ABX prophylaxis for acute appendicitis for E coli, anaerobes, and B fragilis:
Cefoxitin (Mefoxin), PIP-TZN (Zosyn), cipro/flagyl
Large Bowel Obstruction PE
distension, percuss for tympany and peritonitis, palpate for masses, DRE for masses/blood, fever
LBO Sx
N/V, constipation, abd pain, distention, wt loss, bowel sounds present but rare
LBO preob abx
1 gm Cefoxitin (Mefoxin)
LBO dx
colonoscopy; NPO
obstipation
severe constipation; can't pass any stool or gas
SBO
No peritonitis, no fever, no leukocytosis
SBO Sx
vomiting with feculent material and may relieve the pain; percussive tymphany; hyperactive BS; hx of surgery; BS high pictched (tinkles, gurgles, & rushes)
SBO dx
CT & clysis; operative/surgery
Peritoneal signs
think ischemia or perforation
SBO tx
fluids/electrolyte, NGT placement (decompress the small bowel and stomach); may contin suction as long as there is no peritonitis, fever, and elevated WBC
Which Colon CA is more likely to cause obstruction?
LEFT
(LOC); apple-core appearance on radiograph
What is the most appropriate tx for colon CA?
SURGERY
Where does colon CA most commonly occur?
rectosigmoid colon
Colon Ca dx
COLONOSCOPY, barium enema, occult blood, flexible sigmoid
Diverticulitis Complicated
-Antibiotics
-Bowel Rest
-NGT if vomiting severe
-Drainage of abscess
Diverticulitis sx
LLQ, sudden, subrapubic region
Diverticulitis uncomplicated
-abx
-colonoscopy
-diet/fluids/exercise
If pt presents with diverticulitis for the SECOND time, what should you do?
ASAP Surgical referral
Sigmoid volvulus sx
floppy" colon; institutionalized pts; cut off blood supply; if signs of peritonitis, send straight to OR
Sigmoid volvulus dx
proctoscopy or colonoscopy
LBO on plain film- sigmoid volvulus
coffee bean sign- comma sign; haustra in LUQ
Cecal Volvulus
rotates upward; ileostomy if peritonitis
Hesselbach's Triangle
protrudes onto thigh beneath the inguinal ligament; course lateral to femoral vessels
Indirect Hernia
MC passage of intestines through internal inguinal ring down inguinal canal, most common at right side, may pass into scrotum; hits the tip
Direct Hernia-"put that hernia directly on the floor
passage of intestines through through hesselbach triangle; rarely enters the scrotum; hits the side of the finger on exam
Femoral Hernia
MC in females; develops at the empty space at the medial aspect of femoral canal
Reducible
can be pushed back into abdomen
Incarcerated
cannot be pushed back into abd
Strangulated
incarcerated + suspicion of bowel ischemia or perforation
Obturator Hernia
protrude through obturator canal; elderly females; anteromedial thigh
POLST
Physician's Orders for Life-Sustaining Tx
POSLT forms
refuse CPR, whether the pt would like to be taken to the hospital or not, types of medical interventions (i.e. comfort care, abx, or artificially administered nutrition)
POLST
SET OF MEDICAL ORDERS
; not an advanced directive; for those who anticipate their death within 1 yr; does not allow for active euthanasia or assisted suicide
Living Will
unable to make decisions or choices on their own, terminal illness, permanent unconsciousness; most common instructional directive; less specific directives can be general statements of not wanting life sustaining interventions about terminal care
Susjectivism
individual preference
Concentionalism
cultural approval or majority
Situationalism
situation evaluation
Emotivism
personal emotions
Utilitarianism
whatever is best for the majority
Absolutism
always follows the rules
Graded Absolutism
when rules conflict, choose the lesser evil
Croup
stationary head hits a moving object
Contrecoup
moving head hits a stationary object
Uncal Transtenorial
Most common herniation; temporal lobe is displaced inferiorly through the medial edge of the tentorium; Leads to palsy of the distribution of CN III; Unopposed sympathetic activity; Pupillary dilation;
