fish bone in throat how to manage?

ATLS, hx for pain location and any chest pain and PE (Hamman crunch) investigations: lateral neck X-ray (look for radioopaque FB location, prevertebral soft tissue swelling 2772), CXR tro pneumomediastinum

complications of fishbone: migration, esophageal perforation, infection/pharyngeal abscess/mediastinitits, airway obstruction ??injury to heart/trachea

battery??? dentures???

What is Boerhaave syndrome? Transmural rupture of esophagus caused by retching against closed glottis, increased pressure

management of fishbone: NBM, see if can remove the fishbone... management of mediastinitis: ATLS, NBM/NG tube/IV PPI, IV antibiotics broad spectrum prophylaxis

conservative vs surgical surgical if detected early <24hours from onset, primary repair or gastrostomy/jejunostomy conservative if the disruption is well contained and drains back into esophagus, mild infection few symptoms and clinically stable. drainage thoracostomy and nutrition TPN or enteral via tube

Where are the esophageal constrictions? cricoid cartilage C3 arch of aorta T4 Bifurcation of trachea T4 Diaphragm T10

Patient breathless after lap cholecystectomy - management? A, B, C History - any complications during anaesthesia or operation

Physical examination Adjuncts - CXR, ABG

Causes of breathlessness: Lung - atelectasis, aspiration, underlying lung problem Anaesthesia - inadequate reversal, floppy tongue, flash pulmonary oedema Diaphragmatic splinting, perforation

What are the components of ABG? What is base excess? (Ref: Cracking 350, 496) pO2 75 to 100mmHg (10.6 to 13.3kPa) pH 7.35 to 7.45 PCO2 35 to 45mmHg (4.7 to 6.0kPA) HCO3 22 to 26 or 24 to 28?mmol/L BE -2 to +2 Definition of base excess: How far bicarb is removed from normal value i.e. in metabolic alkalosis, how much acid must be added to bring blood to pH 7.4 (at 37 degrees celsius, fully oxygenated, PCO2 of 40mmHg)

How does pulse oximetry work? What affects the pulse oximetry reading? (Ref: Cracking 491-493) Pulse oximetry calculates O2 saturation based on differential reflection of red and infrared light by oxygenated/deoxygenated haemoglobin (doesnt reflect infrared??). Causes of erroneous reading: Peripheral vasoconstriction (e.g. cold peripheries, poor perfusion), abnormal pulse (atrial fibrillation, tricuspid regurgitation) or movement/shivering, altered blood pigments (carbon monoxide poisoning or smoking affects oxyHb, jaundice, anaemia, methaemoglobin), nail polish.

Explain the shape of the oxygen-haemoglobin dissociation curve. What causes shifting of the curve? (Ref Cracking 394-395)

Plot oxygen saturation (SaO2 of the haemoglobin molecules) vs. oxygen partial pressure (PaO2 of the surrounding blood) produces a sigmoid shape. Each O2 molecule that binds haemoglobin increases the affinity of the other sites (4 total) for O2 due to conformational change in structure. but at high concentration lower affinity?? Shift right (decreased affinity, gives up O2 more easily) in presence of increased CO2 and diphosphogluconate (2,3-DPG), increased acidity/decreased pH (lactic acidosis), increased temperature (respiring tissue). Shifted left (increased affinity, holds on to O2 more tightly) the opposite of above, fetal haemoglobin (remove O2 from mothers blood)

How to you classify shock? (Ref: Cracking 510-513) Definition of shock: Sudden generalized hypoperfusion/oxygenation of peripheral tissues/end organs. Usually caused by cardiovascular collapse. Types of shock: Hypovolemic (haemorrhage, fluid sequestration in pancreatitis intestinal obstruction or loss in stoma), cardiogenic (AMI, arrhythmias VF VT fast AF), obstructive (massive PE, tension pneumothorax, cardiac tamponade, ??dissection), distributive (septic, anaphylactic, neurogenic) Classification of hypovolaemic shock: Class I < 15% volume lost, minimal symptoms pulse normal BP and pulse pressure normal, urine output normal > 30ml/hr, pale skin. Class II 15 to 30% volume lost, tachycardia >100bpm, pulse pressure narrowed, urine output 20 to 30ml/h, anxious. Class III 30 to 40%, BP drop, oliguria < 15ml/h, confused. Class IV >40% volume lost, anuria, lethargic/comatose.

