*Prevention of Pulmonary Complications of Flail Chest – Intercostal nerve block, epidural analgesia, Pulmonary Toilet

*Dx Adrenal Mass/Hypokalemia – Likely Conn Syndrome (primary hyperaldosteronism), will have elevated serum Na and urinary K, low serum K, aldosterone/renin ratio greater than 400, low renin activity, high plasma aldosterone, high urine aldosterone after sodium challenge, can localize with MRI, scintography or venous sampling

*Rx Adrenal Insufficiency – IV hydrocortisone, Fluids, ACTH stimulation test, include a mineralocorticoid (Florinef)

*Extra Adrenal Sites of Pheo – Organ of Zuckerandl, near aortic bifurcation, retroperitoneum, vertebral bodies, bladder, opposite adrenal gland, neck, mediastinum

*Rx Pelvic Fracture – Place sheet, external fixator or C-clamp and then go to angio for embolization, if see hematoma after blunt injury in OR, leave it alone, pack, and get patient to angio, if has colon injury with fracture will need colostomy, if greater than 3 cm diastasis of symphysis pubis, need anterior fixator/plating, if sacroiliac joint is displaced, treat with posterior internal fixation with plates, treat sacral/coccygeal fractures conservatively

Definition of O2 Delivery – Cardiac Output X Oxygen Content(Hb x1.34x%O2sat+(PO2x0.003))

Wedge Affected By – Pulmonary HTN, Aortic Regurgitation, MS/MR, High PEEP, LV compliance

O2 Consumption – CO X (Ca02 – Cv02), normal delivery to consumption ratio is 5:1, CO increases to keep the ration constant

*O2 Extraction ratio – (Ca02 – Cv02)/Ca02

*Early Gram Negative Sepsis – Decreased insulin, increased glucose due to impaired utilization

*Anat Right Renal Artery – Goes posterior to IVC

Ventilator Choice in Bronchopleural Fistula – High-frequency jet ventilation

*Most Potent Stimulator of SIRS – Endotoxin Lipopolysaccharide A

*Rx ARDS – Low tidal volumes (6cc/kg), high PEEP (up to 22), permissive hypercapnea (RR less than 35), plateau airway pressure less than 30, FI02 less than 0.5,

*Characteristics of ARDS – Diffuse alveolar damage and increased capillary permeability: 1.Diffuse bilateral infiltrates on CXR, 2.Pa02/FI02 less than 200 3. Wedge less than 18

*V/Q Abnormalities – 1. Shunts (lung perfused, but not ventilated) – Pneumonia/Atelectasis - O2 sat doesn’t increase with 100% O2, 2. Dead Space (lung ventilated, but not perfused) – PHTN, Low CO, PE, high PEEP

*Dx Post-Op Oliguria – Most common cause is hypotension causing ATN, Check FeNa (less than 1), UOsm (greater than 500), UNa (less than 20), BUN/Cr (greater than 20) in pre-renal failure, check ultrasound/foley for post-renal obstruction

*Criteria Brain Death Cerebral GSW – Precluding diagnosis: uremia, temp less than 30, BP less than 70/40, desat with apnea test, drugs (pentobarb, phenobarb), metabolic derangements.

Must have for 6-12 hours (2 separate exams): unresponsive to pain, absent caloric oculovestibular reflexes, oculocephalic reflex, positive apnea test (CO2 increases by 20 or is greater than 60 when disconnected from vent), no corneal reflex, no gag reflex, fixed and dilated pupils. EEG – electrical silence, MRA – no blood flow to brain

*Rx Ventilatory Complication Burn – Perform escharatomy if burns on chest/torso with difficulty ventilating

*Adverse Reaction Silver Sulfadiazene – neutropenia and thrombocytopenia, inhibition of epithelization

Adverse Reaction Silver Nitrate – hyponatremia, hypokalemia, hypocalcemia, hypochloremia and methemoglobinemia in G6PDH deficiency

*Adverse Reaction Sulfamylon – metabolic acidosis

Risk with Claudication – 1% per year of amputation, 2% per year of gangrene

Mimic Claudication – Lumbar Stenosis

*Dx Test Claudication – Rule out neurogenic causes of pain by ordering lumbosacral spine films, EMG, MRI or CT

To diagnose vascular claudication perform ABI/PVR or segmental systolic pressures after walking on treadmill. If has claudication due to vascular disease, the SBP difference will be less than 20 between the brachial and femoral. Gold standard is angiography.

