
Sclerosing Cholangitis?
• Fistulae likely? Crohn’s. Give metronidazole.
• Granulomas on biopsy? Crohn’s. medinfo.ufl.edu/~bms5191/gi/images/cd1a.jpg
commons.wikimedia.org
• Transmural inflammation? Crohn’s.
• Cured by colectomy? UC.
• Smokers have lower risk? UC. Smokers have higher risk for Crohn’s.
• Highest risk of colon cancer? UC. Another reason for colectomy.
• Associated w/ p-ANCA? UC.
http://www.ajronline.org/cgi/con
tent-nw/full/188/6/1604/FIG20
Treatment = ASA, sulfasalzine to maintain remission. Corticosteroids to induce studenthealth.co.uk
remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine,
6MP and methotrexate for severe dz.
Diverticular Disease Colorectal Cancer
• Diverticulosis- • RF
– False diverticulae (only outpocketings of mucosa)
– Occur 2/2 low fiber diet in areas of weakness where blood – Genetics? AFP, Lynch Syndrome, HNPCC, Gardners, Cowdens
vessels penetrate bleed – Other? UC. Need colonoscopy 8-10yrs after dx
– Complications are bleeding, obstruction, diverticulitis
• Diverticulitis-
• Sxs
– Diverticulum becomes obstructed and forms – Right sided cancer = bleeding ourwebdoctor.com
abscess/perforates – Left sided cancer = obstruction
– LLQ pain, either constipation or diarrhea,
– Look for free air, CT is best imaging to
– Rectal cancer = pain/fullness, bleeding/obstruction
evaluate for abscess. No Barium enema! • Work up DRE, transrectal ultrasound (depth of invasion),
– Tx w/ NPO, NG suction, IVF, broad spec abx & pain control. Colonoscopy! CEA to measure recurrance, CT for staging.
• Tx
www.meddean.luc.edu/.../GI/Diverticulit
is2.jpg
– Do colonoscopy: 4-6 weeks later.
– Surgery indicated if: – For colon- remove affected segments & chemo if node +
multiple episodes, age <50. Elective is better than
emergency (can do primary anastamosis) – For rectum- upper/middle 1/3 get a LAR, lower 1/3 gets an APR
(remove sphincter, permanent colostomy)
 AAA Mesenteric Ischemia
• Screening = men 65-75 who have ever smoked. Do abdominal U/S. • Acute Mesenteric Ischemia = surgical emerg!
– Acute abdominal pain in a pt w/ A-fib subtherapeutic
• Sxs = pulsatile abdominal mass. on warfarin or pt s/p high dose vasoconstrictors
• Tx conservatively if: (shock, bypass).
if <5cm and asymptomatic, monitor growth every 3-12mo.
– Work up is angiography (aorta and SMA/IMA)
– Tx is embolectomy. If thrombus, or aortomesenteric
• Surgery indicated if: >5cm, growing <4mm/yr bypass.
• Rupture = • Chronic Mesenteric Ischemia =
– severe sudden abdomen, flank or back, shock, tender
pulsatile mass. – Slow progressing stenosis (req stenosis of 2.5 vessels
– 50% die before reaching the hospital.
Celiac, SMA and IMA).
• Post-op complications = #1 cause of death MI – Severe MEG pain after eating, food fear and weight
loss. “Pain out of proportion to exam”.
– Bloody diarrhea-Ischemic colitis
ASA – Dx w/ duplex or angiography.
– Weakness, decreased pain w/ preserved vibr, prop- syndrome
– 1-2 yrs later if have brisk GI bleeding
– Tx w/ aortomeseteric bypass or transaortic mesenteric
Aortoenteric Fistula endarterectomy.
Peripheral Artery Disease DVT and PE
• Acute arterial occlusion: 5P’s no dopplerable pulses. • High risk after surgery (esp orthopedic)
– Tx w/ immediate heparin + prepare for surgery. • DVT-
– Surgery (embolectomy or bypas) done w/in 6hrs to avoid – Dx w/ Duplex U/S & also check for PE
loss. – Tx w/ heparin, then overlap w/ warfarin for 5 days, then download.imaging.consult.com/...
continue warfarin for 3-6mo. /gr1-midi.jpg
– Thrombolytics may be possible if: no surg in <2wks, – Complications- post-phlebotic syndrome = chronic valvular
hemorrhagic stroke. incompetence, cyanosis and edema
– Complications = compartment syndrome during reperfusion • PE-
period do fasciotomy watch for myoglobinuria. – Random signs = right heart strain on EKG, sinus tach, decr
• Claudication- vascular markings on CXR, wedge infarct, ABG w/ low CO2 and
O2.
