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Absite : the nitty , gritty stuff part 1

Absite : the nitty , gritty stuff part 1. 1/11/08. Contraindications to succinylcholine. Burns Quadraplegia Atypical plasma cholinesterase Malignant hyperthermia Glaucoma Head trauma (increases ICP). Mafenide acetate ? Metabolic disturbance. Metabolic acidosis

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Absite : the nitty , gritty stuff part 1

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  1. Absite:the nitty, gritty stuffpart 1 1/11/08

  2. Contraindications to succinylcholine • Burns • Quadraplegia • Atypical plasma cholinesterase • Malignant hyperthermia • Glaucoma • Head trauma (increases ICP)

  3. Mafenide acetate? Metabolic disturbance • Metabolic acidosis • Inhibits carbonic anhydrase • Penetrates eschar wall • Painful

  4. Drug toxicities • Vincristine/vinblastine • Peripheral neuropathy • Blocks microtubule • Bleomycin • Pulmonary fibrosis • Cyclophosphamide • Hemorrhagic cystitis2

  5. Drug toxicities • Doxtrubicin • Cardiac toxicity • Echo

  6. Mechanism of action • PCN • Inhibits bacterial wall synthesis • Aminoglycosides • Inhibits ribosome 30S • Flagyl • Interrupts DNA transcription

  7. Mechanism of action • Fluconazole • Interferes with formation of membrane sterols  cell lysis • Quinolones • Inhibits DNA gyrase • Digoxin • Blocks Na/K ATPase  increased intracellular Ca  increased contractility

  8. Mechanism of action • Misoprostol • PGE1 agonist (cytoprotective) • Finasteride (proscar) • 5a reductase inhibitor

  9. Inflammatory breast cancer • Full thickness skin bx • Dermal lymphatic invasion • Stage? • Stage 3 • Treatment: • 1st: chemo • 2nd: resection

  10. Nipple discharge • Most common cause of bloody nipple discharge • Benign intraductal papilloma • Pathologic nipple discharge • Unilateral • Spontaneous • Bloody/yellow/green/clear • Associated with palpable mass

  11. Nipple discharge • Physiologic nipple discharge • Both breasts • Clear/milky color • Multiple ducts • Not spontaneously • Negative for occult blood • Contains proteinaceous material

  12. Cardiac tumors • #1 benign primary heart tumor • Myxoma • #1 primary malignant heart tumor • Sarcoma

  13. Penetrating cardiac injury • Stab wound • Right ventricle (most anterior) • GSW • Left ventricle

  14. Penetrating cardiac injury • Tamponade? • Beck’s triad: distended neck veins, muffled heart sounds, hypotension • Treatment: • Pericardiocentesis • Subxiphoid window (gold standard)

  15. Valve lesionswhen to operate • Mitral valve stenosis • Valve area < 1.5cm2 • Pressure gradient > 15mmHg • Pressure gradient = LAP-LVED • Aortic valve stenosis • Valve area < 1cm2 • Pressure gradient > 50 mmHg

  16. Hemoglobin:oxygen dissociation curve • If your SaO2=92%, what is your PaO2? • 60 • Shift curve to the right • Easier or harder to off load O2 to tissues: • Easier • Increased 2,3DPG • Increased temp • Increased CO2 • Acidosis

  17. Hemoglobin:oxygen dissociation curve • Shift curve to the left • Easier or harder to off load O2 to tissues: • Harder • Decreased 2,3DPG • Decreased temp • Decreased CO2 • Alkalosis

  18. Lung volumes • Relationship of PEEP & FRC • PEEP increases FRC • Relationship of PEEP & aldosterone • PEEP increases aldosterone

  19. Lung volumes • 3 capacities • Total lung capacity • Vital capacity • Functional residual capacity • 4 volumes • Residual volume • Tidal volume • Inspiratory residual volume • Expiratory residual volume

  20. Lung volumes

  21. Hiatal hernia • 3 types • Type 1: sliding • Type 2: paraesophageal • Type 3: components of both 1 & 2

  22. Hiatal hernia • Type 1: sliding • GE junction is in the chest • Do you operate? • No! Treat for GERD

  23. Hiatal hernia • Type 2: paraesophageal • GE junction is in the abdomen • Operate: risk of incarceration/strangulation • Treatment • Via abdomen, reduce stomach, excise hernia sac • Close diaphragmatic defect • Anchor stomach to abdoment to prevent recurrence (Nissen, G-tube)

  24. Hiatal hernia • Type 3: paraesophageal with esophageal shortening • GE junction is in the chest • Treatment • Nissen via left chest