What inotropes are available and how do they work? (Ref: Cracking 406, 466-469) Definition: Inotropes increase contractility of heart muscle myocardium (shifts entire Starling curve CO/SV vs LVEDV up). Mechanisms: Alpha agonists cause vasoconstriction ??peripheral. Beta1 agonists increase force of contraction (inotropic) and heart rate (chronotropic). Beta2 agonists cause vasodilatation. Dopamine agonists cause vasodilatation in end organs increasing blood flow to gut (splanchnic flow) and kidneys. Adrenergic, dopaminergic, PDE inhibitors (milrinone)

Mechanisms of common inotropes: Dopamine - Dopamine receptors increase splanchnic flow and renal perfusion + beta1 (medium dose) increases force of contraction and heart rate + alpha (high dose) increases peripheral vasoconstriction

Dobutamine - Beta 1 increases contractility and heart rate (used in cardiogenic shock) Adrenaline Alpha beta1 and beta2, increases force of contraction + heart rate + peripheral vasoconstriction. Noradrenaline Not actually an inotrope; alpha causes peripheral vasoconstriction increasing SVR (used in septic shock)

RTA with GCS increasing from 7 to 10 What is the diagnosis and differentials? (Ref: Cracking 460-462) Lucid interval points to extradural haematoma EDH (produces convex/lens-shaped haematoma respecting sutures stripping dura from skull causes raised ICP by mass effect) ??Poisoning by alcohol/drugs Describe the anatomy of the middle meningeal artery. Middle meningeal artery - branch of internal maxillary artery (which is a branch of facial artery, ECA, CCA, branch of either aortic arch or brachiocephalic trunk) Run below the dura landmarked by pterion (confluence of parietal temporal sphenoid frontal, mid point of angle of eye to tragus 2cm above) What is the Monro-Kellie doctrine? (Ref: Cracking 459) Skull (cranium) is a fixed space containing brain, CSF, blood. Increase in volume of any of these components must be compensated by decrease in volume of another, otherwise intracranial pressure increases. How to manage? (Ref: Cracking 464-465) Management of raised ICP ATLS principles ABC, D Intubate (if not protecting airway) Medical: 1. Head up 30 degrees 2. Permissive hyperventilation avoid hypocarbia (keep PCO2 4.5kPa i.e. 30 to 35mmHg otherwise cerebral vasoconstriction, ischaemia) 3. Mannitol (20% bolus, after discussion with neurosurg). Sedate / phenytoin or BZD to control seizures (??affects CPP); mild hypothermia; inotropes dopamine or adrenaline to increase MAP and therefore CPP. Surgical: ??burr hole. External ventricular drain EVD (decreases ICP). Craniectomy/evacuation of mass lesions, brifrontal craniectomy if intractably raised. CT scan (indication: initial drop in GCS, further deterioration how much??)

blood on urine dipstix but UFEME negative what diagnosis - myoglobinuria due to rhabdomyolysis e.g. crush, ischemia/reperfusion, burns/hypothermia, strenuous exercise What are the complications of ??compartment syndrome or is it crush injury/rhabdomyolysis (Ref: Cracking 435) Systemic rhabdomylosis myoglobinaemia acute renal failure/kidney injury, electrolyte imbalance hyperkalemia hyperphosphatemia hyperuricemia ??hypocalcemia, metabolic acidosis, ??coagulopathy, shock, death local: ??compartment syndrome leads to chronic regional pain syndrome, contractures, muscle weakness, limb necrosis needing amputation management hydration - IV or PO fluids correct electrolyte imbalance, if need renal replacement therapy... correct DIVC - platelets, FFP

scoring of crush injruy: mangled extremity severity score - mechanism (low medium high very high energy 1234), limb ischemia (pulses CRT paralysis/insensate 123), shock (none transient persistent 0 1 2), age (30 50 0 1 2) low score --> higher potential to salvage limb vs amputation

indications for laparotomy: penetrating injury by gunshot/knife in situ, suspect perforation of viscus (free air under diaphragm), raised hemidiaphragm ???, evisceration

for DPL: anything that does not require laparotomy?? ??FAST negative but suspect intraabdominal bleeding