– Pain in butt, calf thigh upon exertion. – If suspected, give heparin 1st! Then work up w/ V/Q scan, then
– Best test? Ankle-Brachial Index spiral CT. Pulmonary angiography is gold standard.
– Normal- >1 – Tx w/ heparin warfarin overlap. Use thrombolytics if severe but
NOT if s/p surgery or hemorrhagic stroke. Surgical
– Claudication & Ulcers- 0.4-0.8, use medical management thrombectomy if life threatening. IVC filter if contraindications
– Limb ischemia- 0.2-0.4, surgery is indicated to chronic coagulation.
– Gangrene <0.2, may require amputation
 Work up of a Thyroid Nodule Work up of an Adrenal Nodule
• #1- check functional status
• 1st step? Check TSH Diagnosis Features Biochemical Tests
• If low? Do RAIU to find the “hot nodule”. Excise or radioactive I131 Pheochromocytoma High blood pressure, Urine- and plasma-free
• If normal? FNA catechol symptoms metanephrines
Primary aldosteronism High blood pressure, low Plasma aldosterone-to-
• If benign? Leave it alone. K+, low PRA* renin ratio
• If malignant? Surgically excise and check pathology Adrenocortical carcinoma Virilization or feminization Urine 17-ketosteroids
Cushing or "silent" Cushing Cushing symptoms or Overnight 1-mg
• If indeterminate? Re-biopsy or check RAIU syndrome normal examination results dexamethasone test
• If cold? Surgically excise and check pathology • #2- if <5cm and non-function observe w/
– Papillary MC type, spreads via lymph, psammoma bodies CT scans q6mo.
– Follicular Spreads via blood, must surgically excise whole thyroid! If >6cm or functional surgical
– Medullary Assoc w/ MENII (look for pheo, hyperCa). Amyloid/calci excision
– Anaplastic 80% mortality in 1st year.
– Thyroid Lymphoma Hashimoto’s predisposes to it. http://emedicine.medscape.com/article/116587-treatment
Parathyroid Disease Work up of a Breast Mass
• Hypoparathryoidism
• U/S can tell if solid or cystic. MRI is good for eval dense
– Typically comes from thyroidectomy
breast tissue, evaluating nodes and determining
– Sxs are perioral numbness, Chvortek, Trousseau
recurrent cancer.
– ↓*Ca+, ↑*PO4+, ↓*PTH+
– Best imaging for the young breast
• Hyperparathyroidism-
– U/S good for determining fibroadenoma/cysto-sarcoma
– Usually asymptomatic ↑Ca, but can present w/ kidney stones, phyllodes.
abdominal or psychiatric sxs
– ↑*Ca+, ↓*PO4+, ↑vitD, ↑*PTH+ • Aspiration of fluid if cystic, FNA for cells if solid
– Dx w/ FNA of suspicious nodules. Can use Sestamibi scan. – Send fluid for cytology if its bloody or recurs x2
– Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 – Fibrocystic change cysts are painful and change w/
glands and implant 1 in forearm. menses. Fluid is typically green or straw colored.
• MEN- • Restrict caffiene, take vitamin E, wear a supportive bra
– MEN1- pituitary adenoma, parathyroid hyperplasia, pancreatic • Excisional biopsy if palpable or if fluid recurs
islet cell tumor.
• Mammaographically guided multiple core biopsies
– MEN2a- parathryoid hyperplasia, medullary thyroid cancer,
pheochromocytoma
– MEN2b- medullary thyroid cancer, pheochromocytoma,
Marfanoid
 Breast Cancer Skin Cancer
• RF: BRCA1 or 2, person hx of breast cancer, nulliparity, www.pathconsultddx.com/.../gr1-sml.jpg • Basal Cell Carcinoma-
endo/exogenous estrogen. – Shave or punch bx then surgical removal (Mohs)
• DCIS-
• Squamous Cell Carcinoma-
– Either excision w/ clear margins or simple mastectomy if multiple
lesions (no node sampling) + adjuvant RT. – AK is precursor lesion (tx w/ 5FU or excision) or http://emedicine.medscape.com/article/
• LCIS- keratoacanthoma. 276624-media
– More often bilateral. Consider bilateral mastectomy only if +FH, – Excisional bx at edge of lesion, then wide local excision.
hormone sensitive, or prior hx of breast cancer – Can use rads for tough locations.