ABI inaccurate in – Diabetics, they have calcified, incompressible vessels. Use Doppler waveforms

Edema Following Lower Extremity Bypass – Check ultrasound for DVT first, then second most common cause is reperfusion injury

*Rx Embolus L Femoral Artery – Heparinization, Open Embolectomy through groin incision, then angiogram. If greater than 4 to 6 hours, perform fasciotomy.

*Technique Fem-Peroneal Graft Surveillance – Color Flow Duplex Ultrasound

Nerve most commonly injured following fasciotomy – Superficial peroneal nerve

*Rx Preop Phimosis – Dorsal Slit

*Most Common Metastasis to SB – Melanoma

*Treatment of Basal Cell Carcinoma – Excision with 0.3 to 0.5 cm margin, XRT if mets, neuro, lymphatic or vascular invasion

*Characteristics of Keloids – Collagen outside of scar, in dark skinned people, treat with steroids, silicone, pressure garments

*Anatomy of Phrenic Nerve – On Anterior Scalene Muscle

*Mircoadenoma in Pituitary – Most commonly is prolactinoma, treat with bromocriptine, if fails medical therapy perform transphenoidal resection, if growth hormone adenoma, treat with resection

Tunnel Vision (Bitemporal Hemianopsia) – Pituitary tumor compressing optic chiasm

*Likely Complication Sella Turcica Fracture – Panhypopituitarism – will have troubling lactating (first sign), amenorrhea, adrenal insufficiency, and hypothyroidism, can also have cranial nerve injuries, CSF rhinorrhea

*Pulsatile, bleeding mass after CEA – Dx: Pseudoaneurysm – prep and drape first, then intubate and repair with bypass of carotid

*Etiology oliguria post AAA repair – Hypoperfusion of kidneys, other less common causes are contrast administration and atheroembolism

*Rx Effort Thrombosis Pitcher – Subclavian vein is thrombosed, start with thrombolytics via catheter, followed by heparin then Warfarin, will likely need first rib resection for thoracic outlet syndrome

*Dx Effort Thrombosis Subclavian Vein – Gold standard is venography

*Femoral Pseudoaneurysm – If small may be observed for resolution in 2-4 weeks, otherwise treat with ultrasound guided compression or with thrombin injection initially, if flow remains or at suture site – repair in OR

*Rx Chylous Ascites PO AAA Repair – NPO and TPN is initial treatment, if does not resolve can ligate thoracic duct

*Signs Primary Hyperparathyroidism – Fatigue, weakness, memory loss, renal stones, bone pain, abdominal pain, psychiatric symptoms, can have neck mass, band keratopathy, and fibro-osseous jaw tumors

Elevated Calcium, low Phosphorous, Chloride to Phosphorous ratio greater than 33, hyperchloremic metabolic acidosis, bicarbonate in urine, elevated renal cAMP, can have osteitis fibrosis cystica – bone lesions from hyperPTH

*Hyperthyroidism in Pregnancy – PTU initially, propanolol may help, if the pregnant patient is not controlled with medical therapy – do subtotal thyroidectomy in 2nd trimester

*Tx Medullary Thyroid Carcinoma – Total thyroidectomy with central node dissection, if has clinically positive nodes do ipsilateral MRND, if both thyroid lobes have cancer do b/l MRND if clinically positive nodes, do prophylactic thyroidectomy and central node dissection if child with MEN at age 2

*Tx Parathyroid Cancer – Radical parathyroidectomy and resect ipsilateral thyroid lobe, recurrence rate is 50%

*Tertiary Parathyroidism – After renal transplant, treat with resecting 3 ½ glands or total parathyroidectomy and reimplant in forearm

* Person with LCIS develops Breast Ca – Most commonly will be Ductal Carcinoma

Most Common Cause Nipple Discharge – Spontaenous discharge from a single duct is intraductal papilloma, bloody discharge is most commonly intraductal papilloma, Green discharge is most commonly fibrocystic disease

*Etiology Unilateral Breast Enlargement Man – In adolescence due to excess of estradiol compared to testosterone, In adults, Gynecomastia possibly associated with hepatic cirrhosis, hypo or hyperthyroidism, estrogen secreting testicular tumors, renal failure, or malnutrition. Digoxin, Thiazides, Estrogens, Theophylline or phenothiazines may exacerbate gynecomastia

*Rx Breast Mass Post NeoAdj Chemoradiation – Mastectomy, radiation and additional chemotherapy

BRCA 1 – Ovarian Ca (50%) and endometrial Ca, treat with TAH/BSO and mastectomy if family hx

BRCA2 – Associated with male Breast Ca

*Pleural Fluid – 1-2L per day, produced by parietal pleural and resorbed by lymphatics in visceral pleura