FAST: ultrasound look for free fluid in 4 areas: splenorenal hepatorenal, pelvis, pericardial. false positives: peritoneal dialysis, ascites, menstruation false negative: small volume of fluid, abdominal fat, operator skill too lousy

DPL: supine, aseptic technique. incision about 2cm in midline infra or supraumbilical, dissect and enter into peritoneum, look for frank pus/blood or bile. instil 1 litre normal saline via

catheter. ??roll to ensure lavage of abdominal contents. place NS bag below abdominal level and let drain, look for pus blood bile, WBC >100K, RBC > 500, gram stain for baceria. also note if chest drain output, urinary catheter increases.

How to perform exploratory laparotomy? (Ref: Cracking 139, http://www.youtube.com/watch?v=N5Wrn1IDP3Y) supine, GA, C&D Midline incision from xiphisternum to pubic symphysis or lower midline. Layers encountered: skin, subcutanoeus tissue fat scarpas fascia fat, aponeurosis/rectus sheath through linea alba (external oblique internal oblique transversus abdominis), transversalis fascia and peritoneum. suction, pack 4 quadrants. look for bleeding and haemostase. [Cracking] inspect and palpate liver gallbladder spleen, diaphragmatic hiatus oesophagus stomach duodenal bulb, bile duct right kidney duodenal loop transverse colon, body and tail of pancreas left kidney, mesenteric root superior mesenteric vessels middle colic artery aorta inferior mesenteric artery, appendix caecum colon rectum, pelvis uterus fallopian tubes bladder, hernia orifices iliac vessels. [Video] palpate 4 quadrants RUQ clockwise, gallbladder, liver, pylorus, duodenum. Body of stomach, transverse colon spleen. Descending colon sigmoid colon left kidney. Caecum ascending colon right kidney. Bladder. Eviscerate small bowel and mesentery and run from ligament of Treitz to ileocaecal valve (look for adhesions obstruction). Washout with copious warm NS in reverse Trendelenburg suction. Close anterior/posterior rectus sheath with running prolene 2/0 (protect bowel with malleable), skin with staples or subcutilar absorbable

What is a massive transfusion? replace total volume of blood over 24 hours. complications - SIRS/ARDS/??TRALI, volulme overload, hypothermia, electrolyte imbalance hyperkaelmia hypocalcemia, coagulopathy due to deficiency of factors or dilutional low platelets DIVC, infection e.g. Hepatitis B/C, hypersensitivity and anaphylaxis, infections

damage control surgery aims: haemostasis, prevent contamination, protect from further injury (avoid triad of doom - coagulopathy, hypothermia, acidosis)

temporary abdominal closure - to allow for repeat surgery

Splenic rupture in RTA Describe the anatomy of the spleen (Ref: Cracking 34) intraperitoneal organ, posterolateral on left side, covered by ribs 9 to 11. Relations: Tail of pancreas. Splenic flexure of colon. Left kidney. ligaments - gastrosplenic, splenorenal, splenodiaphragmatic, splenocolic blood supply - splenic artery which runs next to tail of pancreas, short gastric vessels What are the functions of the spleen? (Ref: Cracking 94) In the adult, 1. Filter resident macrophages remove abnormal RBCs (erythrocytes), cellular debris. 2. Store platelets 3. Immune Remove encapsulated bacteria (which are poorly opsonized); produce antibodies and opsonins How to manage splenic injury? (Ref: Cracking 94-95) Indications for emergency splenectomy: 1. Traumatic rupture (e.g. RTA, fall from height causing direct blunt force or deceleration/compression to left side of abdomen. 2. Spontaneous rupture (enlarged spleen) Grade severity of injury 1 to 5 - <1cm, 1 to 3 cm, >3cm, involves hilar vessels, shattered Indications for conservative treatment: 1. Minor injury grade 1 to 3; 2. Haemodynamically stable. Precautions: Always have a trauma surgeon, OT staff, blood transfusion and ICU facility on standby if so; ultrasound at 5 days and CT scan at 6 weeks, no contact sports for 3 months. Indications for surgical treatment: 1. Haemodynamically unstable or peritonitis, worsening pain and tenderness 2. Severe injury (grade 4 or 5) 3. Persistent coagulopathy/bleeding 4. Additional intraabdominal injury needing surgery or interfering with monitoring e.g. pelvic fracture Procedure: Supine, GA, C&D nipple to groin, antibiotic prophylaxis (IV penicillin) + NG tube (acute gastric distension), incise upper midline (extend to T-shape), confirm spleen source of bleed then resect (mobilize spleen, divide lienorenal ligament, compress vascular pedicle, ligate splenic artery above pancreas with vicryl 0, free left colic flexure attachment to diaphragm, ligate gastrosplenciligament and shrot gastric vessels), haemostase pack spelnic bed drain, mass closure loop nylon 1/0. Post-op: Vaccinate against H influenza, pneumococcus, meningococcus; penicillin prophylaxis (at least 2 years or till adulthood for infants) What are the complications of splenectomy? (Ref: Cracking 96)