  25. Gi absorption • Iron • Duodenum • B12 • Ileum • Zinc • Ileum • Vit C • Ileum

  26. Gastrin releasestimulated by? • Stomach distention • Peptides • Calcium • Vagal input • Alkaline

  27. Gastrin releaseinhibited by? • Low pH • Somatostatin • Secretin • Exception? • Zollinger ellison syndrome  paradoxical increase in gastrin release

  28. secretin • What cells, where? • S cells, duodenum • What does it stimulate? • Pancreatic HCO3 secretion (low Cl) • Increase or decrease bile flow? • Increase, synergistic effect with CCK

  29. Small bowel tumors • Most common malignant tumor • Adenocarcinoma • Most common location/least common location • Duodenum/ileum • Most common benign tumor • leiomyoma

  30. Small bowel tumors • Most common location lymphoma • Ileum

  31. Polypectomy vs. colorectal surgery • Sessile polyp with invasive carcinoma • Segmental resection • Carcinoma in neck of the polyp • Polypectomy

  32. Polypectomy vs. colorectal surgery • Unfavorable factors to endoscopic excision (NEED SURGERY) • Inadequate margin (need 3-5mm) • Poor histological differentiation • Lymphovascular invasion

  33. Genetic mutations • HNPCC (Lynch syndromes) • hMSH2 (mismatch repair) • Hereditary spherocytosis • Spectrin – membrane skeletal protein • Treatment - splenectomy

  34. Appendectomy anyone? • <2cm carcinoid at tip of appendix • Appendectomy • <2cm carcinoid at base of appendix • Right hemicolectomy • >2cm carcinoid at tip of appendix • Right hemicolectomy

  35. Appendectomy anyone? • Creeping fat terminal ileum near base of appendix • No appendectomy

  36. Pancreatic function • How much pancreas do you need to lose to see steatorrhea, diabetes? • 90%

  37. Focal nodular hyperplasia (liver) • Characteristics on CT? • Stellate scar • Sulfur colloid scan? • Diagnostic, kupffer cells • Malignant potential? • Rare

  38. Hepatic adenoma • Potential for rupture? • Yes • Increased risk with OCPs? • Yes • Malignant potential? • Yes

  39. Hepatic abscess • Most common cause? • Cholangitis • Appendicitis • Diverticulitis • Treatment? • Drainage • Abx: polymicrobial

  40. Hepatic abscess • Amebic abscess • Diagnosis? • Indirect hemagglutination assay • Treatment? • Flagyl • Echinococcal cyst • Defining characteristics on ultrasound? • Daughter cysts • Treatment? • Mebendazole

  41. Treatment thyroid stormmechanism of action • Lugol’s solution • Blocks release of thyroxin • PTU • Blocks synthesis of thyroxin • Steroids • Blocks conversion of thyroxin to active form • B-blockers • Acts on receptors

  42. Whda????? • Patient presents with dehydration & diarrhea • Watery diarrhea, hypokalemia, achlorhydria • What type of endocrine pancreatic tumor? • VIPoma • Benign or malignant? • Malignant

  43. Name the congenital anomaly !!!! • Intra-uterine rupture of umbilical cord • Gastrochisis • Peritoneal sac? • No • Relationship to umbilicus • To the right

  44. Name the congenital anomaly !!!! • Failure to fuse abdominal wall folds • Omphalocele • Peritoneal sac? • Yes • Relationship to umbilicus • At the umbilicus • Associated with what congenital anomalies? • GI, GU, CV, neurologic

  45. Name the congenital anomaly !!!! • Called to the NICU…. Baby is cyanotic, but pink when crying • Choanal atresia

  46. Fractures & nerve injury • Humeral shaft fx • Radial nerve • Distal humeral fx • Radial nerve • Proximal humeral fx • Axillary nerve

  47. Fractures & other injuries • Knee dislocation • Popliteal artery • Supracondylar fx of humerus • Brachial artery  volkmann’s ischemic contracture • Ischemic injury to muscles & nerves  scar tissue & fibrosis  shortening of involved muscle, flexion deformity of wrist & fingers

  48. Bone tumors • Most common primary benign tumor • Nonossifying fibroma • Most common primary malignant tumor • Adults? • Multiple myeloma • Kids? • Osteosarcoma (#1), Ewing’s sarcoma (#2)

  49. Bone tumors & radiological findings • Osteosarcoma? • Sunburst • Ewing’s sarcoma? • Onion skin • Multiple myeloma? • Punched out

  50. reflexes • L4 • Knee jerk • L5 • 1st toe dorsiflexion • S1 • Plantar flexion (ankle jerk)

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