• Infiltrating ductal/lobular carcinoma- • Melanoma-
– If small and away from nipple, can do lumpectomy w/ ax node – Superficial spreading (best prog, most common)
sampling. Adjuvant RT. Chemo if node +. Tamoxifen or Raloxifen if ER +
– Nodular (poor prog) http://emedicine.medscape.com/article/1
101535-media
– Modified radical mastectomy w/ ax node sampling w/o adjuvant RT
gives same prognosis. – Acrolintiginous (palms, soles, mucous membranes in darker
• Paget’s Dz- complected races).
– Looks like eczema of the nipple. Do mammogram to find the mass. – Lentigo Maligna (head and neck, good prog)
• Inflammatory- – Need full thickness biopsy b/c depth is #1 prog
– Red, hot, swollen breast. Orange peal skin. Nipple retratction. – Tx w/ excision-1cm margin if <1mm thick,
2cm margin if 1-4mm thick, 3cm margin if >4mm
myhealth.ucsd.edu
riversideonline.com
– High dose IFN or IL2 may help
Sarcoma Work up of a Neck Mass
• Soft Tissue Sarcoma- • 7 days = inflammatory, 7 mo = cancer, 7 yrs =
– Painless enlarging mass. (Don’t confuse w/ bruised muscle. congenital
– Dx w/ biopsy (NOT FNA). Excisional if <3cm otherwise – MC is a reactive node, so #1 step is to examine teeth,
incisional. tonsils, etc for inflammatory lesion
– If you find a lesion that’s still there in 2 week FNA it!
– Tx w/ wide, local excision or ampulation + RT.
– If node is firm, rubbery and “B sxs” are present
– Spreads 1st to the lungs (hematogenously) can do excisional bx looking for Lymphoma
wedge resection if only met and primary is under control. • Hodgkins = lymphocyte predom is good prog factor. Reed
Sternberg cells.
• Liposarcoma-
lmp.ualberta.ca
• Non-Hodgkins = nodular and well-dif are good prog factor.
– 99% DON’T come from lipoma • Staging CT, CXR and laparotomy for chemo and XRT treatment
• Fibrosarcoma/Rhabdomyosarcoma/ • If midline thyroglossal duct cyst, move tongue
Lymphangiosarcoma- mass moves. Remove surgically. cssd.us
– Hard round mass on extremity. Can occur in areas of • If anterior to SCM brancial cleft cyst
chronic lymphedema • If spongy, diffuse and lateral to SCM cystic hygroma
(Turners, Down’s, Klinefelters)
 ENT Cancers Pedi-Surg
• Oral Cancer- Baby is born w/ respiratory distress,
– Most freq squamous cell. In smokers & drinkers scaphoid abdomen & this CXR.
– Tx w/ XRT or radical dissection (jaw/neck) Diaphragmatic hernia
• Laryngeal Cancer-
– Laryngeal papilloma in kiddo w/ stridor or cough
• Biggest concern? Pulmonary hypoplasia
– Squamous cell in adults.
emedicine.medscape.com
• Best treatment? If dx prenatally, plan
– Tx w/ laryngoscope laser or resection delivery at @ place w/
• Pleomorphic Adenoma-
atlasgeneticsoncology.org
ECMO. Let lungs mature
– MC salivary glad tumor. Usually on parotid. Benign but recurs 3-4 days then do surg
• Warthlin’s Tumor- Baby is born w/ respiratory
TE- Fistula
– Papillary cystadenoma lymphomatosum. Benign on parotid distress w/ excess drooling.
gland.
• Best diagnostic test? Place feeding tube, take xray, see it
– Can injure facial nerve (look for palsy sxs in ? Stem) coiled in thorax
• Mucoepidermoid Carcinoma-
– MC malignant tumor. Arises from duct. Causes pain and CNVII
palsy
GI disorders Gastroschisis A vomiting baby
• Defect lateral (usually R) of *will see high • 4wk old infant w/ non-
maternal AFP Pyloric Stenosis
the midline, no sac. bileous vomiting and
– Assoc w/ other disorders? Not usually. bms.brown.edu palpable “olive”
– Complications? May be atretic or necrotic req – Metabolic complications? Hypochloremic, metabolic alkalosis
removal. Short gut syndrome
Omphalocele – Tx? Immediate surg referral for myotomy
• Defect in the midline. • 2wk old infant w/ bileous
Intestinal Atresia
Covered by sac. vomiting. The pregnancy Or Annular Pancreas
– Assoc w/ other disorders? Yes bms.brown.edu
was complicated by poly-
hydramnios.