GA: Chest infection General: bleeding, Subphrenic abscess, Injury to stomach/splenic flexure of colon, diaphragm, pancreas (pancreatic fistula) Abnormality of blood components: Thrombocytosis or low platelets?? and leukocytosis + ??polycythaemia (if done for hypersplenism) Infection by encapsulated bacteria (pneumococcus meningococcus E coli H influenzae)/malaria and Overwhelming post-splenectomy sepsis OPSS (flu-like prodrome, headache fever malaise, coma, adrenal haemorrhage, circulatory collapse; mortality up to 90%) Small bowel obstruction, acute gastric dilatation Splenunculi

Burns What are the complications of burns? (Ref: Cracking 432) Early Local blisters/infection Regional - compartment syndrome, eschar respiratory compromise/death Systemic rhabdomyolysis myoglobinaemia renal failure, hypovolemia and shock, electrolyte imbalance hyperkalemia, SIRS/sepsis, ARDS, coagulopathy DIVC Late Local limb loss, scarring/contracture, chronic regional pain syndrome, functional disability How to give fluids in burns? (Ref: Cracking 430) Parklands formula (volume of crystalloid needed for resuscitation over 24 hours = 4 x BSA burn x weight in kg) give half in 1st 8 hours, half in next 16 hours. Or Muir and Barclay formula for albumin Monitor fluid balance.

Pelvic fractures How to classify? Stable or unstable (high velocity trauma or fall from height). based on physical examination - ???shearing opening force

What are the complications? Hypovolemic shock due to blood loss up to 5L, local injury to urethra/bladder, rectum/colon, reproductive organs How to manage? ATLS. primary survey secure A B C. give IV fluids put a pelvic binder/harness. adjuncts like urinary catheter if no urethral injury. get trauma team including ortho use ex fix.

Rectal cancer Definition up to 15cm from anal verge (cutaneous opening), no taenia coli or appendices epiploica. malignant tumour of the rectum??? How to investigate? (Ref: Cracking 202) Basic blood investigations FBC (microytic anaemia), urea/electrolytes (pre-op workup), liver function tests (hepatic involvement) Diagnosis: colonoscopy/proctoscopy and biopsy; alternatively, barium enema showing applecore lesion or CT colonography Staging: MRI pelvis (or endoscopic ultrasound) for local depth, CT Thorax (?or CXR + US liver) CTAP for local invasion and lymph nodes and mets How to manage? (Ref: Cracking 204-209) multidisciplinary team different modalities involved - surgery, radiotherapy, chemotherapy

aims curative vs palliative depending on stage

surgical management curative: depends on tumour location, involvement of sphincter. need to get 2cm clear distal margins (??total mesorectal excision), so if low rectal (within 2cm of sphincter), will need or abdominoperineal resection and end colostomy. if high rectal (further than 2cm away from sphincter), anterior resection ??+/- primary/staged anastomosis?? For obstructed tumour, Hartmann operation (resection, oversewing of rectal stump, endcolostomy) vs. primary resection and anastomosis (pre-op: bowel prep, stoma nurse counselling and siting, anaes review, epidural, prophylactic antibitiocs)

chemotherapy (for Duke C i.e. N1 and above. 5-fluorouracil and folinic acid) and radiotherapy as neoadjuvant or adjuvant therapy

