Rectus sheath Hematoma: anticoagulation

Acute onset periumbilical pain w palpable abdo mass/fullness +/- rebound/guarding

Tenderness may worsen with abdo contraction eg cough

Management: Stable: reverse anticoagulation

Unstable: Angiography w embolisation; surgical ligation

Duodenal Hematoma/Traumatic pancreatitis

Severe epigastric tenderness, n/v, hypotension and tachy

Decreased bowel sounds

Norm abdo US and LFTs

Dx: CT Abdo

Burns Victims

Lactated Ringer solution preferred over normal saline

LR balanced as has near physiologic levels of Cl, K, Ca etc -> maintains blood pH

Normal saline is unbalanced as has high Cl ——>> hyperchloraemic metabolic acidosis

Laparoscopic Intervention ——> AV block, bradycardia and sometimes asystole

Prep involves CO2 suffocation to create space

—->>> peritoneal stretch receptors sense increase in intraabdo P ——> increase vagal tone

Septal hematoma

Soft, fluctuant mass

Risk of avascular necrosis of nasal septum —->>>> incision and drainage

——>> ant nasal packing after to compress perichondrium

Barotrauma of Ear

URTI can cause functional dysfunction of Eustacian tube

—->> stretching of TM: Ear pain and hearing loss

Complication: Rupture of TM: pain relieved but minor bleeding and persistent hearing loss

—> heal spontaneously in a few wks

Human Bite Wound: Polymicrobial

Tx: AmoxiClav

Hypovolaemic Shock

Mechanical ventilation (PEEP)—->> increases intrathoracic P —->> Cuts off venous return

—> Acute resp failure and cardiac arrest!

Hepatojugular Reflex

DDX between cardiac (+) and liver disease in pts with lower extremity oedema

Cardiac cause: JVP elevation and hepatojugular reflex

Hepatic cause: norm/low JVP and no reflex

Blunt abdo trauma:

Duodenal tear: Retroperitoneal free air

Renal/pancreatic injury: retroperitoneal Free fluid

Stomach and transverse colon susceptible but intraperitoneal

Oesophageal perforation

Etiology: Instrumentation (endoscopy; TEE); Effort (Boerhaave); Esophagitis

Chest/back/epigastric pain w Crepitus

Pleural effusion with atypical (green; amylase) fluid

Widened mediastinum; pneumothorax and pleural effusion

Dx: Esophagography with water soluble contrast —> leak from perforation

Barium more sensitive but can cause Granulomatous inflamm response

Management: NPO, IV Abs and PPIs; Emergent surgical consult

Rhinoplasty

Nasal septal perforation (d/t hematoma/abscess): Whistling noise during respiration

Postoperative Fever -> Mediated by pyretic cytokines; >38 C

Immediate: 0-6 hrs

D/t tissue damage; fever and leukocytosis last < 3dys; Tx symptomatic

Others: Blood products (hypotension); drug reactions and malignant hyperthermia

Acute: 24 hrs-1 wk

D/t Nosocomial infections; MI/PE/DVT

Subacute: 1 wk -1 month

D/t abscess/infection of central line or surgical site; PE/DVT

Delayed: >1 month: d/t virus or indolent organism

Incisional hernia

Palpable mass at level of incision

Causes SI Obstruction

Tx: emergent laparotomy

Frost Bite
Tx: Rapid rewarming in 37-39 C water bath; analgesia + wound care

Thrombolysis in severe, limb threatening cases

Post amputation pain:

