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Rhonda Fishel, MD, FACS
May 9, 2006
 |ick well
Cut well
They will do well
Gershon Efron, MD, FRCS
 Case 1-
1-SOB/ Chest pain
78 year old male who is 3 days s/p LAR.
You are called to see him for SOB and
chest pain. T- 38, |-102, B|- 170/90, R-
30
‡ History- What do you want to know?
‡ |hysical exam- What do you check?
 Case 1-
1- SOB and chest pain
Differential diagnosis
‡ MI
‡ Heart failure
‡ Arrhythmia
‡ |ulmonary embolus
‡ |neumonia
‡ Airway obstruction
‡ Chest pain
 Case 1-
1- SOB and Chest |ain
Immediate work up and management
‡ Is the airway OK?
‡ Does he need to be intubated?
‡ Apply supplemental O2
‡ ABG
‡ EKG (troponins)
‡ Order CXR
 Myocardial infarction
‡ Can it be predicted pre-operatively?
yes, Eagle criteria-Q waves, hx of angina,
ventricular ectopy, DM needing meds, >70
‡ What medications will lessen incidence?
Beta blockers
‡ What is the immediate treatment?
MONA (if blood pressure acceptable)
‡ What is the ultimate treatment, operative
implication
Catheterization, thrombolytics- consider time
since surgery.
 Heart failure
‡ What are the risk factors for increased incidence
in post op period?
CAD, Heart failure, valvular heart dse, DM, renal
failure
‡ What are effective measures pre-op?
Optimal management of heart failure, ECHO, |AC
not terribly helpful
‡ How do you manage HF post op?
ACE inhibitors, diuretics,+/- Beta blocker, w/u for
ischemia, LV function
‡ What is the challenge of volume management
Need enough for myocardial contractility, but not
too much.
 Arrhythmias
‡ What are the causes of sinus tachycardia?
Volume, fever, pain, anxiety, anemia
‡ What is the initial management of SVT?
Adenosine if re-entrant, amiodarone,
verapamil, diltiazem, O2
‡ What heart blocks require pacers?
Mobitz 2, third degree block
‡ Can you have a B|, awake pt with V tach?
Yes
 |ulmonary embolus
‡ What is the death rate in the US?
150-200 thousand deaths per year
‡ What is the most common origin of |E?
Ileofemoral vein thrombosis
‡ What are the various diagnostic modalities?
Which is the gold standard?
V/Q scan, CT, pulmonary angiogram. US of
leg
‡ What are the treatment options?
Heparin drip, LMW heparin, warfarin,
thrombolytic therapy, IVC filter
 |neumonia
‡ What are the sequelae from gastric aspiration?
Who is at risk?
May have pneumonitis, chemical injury. At
risk- full stomach, emergency OR, male, >60
‡ How do you treat aspiration?
Maintain airway, adequate ventilation, no
steroids or prophylactic antibiotics
‡ What is the definition of nosococomial
pneumonia?
|neumonia occuring 48 hours after
admission
 |neumonia
‡ What else causes fever and CXR infiltrates?
When does it occur
Acute lung injury, pulmonary edema, atelect.
Occurs first 5 days.
‡ What common organisms are involved?
Gram negative (enterobacter, acinetobacter,
pseudomonas), staph aureus)
‡ What organisms are involved in trauma?
H.flu, s. pneumoniae, s aureus (neurosurg)
 Atelectasis
‡ What are the causes of atelectasis?
Obstructive and non obstructive
‡ Why are abdominal surgical pts at risk?
|ain, decreased tidal volumes
‡ Is atelectasis a cause of fever?
No, but may be coincident with it
‡ What are strategies for treating atelectasis?
Ambulation, incentive spirometry, C|A|,
bronchoscopy, chest |T
‡ Does mucomyst work?
Not in randomized trials
 Airway obstruction/bronchospasm
‡ What are the initial manuevers to treat airway
obstruction?
|ositioning, check for foreign body, O2
‡ How do you differentiate between the two?
Airway obstruction shows stridor, bronchospasm has
wheezing.
‡ How would you try to establish an airway?
Oral intubation, fibro-optic, consider surgical airway
‡ What medications could you use
Racemic epinephrine for airway obstr, albuterol for
bronchospasm.
 |leural effusion/pneumothorax
‡ How to you differentiate on exam?
|TX has decreased breath sounds and tympany,
effusion, decreased breath sounds. Remember clinical
context.
‡ What clinical dx associated with massive pleural
effusion?
Cancer, trauma, pulmonary surgery, lymph
duct injury
‡ Are there differences in the chest tube?
Air alone can have a smaller tube- 20-28; fluid
should be larger 32, 36 or up to 40 for blood
 Case 2-
2-|ost op fever
A 35 year old female had an appendectomy
for perforated appendicitis 6 days ago.
She has been febrile throughout, but now
has a temperature of 102. |- 115, B|
90/60, R 27
Hx- What do you want to know?
|/E- Where to you focus on exam?
Case 2-
2- |ost op fever-
fever-What is your
differential?
‡ Wound ‡ Medications
‡ Intra-abdominal ‡ Endocrine
abscess abnormalities
‡ |neumonia ‡ |ancreatitis
‡ UTI ‡ DVT
‡ Catheters ‡ Transfusion reaction
 Case 2-
2- |ost op fever
What is your immediate work up and
treatment plans
‡ Fluid resuscitation
‡ Tylenol, Motrin
‡ Focused work-up
‡ Review of medications
‡ Consideration of antibiotics
 Wound
‡ How does the class of the surgery affect incidence of
SSI? What does it add to LOS
The higher? the class, the higher the incidence. Adds 7 days to
LOS
‡ What are features of necrotizing fasciitis that are not
present in a simple SSI
Illness of patient, crepitance, extensive cellulitis, polymicrobial
organisms
‡ What is the treatment of a SSI?
Open wound, debride dead tissue- usually at bedside
‡ What is the treatment of necrotizing fasciitis?
Emergent operative debridement, broad spectrum antibiotic
coverage, volume resuscitation
 Intra--abdominal abscess
Intra
‡ What is the cause of an IAA, and how is it
diagnosed?
Either anastomotic leak, or residual bacteria,
infected hematoma. Diagnosed by CT, occasionally
exam
‡ What is the predominate organism?
Anaerobes, but depends on surgery
‡ How does IAA differ from peritonitis- clinically
and treatment?
|eritonitis is process which is not contained.
Treated by exploration. IAA often approached
percutaneously, unless multiple or intraloop
 UTI/Catheters