palliative: relieve obstruction surgical treatment resection/debulking laser treatment electrocoagulation contact irradiation, bypass/defunctioning colostomy/ileostomy, stent radiotherapy for bone mets, chemotherapy Complications of surgery General anaesthetic, AMI, PE, DVT, renal failure Specific Early: infection, wound dehiscence, anastomotic leak, pain/urinary retention/post op ileus, injury to ureters/bladder Late: anastomotic stricture, sexual dysfunction (damage to splanchnic nerves), phantom rectum Follow-up Surveillance for recurrence: colonoscopy/barium enema, CEA, US/CT liver pelvis Check for post-op complications Ensure appropriate adjuvant therapy

Breast cancer How to manage? (Ref: Cracking 185-188) Multidisciplinary approach (breast nurse) Modalities used - surgery, radiotherapy, hormonal therapy, chemotherapy stage the breast cancer with ??CT thorax aim for curative or palliative depending on stage

surgery +/- RT for breast wide local excision (clear margins >5mm) with RT (for local disease control if recurrence risk >15%) or skin-sparing mastectomy (Depends on tumour to breast ratio, involvement of multiple quadrants, patient choice. contraindication to RT such as previous RT, pregnancy/breastfeeding, connective tissue disease, poor patient compliance

Consider breast reconstruction immediate or delayed with flap (TRAM/LD) +/- prosthesis (implant)

For axilla Sampling (sentinel lymph node biopsy with technetium+ blue dye - for T1 or T2 disease, no clinical lymphadenopathy i.e. N0) + radiotherapy vs. axillary clearance (level 1 below pec minor, level 2 up to upper border of pec minoir, level 3 to first rib) complications: lymphedema, cellulitis, injury to long thoracic nerve/thoracodorsal nerve causing winging of scapula and weakness of latissimus dorsi

Systemic medical treatment adjuvant therapy hormonal therapy - tamoxifen for ER-positive, goserelin/Zoladex. Herceptin/trastuzumab for HER2 (human epidermal growth factor 2 receptor) positive (reduces recurrence) chemotherapy in advanced illness (paclitaxel, reduces mortality)

palliative resection of ulcerating tumours, radiotherapy bone mets causing pain and hypercalcemia bisphophonates, analgesia lung mets causing pleural effusion aspiration, pleurodesis anaemia of chronic diseas blood transfusion

Enterocutaneous fistula (Ref: Cracking 67-70) Definition of fistula: abnormal communication between 2 epithelial-lined surfaces Contrast sinus: blind-ending tract communicating with 1 epithelial surface, normal e.g. carotid OR abnormal How to manage enterocutaneous fistula? S - sepsis treatment drain any abscess, give antibiotics N - nutrition via TPN A - anatomy define with fistulogram or CT locate the internal opening P - plan for surgery if high output (>400ml) or conservative treatment if low output. Surgery excise tract, curette to promote granulation

S - skin protection wound care

Total parenteral nutrition (Ref: Cracking 480-481) Definition: Nutrition through intravenous route; advantage doesnt require intact GI system Indications: intestinal failure, hypercatabolic state (starvation), post-operative (e.g. gastroparesis, failed absorption) How to give TPN? Volume (30ml/kg/day or the complicated way 100ml/kg x 10kg, 50ml/kg x 10kg, 20ml/kg or total about) Calories with 70% carbohydrates 30% fats 1g/kg/day (30kcal/day with advice of nutritionist) + aminoacids Electrolytes (potassium 0.5-1mmol/kg, Na 1-2mmol/kg, Cl, Ca, Mg, PO4), vitamins ADEK and B and C Route: Indwelling central venous catheter (position 2.5cm above SVC??)/Hickman line. Peripheral line in antecubital fossa.

What are the complications of TPN? Line sepsis. Venous access problems e.g. scarring Jaundice - bile stasis causing gallstones, steatohepatitis (fatty liver) Metabolic derangement hypokalemia etc, ???refeeding syndrome (starts with hypophosphatemia then hypokaelmia hypomagnesemia) Monitoring Body weight, fluid balance (I/O chart), temperature (signs of sepsis) Bloods LFTs for albumin, urea/electrolytes and glucose, FBC for sepsis