Lack of pupillary constriction to light; Contralatera
TBI Noncontrast CT Rules
Adults with GSC < 15
Minor Diffuse Brain Injury CT
CT if GCS <14 2 hours post injury or <13 at any point
Complications for Skull Fractures
Vanc + ceftriaxone and tetanus
Epidural Hematoma
middle menigeal artery; bleeding between the skull and dura ; lens like; lucid internal within several min; surgical evacuation and ligation
Cushing Response
bradycardia, high BP, respiratory irregularity- about to have herniation of brain
Mannitol
Osmotic agent that can reduce ICP within 30 min/lasts 6-8 hrs and improve cerebral blood flow, CPP, and brain metabolism; scavenges free radicals; initially can reduce hypotension; give w/fluids
What medications should be d/c or modified b/f surgery-AAHC
antiplatelet agents, anticoagulants, hypoglycemic drugs and corticosteroids
Anticoagulant
-IV heparin = 6 hrs
-LMWH= 12-24 hrs
-Coumadin = 3-5 days
Antiplatelets
-Clopidogrel (plavix) = 3-7 days
-ASA = continue for minor surg; d/c for major for 5-10 days
-NSAIDS = 1-3
Oral hypoglycemics
Intermediate acting insulin
Basal insulin
-d/c 12-72 hrs
-give 1/2-2/3rds of morning dose
-cont or reduce dose
Corticosteroids
increase to stress dose
MAOI
SSRIS
Lithium and antipsychotics
-d/c 10-14 days
-2-3 wks
-Cont
Hold diuretics
if hypoglycemia
Cardiac surgery
-Cefazolin + Vancomycin
-PCN/Cephalosporin allergy: Vancomycin or clindamycin plus Gentamycin.
Orthopedic Surgery
-Cefazolin
-If arthroplastics add Vancomycin. -PCN/Cephalosporin allergy: Vancomycin or Clindamycin.
Colon surgery
- Cefazolin Plus Metronidazole. -PCN/Cephalosporin Allergy: Clindamycin and Gentamycin.
Gynecologic Surgery/Hysterectomy:
-Cefazolin
-PCN/Cephalosporin allergy: Clindamycin and Gentamycin.
When do you d/c abx for cardiac surgery?
48 hrs after anesthesia end time
Adrenal Insufficiency Stress Dose for MAJOR Surgery
chronic steroid use; 100 mg preop, then 50 mg q 8 hs for 2-3 days
Discriminatory Zone
for ectopic preg; serum b-hCG lvls, doubles 48-72 hrs until it reaches 10,000-20,000
1500-1800
transvaginal US
6000-65000
abd US
Esophageal perforation
instrumentation, injection of foreign body, or penetrating trauma
Boerhaave Syndrome
lethal version of Mallory Wise tier
Esophageal perforation Clinical presenstation
epigastric abd pain and shoulder pain, abd tenderness, abd distention, sub q emphysema, dimished breath sounds on side of hydropenumothorax
Esophageal Perforation Dx
CXR than reveal mediastinal emphysema, pleural effusion, hydropneumothorax; esophageal contrast study can confirm location of perforation
Esophageal Perforation Management
exploratory thoracotomy with repair of perforation; pleural space drainage w/ chest tubes postoperatively
EP mortality
> 50% if untreated within 24 hrs
Perforated Viscous
pts with ulcers and diverticulitis
Agitation of psych
GEODON
Organic cause
visual
Psychiatric cause
auditory
Lead-pipe rigidity, slower onset (1-3 days), leukocytosis, elevated CPK, muscle rigidity, fever, autonomic dysfunction, AMS
Neuroleptic Malignant Syndrome- tx with Dantrolene
Axis 1
psych disorders -MDD, schizophrenia, eating disorders, anxiety disorders, sleep or mood disorders, dissociative disorders
Axis 2
personality disorders; mental retardation
Axis 3
medical conditions
Axis 4
environment
Axis 5
global assessment 0-100
Personality disorders
paranoid, schizoid, schizotypal, antisocial, borderline, narcissistic, avoidant, dependent, OCD
MC pathogen involving dog bite
Pasteurella- PNC V or Clinda + FQ
MC pathogen involving cat bite
Pasteurella multocida-PNC V or amphicillin;
if allergic give Doxy or cefuroxime
What abx is most commonly used for therapy and prophylaxis of mammalian bite?