Site of Lung Abscess – Posterior portion of RUL, superior portion of RLL

*Best Long Term Graft Patency for CABG – LIMA

*Blood Supply Cervical Esophagus – Inferior Thyroid Artery

*Treatment of Zenker’s Diverticulum – Cricopharyngeal myotomy, don’t necessarily need to resect diverticulum

Tx Achalasia – Calcium Channel Blockers first, dilation may help, if failure of medical therapy perform Heller Myotomy via left thoracotomy, transect circular muscle layer of lower esophagus and then perform partial 180 degree Nissen

*Dx/Rx Antithrombin III Deficiency – Associated with recurrent thrombosis and pulmonary embolism, found in patients who are resistant to heparin therapy that do not show an increase in PTT, treatment is FFP or ATIII concentrate, then Heparin, then Coumadin

*Type II Hiatal Hernia – Paraesophageal Hernia, all need surgical repair due to incarceration risk, perform NIssen as well

*Rx Perforation of Esophagus – Left Thoracotomy, longitudinal myotomy to see extent of injury, primary repair with buttressing with healthy tissue, place chest tubes, if greater than 24 hours – debride tissue, create esophagostomy, wide drainage, and placement of G tube

Indication Gastric Bypass – BMI greater than 40, BMI greater than 35 with comorbidities, psychologically stable, no substance dependence, failure of non-surgical methods of weight reduction

*Rx GIST – AKA Gastric leiomyoma, seen as hypoechoic on ultrasound with smooth edges, gastric wedge resection with 1cm margins, no lymph node dissection, chemotherapy if greater than 5cm or 5-10 mitoses per HPF, chemo is Gleevac if unresectable and metastatic

*Gastric Cancer Risk Factors – Adenomatous polyps, chronic atrophic gastritis, type A blood type, intestinal metaplasia, nitrosamines, tobacco, previous gastric surgery, pernicious anemia, hyperplastic polyps

*MALT Treatment – Triple antibiotics for H. Pylori, if does not cure, then treat with surgery,chemotherapy (CHOP), and radiation

*Right Hepatic Artery Variation – Most commonly off of SMA

*Rx Varices Assoc Splenic Vein Thrombosis – Splenectomy

*Characteristics of Lithogenic Bile (Stone Forming) – Supersaturated with cholesterol, low amount of bile acids and lecithin, in obese patients often due to overactive HMG CoA reductase, in thin people due to 7 alpha hydroxylase, pigmented stones due to precipitation of calcium bilirubinate and unconjugated bilirubin

*Characteristics Focal Nodular Hyperplasia Liver – Central stellate scar in liver looks like cancer, however FNH is benign, Uptakes Sulfer Colloid on liver scan (hot nodule), MRI/CT shows hypervascular tumor, treatment is conservative

*Hepatic Adenoma – Women, OCPs, steroids and Type I Collagen Vascular Disease risk factors, 10-20% risk of rupture, does NOT uptake Sulfer Colloid on liver scan (cold nodule), CT shows hypervascular tumor, commonly in right lobe, can become malignant, if asymptomatic stop OCPs and observe, if symptomatic do resection or emoblize if multiple

Amebic Liver Abscess – Commonly in right lobe from amebic colitis and seeding through portal vein, due to E Histolytica, treat with Flagyl, aspiration if refractory, may see anchovy paste in aspirate

*Pyogenic Liver Abscess – Most common abscess, most common organism is E Coli, often due to contiguous infection from biliary tract, treat with CT guided drainage and antibiotics, only drain surgically if patient is unstable or septic

Echinococus Liver Abscess – Sheep are carriers, transmitted by dog bites, positive Casoni skin test and positive indirect hemagglutination, CT shows ecto and endocyst with calcifications, treat with albendazole and then surgical removal of cyst wall, can inject alcohol to kill organisms, DO NOT ASPIRATE FIRST, can cause anaphylactic shock

*Etiology Shock Post Op Lap Chole – In first 24 hours due to hemorrhagic shock from clip that fell off cystic artery, after 24 hours from septic shock on clip on CBD with cholangitis, diagnose with RUQ U/S to look for collection, then HIDA to look for leak

*Rx Laparoscopic Injury CBD – Place T tube and transfer to tertiary center, if performing repair and less than 50% of circumference perform primary repair, in other cases will need choledocho/hepaticojejunostomy

