USMLE Step 2 CK Lecture Notes SurgeryAUTHORS ‘Surgery Carlos Pestana, M.D., Ph.D. merits Professor of Surgery University of Texas Modizal Shoo! at Sam Antonio San Antonio, Texas Adil Farooqui, M.D. Albert Binsin Cllge of Medicine Brom, New York Executive Director of Curriculum Richard Friedland, DPM. Contributing Editors isa Levy, M.D. Sonia Reichert, MLD. Managing Editor Kate McGreery Production Editor ‘william Neg Assistant Production Manager Michael Wolf Cover Design Foanoa MylloSection |. Surgery Chapter 1. Tauma 1 Chapter 2. Onhopedics 8 ‘Chapter 3. Pre-Op and Post-Op Care. (Chapter 4, General Surgery oes. cseecsesseseeceseeseeeeesees 29 (Chapter 5. Pediatric Surgery .....-.. . 6 Chapter 6, Surgical Speciaies ........ cecseetieseeseses Section Il. Surgery Vignettes Chapter 7. Trauma... 65 Chapter 8. Orthopedics o.oo ceesteeetesseeseeesiesneeeeen 7 hapter 9, Pe-Op and Post Op Gate «ess scvseesseesseeennecreesee Chapter 10 General SUNY... eesseecscesseesseeeseeseess eee TT Chapter 1, Pet SUTGENY 2... ssseess sees eesseessenseess eee IT Chapter 12. Surgical Specialties : 168 iiédicalSECTION | SurgeryTrauma INITIAL SURVEY (THE ABCs) Airway ‘An airways present ithe patient is conscious and speaking in anormal tne of wie. The ‘ay wil soon st if thee san expanding hematoma or emphysema the neck An i ‘hould be vecsed efore the sts becomes ries ‘An airway i needed if the patient is unconscious or his breathing is noisy or gurgly. 1 an indication for securing an sirwsy exists in a patent with potential cervical spine injury, the airway has tobe secured before dealing with the cervical spine injury. [An airway can be secured inthe field by crcothyroidotomy. In the emergency room (ER) itis best done by rapid induction and orotracheal intubation, with monitoring of pulse oxymety. Inthe presence ofa cervical spine injury, orotracheal intubation can ill be done ifthe head is secured snd not moved, Another option in that seting is nasotrecheal intubation over 2 fiberoptic onchoscope. In the presence of maxillofacial juries, ercothyroidotomy or percu- taneous transtracheal vettion are the options. Te ater is nt suitable if hyperventilation is requied for ONS injuries Breathing Hearing breath sounds on both sds ofthe chest and having sastatry pale oximetry estab The that retin okay. ‘Shock (Clinical signs of shock include low blood pressure (BP) (under 90 mm Big systolic), as feble pulse, and low urinary output (under 0.5 m/kg/h) in patient who is pale, cold, shivering, ‘swsating thirsty, and apprehensive In the trauma setting, shock is caused by cther bleeding (hypovolemic-hemorbagic, by far the most common cause) pericardial tamponade, of tension peumothorsx. For either ofthe last wo to occur, there mist be trauma tothe chest (Blunt or penetrating). In shock caused by bleeding, the central venous preseure (CV) is lowe (empty veins clinically) noth perianal tamponade and tension pneumothorax, CVP is hgh (big distended head and neck veins clin- cally) In pericardial tamponade there sno respiratory dstes. In tension pneumothorax there {esevere respiratory distress, one side ofthe chest has no breath sounds andi hyperresonant to percussion, and the mediastinum is displaced to the opposite side (rachel deviation). ‘The treatment of hemorrhagic shock inthe urban setting (big trauma center nearby), with penetrating injures that will require surgery anyway, starts with the surgical intervention toUSMLE Step 2: Surgery stop the bleeding, and volume replacement takes place afterward, In ll other settings, volume replacement isthe first step, starting with about 21 of Ringe lactate (without sua), and fl lowed by blood (packed red calls) until urinary output reaches 05 to 2 mlkg/h, while not exceeding CVP of 15 mm Hg, Preferred route of laid resuscitation in the trauma setting is two 16 gage, peripheral IV lines I they cannot be inserted, pereutancous femoral vein catheter or saphenous vein eu-dovens are alternative. In chien under years of ae, intraosseus cannulation ofthe proximal bias the alternate route, Management of pericardial tamponade is aso on nical diagnosis (do not onder x-rays—if diagnosis is unclear choose sonogram), and centered on prompt evacuation ofthe pericardial sac (by pericardiocemess tube, pericardial window, or open thoracotomy). Fuid and blood administration while evacuation is bing setup is helpful. “Management of tension pneumothorax is also based on clinical diagnosis (do not order x-aye ‘or wait for blood gases). Start with big neal or big IV eathetr inc the pleural space. Follow With chest tube connected to underwater seal (bots inserted high inthe anterior ches wall). Brief Detour: shock in the nontrauma setting ‘Can also be hypovolemic, because of bleeding or other sources of massive fad loss (burns, peritonitis pancreatitis, masivediashea). Same clinical picture as described above, with key finding of law CVP. Treat by stopping the Bleeding and blood volume eplacerent Intrinsic cardiogenic shock is caused by massive myocardial damage (snassive myocardial Infarction [MI], or fulminating myocarditis). Same clinical picture as above, except fr high CUP (big distended veins) Teat with circulatory support. Differential