Amoxicillin-clavulanate
Bee sting tx
Epinephrine 0.3 mg 1:1000
Positive vs Negative Inotrophy
contractility
Chronotropy
firing of SA node
Dromotrophy
affects conduction speed in AV node and electrical impulse of the heart
Lustitropy
myocardial relaxant
Which is the MC volvulus?
sigmoid
Elderly; hx of chronic constipation; acute onset of crampy abdominal pain and distention; abdomen is distended and tender to palpation; peritoneal signs of rebound tenderness and involuntary guarding may be present; frank peritonitis and shock may follow
volvulus
distended colon with a "bird's beak
radigraphic findings for volvulus
Sigmoid volvulus tx
reduced by rectal tube, enemas, or proctosopy; operative repair after initial intervention
Cecal Volvulus
OPERATION intervention
Vomiting occurs in early proximal obstruction, with later feculent vomiting with distal obstuction
SBO
Distended loops of small bowel w.
multiple AIR FLUID lvls
Radiographic finding w/ SBO
SBO tx
nasograstric decompression
of stomach to relieve distension; fluids; surgery if ischemia or perforation
LLQ; MC in sigmoid colon; progresses over several days;
Acute Diverticulitis
Leukocytosis, hemoccult + stool, abd radiograms usually NL
Acute Diverticulitis dx
Pericolic fat strands, bowel wall thickening, +/- abscess
CT w/or w/out contrast of Acute Diverticulitis
Acute Diverticulitis tx
PO abx; severe cases require hospitalization and bowel rest and IV abx; if no improvemet within 48 hrs, repeat CT with I & D
Murphy's signs
acute cholecystitis
Acute Cholecystitis
hepatobiliary U/S
GI cocktail
Mallox and lidocaine
AAA subtypes
Saccular: portion of artery forms an out-pouching
Fusiform: entire arterial diameter grows
Pseudo: involvement of one or two arterial wall layers
True: involvement of all arterial wall layers (intima, media, adventitia)
AAA dilation
>1.5 x normal size of artery
Branches of abd aorta
celiac trunk, SMA, IMA, renal arteries, and gonadal arteries
Most AAA occur where?
distal to RENAL arteries
MCC cause of AAA?
atherosclerosis
AAA dx
CT w/ contrast
back pain, pulsatile abd mass,
AAA
postprandial pain
mesenteric ischemia
SMA supplies
cecum, ascending colon, and proximal to mid-transverse colon
IMA
the rest to rectum
Mesenteric Ischemia Radiograph
thumb-printing
Mesenteric Ischemia tx
emergent laparotomy
Visceral Pain
stretch receptors; unmyelinated fibers; precede from midline
Somatic Pain
pain receptors in parietal peritoneum; myelinated afferent fivers
Visceral pain signs
skin pallor, diaphroesis
ABx
gram -, anaerobes, FQ and metro
pneumoperitoneum
air in abd cavity or from gas gangrene
Extravaginal torsion
gubernaculum if free to rotate in scrotum, infants
Intravaginal torsion
bell clapper
Appendix testes
mullerian duct; blue dot
Testicular Torsion
pain decreases as necrosis advances; NEG Prehn sign and absent cremaster reflex
Prehn sign
elevates testes and pain goes away
Dermoid cyst
most commonly causes ovarian torsion
ovarian torsion dx
U/S color flow doppler
ovarian torsion tx
laparoscopy for detorsion +/- salpingo-oophorectomy
Ectopic Pregnancy Risk Factor
progesterone-only OCP
Ectopic Preg Triad
abd pain, amenorrhea, vaginal bleeding
Ectopic Preg dx
empty uterus; + HCG
Ectopic Preg tx
laparoscopy or methotrexate
MC place for ectopic preg
cornual/
interstitial
-requires surgical excisions
PID
chlamydia trachomatis; fever
PID dx/tx
laparoscopy; empiric abx for females currently sexually active and presents with lower abd/pelvic pain
TOA
abscess; I&D