*Rx Adenoca Gallbladder – If confined to mucosa (Stage 1) only need cholecystectomy, if into muscular layer (Stage Ib) need cholecystectomy, wedge resection of liver and lymphadenectomy of hepatoduodenal ligament/portal triad, if IIa/IIb( through serosa or into liver), needs hepatic 4b and 5 segmentectomy, Stage 3 (into hepatic artery, portal vein) or Stage 4 (distant mets) are unresectable

*Volume-Outcome Pancreatic Cancer – 3-5x higher mortality at low volume centers (less than 5) when compared to centers doing more than 20 per year

Insulinoma – Occurs throughout pancreas, 85-95% benign, if <2cm – enucleate, if >2cm resection, if metastatic to liver treat with octreotide, 5-FU, streptozicin, presents with Whipple’s triad (FS<50, symptoms of hypoglycemia and relief with glucose)

Gastrinoma – Most common pancreatic tumor in MEN I, occurs in gastrinoma triangle (CBD, 3rd portion of duodenum, head of pancreas), diagnosis is gastrin greater than 200 can be greater than 1000, secretin stimulation test causes increase of gastrin, best localization is somatostatin scintography, can also do CT or MRI, if can’t find gastrinoma open duodenum to look for microgastrinomas, if <2cm – enucleate, if >2cm resection, if unresectable do vagotomy and pyloroplasty

Somatostatinoma – In head of pancreas, diagnose with elevated somatostatin level, presents with diabetes, steatorrhea, weight loss, gallstones, do cholecystectomy with resection

*VIPoma – In distal pancreas, presents with achlorhydria, hypokalemia, watery diarrhea, diagnosed with elevated VIP level, treat with distal pancreatectomy, 10% in retroperitoneum or thorax

*Glucagonoma – Most in distal pancreas, glucagon level greater than 500, presents with diabetes, stomatitis, necrolytic migratory erythema (treat with parenteral amino acids), weight loss, treat with distal pancreatectomy, octreotide if unresectable or has recurrence

*Characterstics Puetz-Jeghers Syndrome – Autosomal Dominant, ileal and jejunal hamartomas most frequent sites, 50% with colorectal polys, 25% with gastric polyps, melanotic mucocutaneous pigmentation, increased risk of colon cancer in patients with polyps, neurogenic cancers, hemangiomas, lipomas, 2% risk duodenal cancers, increased risk of biliary, breast, and gonadal cancers

*Fuel Source Colonocyte – Short Chain Fatty Acids (Butyrate)

*Rx Occult Blood in Feces - Colonoscopy

*Etiology Death Familial Adenomatous Polyposis – Metastatic colon cancer but if resected already, periampullary tumors of duodenum

*FAP – Autosomal dominant, Multiple polyps, need total proctocolectomy with ileoanal J pouch by age 20, get duodenal polys, need EGD every 2 years, associated with Gardner’s Syndrome (sarcomas, osteomas) and Turcot’s Syndrome (brain tumors)

*Rx Hematochezia Unknown Source – If unstable, needs subtotal colectomy if no bleeding source identified

HNPCC – Right sided colon cancers, metachronous lesions, surveillance by age 25 or 10 years before first familial cancer, Lynch I – only colorectal ca, Lynch II – ovarian, breast, bladder, stomach cancers, perform subtotal colectomy with first operation

*Risk Factors Ovarian Cancer – Early menarche, late menopause, lack of OCP use, late first pregnancy (after 30), late first breast feeding (after 30), nulliparity, perineal talc use, personal or family history of colon, ovarian or endometrial cancer, age, diet, geography

*Risk Factor Endometrial Cancer – Obesity, nulliparity, tamoxifen, unopposed estrogen, late first pregnancy, early menarche, diabetes, HTN, late menopause

*Rx Squamous Cell Cancer Penis – Penectomy with 2 cm margin, may have reactive lymph nodes that need to be treated with antibiotics. If has adenopathy on CT, needs lymph node dissection. If palpable inguinal LAD, needs dissection. If has pelvic mets, needs chemo

*Rx Fracture Distal Femur – If minimally displaced can be treated with knee immobilizer or long leg cast. Delayed weightbearing. If displaced or has articular involvement, use IM nail or condylar plates

*Etiology Wrist Drop Associated Upper Extremity Fracture – Radial nerve injury along proximal humerus

*Nerve Injury Associated Fibulectomy – Peroneal Nerve

*Indication Preop Nutrition Gastric AdenoCa – History of weight loss greater than 15% albumin less than 3 makes higher risk for complications. Preop nutrition for 7-10 days decreases septic complications. Randomized controlled trials have shown benefit of IV nutrition in severely malnourished patients with upper GI tumors

*Rx Nerve Injury Lap Inguinal Hernia Repair – If neuralgia in RR, need prompt re-exploration, otherwise reassurance, NSAIDS and nerve blocks help.