Acute stump pain: Tissue and nerve injury; severe pain lasting 1-3 wks

Ischaemic pain: Wound breakdown; skin discolouration

Post-traumatic neuroma: Wks to months after amputation

Focal boggy tenderness, Gentle P reproduces pain which radiates up limb

Phantom Limb pain: Onset usually within 1 wk

Fournier Gangrene -> polymicrobial infection

Life threatening necrotising fasciitis ==> sepsis ==> death

Risk greatest in poorly controlled DM and obesity

Rapid onset skin infection of lower abdo, scrotum and perineum

Severe Systemic sx w crepitus

Management: broad spec Abs and fluids, surgical debridement

Criteria for extubation

pH > 7.25

Adequate oxygenation on minimal support: FiO2 <40% and PEEP <5

Intact Inspiratory effort and sufficient mental alertness to protect airway

Drowning injuries

Complications: ARDS; Cerebral edema (>5min/resuscitation efforts delayed or prolonged);

Cancer related pain

Mild to moderate —> non opioid based analgesics or intermittent doses of short acting opioids

—> morphine, hydromorphine, oxycodone

If insufficient pain relief —> long acting opioids used: sustained release morphine —-> overnight
relief

Opioids can cause LH suppression

Mechanical Prosthetic Heart Valve Thrombosis (aortic/mitral): MV risk > AV

Prevention: Aspirin + warfarin

Obstructive thrombus mimics valvular stenosis —> HF; Systemic thromboembolic events etc

Tx: Anticoag (Heparin); Fibrinolytic tx avoided if poss; Surgery

Chemotherapy induced Cardiotoxicity

Myocyte necrosis & destruction (fibrosis) -> Progression to overt HF

Less likely to be rev

Type 2: Trastuzumab associated

Myocardial stunning/hibernation w/o myocyte destruction —-> loss of contractility

More likely to be reversible

Metastasis to the brain

—> vasogenic edema ———> tx w corticosteroids!

Arteriovenous Fistula

Continual bruit (arterial P exceeds venous P throughout cardiac cycle) w palpable thrill

Localised swelling and tenderness

Femoral A Pseudoaneurysm -> Complication of cardiac cath

Tender, pulsatile mass ——> systolic bruit

Strongest RF is inadequate post procedural arterial compression

Dx: US

Depolarising NM Blockers: Succinylcholine

Avoid in pts with a condition that could lead to upregulation of postsynaptic Acetylcholine R

——->> Skeletal muscle trauma, burns, stroke

Can result in life threatening hyperkalaemia

Etomidate: Inhibits 11 beta hydroxylase —->> can cause adrenal insufficiency

Halothane: Can cause acute liver failure d/t hepatotoxic intermediary

Nitrous Oxide

Inactivates vitamin B12 —->> inhibits methionine synthase activity

—->> subsequent neurotoxicity (eg periph neuropathy) in those with preexisting B12 deficiency

Propofol -> Avoid in children

Severe hypotension d/t myocardial depression —> Avoid in those with LV dysfunction

Delayed emergence from anaesthesia: > 15min of extubation

Resp failure, bradypnea and bradycardia ——>>> hypoventilation

Drug effect: Metabolic disorder: Neurological disorder

Postop wound complications

More common in obese pts, immunocompromised; those with increased intraabdo straining

Superficial wound dehiscence: intact rectus fascia

Secondary to abnormal subcutaneous fluid build up eg seroma

—->>>> Scant Serosanguineous Fluid Drainage

Management:

No signs of infection: Regular dressing changes, conservative

——>> removes excess fluid and closes physiological dead space

Primary closure

Deep (fascial) dehiscence: Non intact rectum fascia

Often d/t infection

Surgical emergency d/t risk of bowel evisceration and strangulation

Infected wound

Incision, drainage and leave open!