Umbilical Hernia – Assoc w/? Down Syndrome (esp duodenal) Learningradiology.com
• Defect in the midline. No
bowel present. • 1 wk old baby w/ bileous
– Assoc w/ other disorders? Assoc w/ congenital hypo- vomiting, draws up his legs, Malrotation and volvulus
*Ladd’s bands can kink the duodenum
– Treatment? thyroidism. (also big tongue) has abd distension.
images.suite101.com/617141_c
Repair not needed unless persists past age 2 or 3.
om_picture067.jpg
– Pathophys? Doesn’t rotate 270 ccw around SMA
 Pooping Problems Urology
• A 3 day old newborn has Meconium ileus- consider CF if +FH • BPH-
*gastrograffin enema is dx & tx – Anticholinergics meds make it worse foley for acute urinary
still not passed meconium. retention.
Hirschsprung’s- DRE explosion of poo.
– DDX? (name 2) – Medical Tx 1st w/ tamsulosin or finasteride
bx showing no ganglia is gold standard
– Surgical Tx w/ TURP (hyponatremia, retro-ejac)
• A 5 day old former 33
• Prostate Cancer-
weeker develops bloody Necrotizing Enterocolitis – Nodules on DRE or elevated/rising PSA means transrectal
diarrhea ultrasound and bx. Bone scan looks for blastic lesions.
– What do you see on xray? Pneumocystis intestinalis (air in the wall) – Tx w/ surgery, radiation, leuprolide or flutamide.
• Kidney Stones-
– Treatment? NPO, TPN (if nec), antibiotics and resection of necrotic bowel – CT is best test. If stone <5mm, hydrate and let it pass. If >5mm, do
– Risk factors? Premature gut, introduction of feeds, formula. shock wave lithotripsy. Surgical removal if >2cm.
• A 2mo old baby has colicky • Scrotal Mass-
Intussusception – Transilluminate, U/S, excision! (don’t bx). Know hormone markers!
abd pain and current jelly • Testicular Torsion-
*Barium enema is dx and tx
stool w/ a sausage shapend – Acute pain and swelling w/ high riding testis.
mass in the RUQ. – Do STAT doppler U/S will show no flow (contrast w/ epididymitis)
– Can surgically salvage if <6hrs. Do orchiopexy to BOTH testes.
Ortho Transplant
• Avascular Necrosis- img.medscape.com/.../329097-333364-4215.jpg
• Hyperacute Rejection-
– In kids Leg-Calve-Perthe’s dz in 4-5 y/o w/ a painless – Vascular thrombosis w/in minutes
limp and SCFE in a 12-13 y/o w/ knee pain or sickle cell pts – Caused by preformed antibodies
– In adults steroid use, s/p femur fracture. • Acute Rejection-
• Osteosarcoma- – Organ dysfunction (incr GGT or Cr depending on organ)
– Seen in distal femur, proximal tibia w/in 5days – 3mo. Due to T-lymphocytes.
@ metaphysis, around the knee – Technical problems common in Liver 1st check for biliary
– Codman’s triangle and Sunray appearance obstruction w/ U/S then check for thrombosis by Doppler.
– In heart, sxs come late, so check ventricular bx periodically.
• Ewing Sarcoma-
img.medscape.com/.../329097-333364-4215.jpg – Tx w/ steroid bolus and antilymphocyte agent (OKT3)
– Seen at diaphysis of long bones,
night pain, fever & elevated ESR
• Chronic Rejection-
– Lytic bone lesions, “onion skinning”. – Occurs after years. Due to T-lymphocytes.
– Neuroendocrine (small blue) tumor – Can’t treat it. Need re-transplantation.
www.learningradiology.com/.../cow279lg.jpg
 Anesthesia
• Local- (lidocaine, etc) To prevent systemic absorption numb
– Why give with epi? tongue, seizures hypotension, bradycardia,
arrhythmias
– No epi where? Fingers, nose, penis, toes
• Spinal-Subarachnoid- (bupivacaine, etc)
– For ppl who can’t be intubated. Can’t give if incr ICP or hypotensive.
• Epidural- (local + opiod)
– If “high block” blocks heart’s SNS nerves and phrenic nerve.
• General-
– Merperidine: Norperidine metabolite can lower seizure
threshold esp in pts w/ renal failure.
– Succinylcholine: Can cause malignant hyperthermia, hyperK (not
for burn or crush victim)
– Rocuronium, etc: Sometimes allergic rxn in asthmatics
– Halothane, etc: Can cause malignant hyperthermia (dantroline
Na), liver toxicity.