*Rx Seroma PO Ventral Hernia Repair – Serial aspiration under sterile technique, if persistent open the incision and pack with saline gauze

*Achievement Anticoagulation Antithrombin III – Neutralizes factor IXa, Xa, Xia and eventually inhibits thrombin, heparin causes conformational change in ATIII and accelerates inhibitory reaction

*Drugs Affecting Warfarin Metabolism – Barbiturates, rifampin and dilantin increase clearance of warfarin by activating hepatic enzymes. Flagyl, Allopurinol, cimetadine, amiodarone, phenylbutazone, sulfinpyrazone, disulfiram and alcohol increase response of warfarin (bleeding)

*Conditions Associated with Normal INR/Abnormal PTT – Heparin therapy, Lupus Anticoagulant, Hemophilia A/B

*Etiology Obscured Clinical Difference – Type 1 error (falsely reject null hypothesis) – use p<0.05 to prevent this, means less than 5% chance of difference being random, Type 2 error(accepts null hypothesis when in fact it is false) is due to a small sample size

*Ethics and Physician Error – Physician has ethical duty to admit mistakes to patient, if complication resulted from mistake, physician is ethically required to inform patient of what occurred

*Etiology Pneumoperitoneum HIV Pt – Terminal ileum and colon are most common sites for perforation due to CMV, diagnosis of CMV is made by seeing intranuclear inclusion bodies on biopsy, suture plicate gastroduodenal perforations, perform SBR if SB involved and colostomy for colonic perforation, perforation is an ischemic lesion as CMV affects arterioles of GI tract

*Treatment of Malignant Hyperthermia – stop inhalation agent, dantrolene, 100% oxygen, cooling blanket, cold IV, correct acidosis and hyperkalemia

*Characteristics of Blood Circulation – Fetal circulation has 2 umbilical arteries which are branches of iliac arteries and 1 umbilical vein which drains to ductus venosus

*Characteristics of AIDS-related Lymphoma – B-cell lymphoma, usually poorly differentiated and aggressive, managed with chemotherapy, surgery only for GI bleeding, obstruction, or perforation

*Antibiotic Treatment of Human Bite Wound – Cefoxitin or cefotetan with a penicillin to cover Eikenella corrodens, continue for 24 to 48 hours

*Characteristics Epidural Anesthesia – Anesthesia (epinephrine/lidocaine) injected into lumbar or thoracic epidural space. Shown to decrease blood loss, risk of DVT, better pain control, earlier ambulation, earlier return of bowel function, and superior pulmonary function. Risk is spinal hematoma, epidural abscess, hypotension, headache, urinary retention.

*Etiology of Hypokalemia in Gastric Outlet Obstruction – Due to vomiting of material with potassium and hydrogen, potassium is then excreted in urine for exchange of sodium lost in vomitus

*Metabolism of Cancer Cells – Catabolize glucose at a high rate due to hexokinase that is bound on the outer mitochondrial membrane, cancer cells are able to maintain increased rates of glucose utilization and high rates of glycolysis under aerobic conditions

*Metabolic Acidosis after Kidney/Pancreas Transplant – Due to excessive urinary loss of bicarbonate containing exocrine fluids from the pancreas transplant

Most common congenital hypercoagulable disorder – Factor V Leiden

*Treatment of Intra-Operative Bleeding with ESRD – DDAVP, cryoprecipitate, estrogens

*Treatment of HIT – Argatroban or Hirudin

Hemophilia A – need Factor VIII levels 100% preop and 30% postop, treat with Factor VIII or cryo

*Most common bacteria in colon – Bacteroides vulgatus

*Surgical infection within 48 hours – Clostridium or Beta-hemolytic strep

Gentamicin peak too high – Decrease dose

Gentamicin trough too high – Decrease interval of dose

*Intubated patient with sudden drop in ETC02 – With decreased mixed venous CO2 in venous air embolism, with increased mixed venous CO2 can be CHF, MI, PTX, PE, atelectasis, hypotension

Glycogen Stores – Depleted after 24-36 hours of starvation, body then switches to fat

*P53 – on Chromosome 17, involved in cell cycle arrest and apoptosis, abnormal gene allows unrestrained growth

Cyclosporin – Binds cyclophilin protein and inhibits cytokine synthesis, side effect is nephrotoxicity, hepatotoxicity, HUS, tremors, seizures, metabolized in liver and excreted through bile

*Lamivudine – Used in post-op liver transplant patients to treat Hep B recurrence

*Macrophages – Essential for wound healing