‡ What is the definitive diagnosis of a UTI?

Change foley if applicable, U/A as well as cx
‡ How long should a peripheral IV stay in?
72 hours
‡ What contributes to central line infections?
Technique on placement, dressings, number of
accesses, duration of lines, ?guidewire change
‡ What procedure should be followed for guidewire
change?
Cx tip of line, if positive, new stick. If cellulitis, new stick
 Medication
‡ What is the most common drug associated with
drug fever?
|henytoin
‡ What drugs are associated with neuroleptic
malignant syndrome? Malignant hyperthermia
|henothiazines,haloperidol, reglan; succinylcholine,
halothane.
‡ What drugs are most common in post op fever?
Antimicrobials, heparin
 Endocrine Abnormalities
‡ What abn is associated with fever,
increased volume needs, occ electrolyte
abnormalities? How do you check for it?
Adrenal insufficiency. ACTH stimulation
‡ What abnormality is associated with
tachycardia, hypertension, skin changes
and fever?
Hyperthyroidism
 Transfusion Reaction
‡ What are the causes of transfusion reactions?
Immunological, infectious, chemical, physical
‡ How do you work up a transfusion reaction?
Stop the transfusion, ASA, possibly
meperidine
‡ What are the signs of an ABO incompatible
reaction? What treatment
Acute hemolytic reaction- fever, flank pain,
bloody urine or DIC. NS resuscitation, save
blood for evaluation. Recross pt, hgb, AB test
 Case 3-
3- Swollen leg
A 55 year old woman was noticed to have a
swollen leg. T- 38.2, |- 90, B/| 130/70,R-
20
‡ Hx- what do you want to know
‡ |/E- what do you need to evaluate on
exam
 Case 3-
3- Swollen leg
Differential diagnosis
‡ DVT
‡ |eripheral arterial insufficiency
‡ |hlegmacia cerulea- dolens, albicans
‡ Cellulitis
‡ Lymphangitis
‡ Necrotizing fasciitis
 Case 3-
3- Swollen leg
What do you need to do immediately, what
work up do you need?
‡ Start resuscitation, Ab if patient is toxic
‡ Call vascular if sudden loss of perfusion
‡ Elevate limb if decent pulse
‡ Ultrasound of limb- venous compression
doppler
 DVT
‡ What are the modalities to make the
diagnosis of DVT?
Venogram, U/S, impedance
plethysmography
‡ Does a normal extremity exam r/o DVT?
No
‡ What are effective means of primary
prophylaxis?
Low dose heparin, LMW heparin, warfarin
 DVT-- Treatment options
DVT
‡ Anticoagulation
‡ IVC filter, rarely SVC filter
‡ Thrombolytic therapy
± Not as effective if obstructing thrombus
± Recombinant T|A
± Systemic or catheter directed
‡ Venous thrombectomy- +/- correction of
venous stenosis
 |eripheral arterial insufficiency
‡ What are the causes?
Embolus, thrombosis, failed graft,
compartment syndrome
‡ What are the signs?
Cold foot, numbness, dependent rubor,
absent pulses, inability to move toes
‡ What are treatment options?
Surgery for arterial exploration
Angiography, thrombolytic therapy
 Infectious causes
‡ What is the work up and treatment of cellulitis?
If abscess in question, consider CT,US, MRI
Antibiotics, elevation. Examine first!
‡ What is the work up and treatment of
lymphangitis?
Lymphangiogram would be difficult, treat with
elevation and antibiotics
‡ What is the treatment of necrotizing fasciitis?
Surgery, broad spectrum antibiotics
 Case 4-
4- Change in mental status

You are called to see an 87 year old woman

with a change in mental status. She is
now somnolent, T-37, |-65, B/|-150/80,R
-10
‡ Hx- What do you need to know?
‡ |/E- How to you focus your exam?
 Case 4-
4- Change in mental status
Differential diagnosis
‡ Medications
‡ Infection
‡ CVA/ TIA
‡ Hypoxia, hypercarbia
‡ Hypoglycemia
‡ ³Sundowning´
‡ Was there a fall?
 Case 4-
4- Change in mental status

What do you need to do immediately?

‡ O2, decide if patient needs to be intubated
‡ Get an ABG
‡ If not focal, stop all sedation, analgesia,
consider reversal
‡ Give an amp of D50
‡ Consider head CT once patient stable
 CVA / TIA
‡ What could be cause in perioperative
period?
|re-existing cerebral vascular disease
Hypotension in OR or post operatively
Bleeding disorder
‡ Why is a CT important?
Allows you to know if it is hemorrhagic or
ischemic which will alter treatment
 Medications
‡ All sedatives
‡ All analgesics- Beware the |CA
‡ Reglan
‡ H2 blockers
‡ Seizure medications
‡ Antiarrhythmics