Once infection cleared and granulation tissue appears wound can be closed

Sternal Dehiscence

Chest wall instability and ‘clicking’ with chest movement

Palpable rocking/clicking of sternum

Surgical emergency

Mediastinitis

High mortality complication of dehiscence

Classically presents w systemic sx, chest pain, chest wall edema/crepitus

And purulent wound discharge

Atypical presentations can also occur

====>>>> any pt w significant Sternal wound drainage needs chest and Sternal imaging

Tx: Surgical debridement; cultures and empiric IV Abs

Necrotising surgical site infection

Pain, edema or erythema spreading beyond surgical site; Systemic signs

Parathesias /anaesthesia at edges of wound

Purulent, cloudy-gray discharge (dishwater drainage)

Sc gas/crepitus

Managment: Surgical exploration for debridement; Antibiotics

Postop Neck Hematoma

Immediate wound exploration and drainage

Life threatening d/t potential airway obstruction

—>> tripod positioning, stridor, dysphagia, voice changes all signs of imminent obstruction

—> initial sx can simply be neck tightening

Flail chest

Paradoxical motion of chest wall

Impaired generation of negative Inspiratory pressure

Ventilation with high PEEP

Postop Compartment Syndrome

Prolonged abdo surgery in which pt receives aggressive fluid replacement

——>> fluid in peritoneal cavity accumulates-> intraabdo HTN —->> compartment syndrome

——>>> organ compression and damage: SOB, decreased urine output

Tx: Decompressive Laporotomy and fluid therapy

SUNBURN

Mild to moderate: Erythema and tenderness (can be widespread)

Severe: As above + blistering, systemic sx (fever, vomiting, HA)

Tx: Mild to Moderate: Topical: Compress, calamine, aloe vera

Oral: NSAIDs

Severe: Hospitalisation; IV Fluids and analgesia; wound care

Bleeding Management

Packed RBC Transfusions (PRBCs) -> Can increase O2 carrying capacity

Acute GIT bleeding for pts with Hb < 7

==> <9 in unstable pts/ ACS/ active bleeding and hypovolemia

Whole blood transfusion: PRBCs + Plasma -> Massive hemorrhage to assist volume
expansion

Fresh frozen plasma: Clotting Factors and Plasma Proteins

Severe coagulopathy w active bleeding

PCC (Prothrombin Complex Concentrate)

Concentrate of Vit K dependent factors

Give w IV Vit K to provide substrate

PCC/FFP to rev warfarin

Protamine Sulphate to rev heparin

Cryoprecipitate: correction of hypofibrinogenemia in dilutional coagulopathy, DIC and liver

Colloids inc FFP and albumin

Allergy/adverse reaction: egg avoid propofol, seafood avoid iodinated contrast

Corticosteroid usage within last 6 months (avoid perioperative adrenal insufficiency)

DOC: Cefazolin: First Gen; skin and soft tissue

Penicillin allergy: Vancomycin/ Clindamycin/ Gentamicin

Bacteroides coverage: Metronidazole

Principal means of minimising atelectasis is deep inspiration and cough

Incentive spirometry —-> hyperinflation to overcome shallow breathing

Smoking biggest risk factor for postop pulm complications

Postop resp failure develops within 48 hrs cf ARDS

Hypovolaemia leads to dry secretions and thick sputum ——> atelecstasis

High FiO2 in COPD pts removes stabilising gas nitrogen from alveoli so predisposing alveolar
collapse

IgA deficiency: Use washed RBCs

WBC- reduced RBCs (leukoreduction):

HLA alloimmunisation, CMV and febrile nonhemolytic transfusion reactions

Those at risk of transfusion associated graft v host disease: Irradiated RBCs

Postoperative pain

Opioids mainstay of tx for postop pain:

Stimulate descending brain stem system that contributes to pain inhibition

Respiratory depression rare in this situation (extreme pain) as pain itself is a powerful respiratory
stimulant

Meperidine shorter duration than morphine

Methadone has long half life (6-10hrs)

Non opioids:

Ketorolac is an NSAID (no resp depression)

Aspirin avoided postop d/t interference with platelet function and anticoagulants

Continuous epidural analgesia (morphine)

Less resp depression, sym, motor or sensory disturbances.

With or w/o bupivicaine

Longer acting, delayed onset

Side effects: pruritus, nausea and urinary retention

Intercostal Block

Prevents muscle spasm d/t cutaneous pain