diagnosis s essential, because additional fuid and blood administration in this ting would be lethal ‘Vasomotor shock is seen in anaphylactic reactions and high spinal cord transection or high spinal anesthetic. Circulatory cllapse occuts in flushed, "pink and warm” patient. CVPis lv Pharmacologic treatment to restore peripheral resistance i the main therapy. Additional Muids will help. A REVIEW FROM HEAD TO TOE Head Trauma Penetrating head trauma as rule roquites surgical intervention and repair ofthe damage. Linear skull fractures are let alone if they are closed (no overlying wound). Open fractures require wound closure If comminuted ot depressed, they have to he treated in the operating room (OR), ‘Anyone with head trauma whe has become unconscious gets a computed tomography (CT) scan to look for intracranial hematomas. If negative and neurologically intact, they can go home if the family will wake them up frequently during the next 24 ours to make sure they are ‘ot gong into coma. Signs of bas of the skull fracture include raccoon eyes thinorche, end otorthea or echymo- sis behind the ear. Expectant therapy isthe rule Antibiotics are not indicated, but cervical spine scrays (or CT scan) are needed. IFCT of the head was done because of history of unconscious nest ean he extended to include the neck,"Neurologic damage from trauma can be cause by three components the ntl blow, the sub- sequent development ofa hematoma that cisplace the midline structures, and the later devel ‘opment of increased intracranial pressure (ICP). There is no treatment for the fist, surgery can relieve the second, and medical measures can prevent oF minimize the thi. [Acute epidural hematoma occurs with modest trauma to the side ofthe bead, and has classic Sequence of trauma, unconsciousness, uc interval (with completly asymptomatic patient who "returns to his previous acti), gradual apsing into coma again, ied ated pupil (60% ofthe time onthe side of the hematoma), and contralateral hemiparesis with decererate posture. CT scan shows biconves ensshaped hematoma. Emergency craniotomy produces dramatic cue. Because every patient who has been unconscious gots CT sean, the full-blown pictare with the fixed pupil and the contralateral hemiparesis is seldom seen. Acute subdural hematoma has the sume sequence, ut the trauma is much bigger, the patent js usually much sicker (not fully awake and asymptomatic at any point), and the newologic ‘damage i severe (because of the intial blow). CT scan will show seminar, crescent-shaped hematoma, If ridne structures are deviated, craiotomy wil help, but prognosis is bad. If there is no deviation, therapy is centered on preventing further damage ffom subsequent increased ICP. Do ICP monitoring, elevate head, hypecventlate, avoid uid overioad, and give ‘mannitl ot frosemide. Do not diutese tothe point of lowering systemic arterial pressure. Sedation has heen use to decrease brain atvity (and oxygen demand). Hypothermia is cut- rently suggested a a etter option t reduce oxygen demand. Diffuse axonal injury occurs ia more severe trauma. CT scan shows diffuse blrsng ofthe ray ‘white mater interface and maliple small punctate hemorrhages. Without hematomas there no ‘ole fr surgery. Therapy i rected at preventing farther damage from increased ICP. (Chronic subdural hematoma occurs in the very old or in severe alcoholics. shrunken brain Sgratted around the head by minor trauma, tearing venous sinuses. Over several days or weeks, ‘mental Function deteriorates as hematoma forms. CT scan is dagnosti, and surgical evacua- ‘ion provides dramatic eure [Hypovolemic shock cannot happen from intracranial bleeding. There isn't enough space inside the head forthe amount of blood les aceded to produce shock. Lpak for another source. Neck Trauma Penetrating trauma tothe eck eds to surgi exploration in all cases where there isan expand> ing hematomas, deteriorating vital sigas, or clear signs of esophageal or tracheal injury (coughing ‘or pting up blood). A strong tradition of surgical exploration forall gunshot wounds of he mig dle vone ofthe neck (regards of symptoms) i giving way toa more selective approach. More selective approaches in other ettngsincde the following: for gunshot wounds tothe "upper ane, arteringraphic diagnosis nd managements prefered for gunshot wounds the bate of the nec, arteriography, esophagoaram (water-soluble fllowe by barium if negate), csophagoscopy, and bronchoscopy before surgery help decide the specific surgical approach. Stab wounds to the upper and middle zones in asymptomatic patients can be safely observed. {mall patients with severe blunt trauma to the neck, the integrity ofthe cervical spine has to beascerlained, I there are neurologic deficits the nee to radiologically check the cervical spine ‘s obvious, but tals has tobe done in neurologically intact patients who have pain to local pal- pation over the cervieal spine. Start with anteroposterior (AP) and lateral czrical spine films (including T1) as wel ax edontoid views Ix-rays are negative and there is stil strong elinical suspicion, do CT scan, ICT of the head was done because of head trauma, it can be extended to include the neck.