Surgery risk classes
Class 1: benefits outweigh risk, should be done
Class 2a: reasonable to perform
Class 2b: should be considered
Class 3: rarely
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General rules for surgery: testing
ECG before surgery only if coronary disease, except when low risk surgery
Stress test not indicated before surgery
Do not do prophylactic coronary revascularization
Meds before surgery
- Diabetic agents: Use insulin therapy to maintain glycemic goals(iii) Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-1 agonists
- Do not start aspirin before surgery
- Stop Warfarin 5 days before surgery. May be bridged with Lovenox.
- Do not stop statin before surgery
- Do not start beta-blocker on day of surgery, but may continue
Assessment of surgical risk
- Unstable cardiac condition (recent MI, active angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD
- patient stable or unstable?
- urgency of the procedure (oncology will be time sensitive)
- risk of procedure
- nutritional status
- immune competence
- determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk)
Low risk surgeries
catarcts
breast biopsy
cystoscopy, vasectomy
laporascopic procedures
Plastic surgery
intermediate risk surgeries
Head/ neck surgery
thyroidectomy
Intraperitoneal
Prostate
Laminectomy
Hip/ knee
Hysterectomy
cholecystectomy
nephrectomy
non majot intrathoracic
High risk surgeries
aortic/ cabg
transplants
spinal reconstruction
peripheral vascular surgery
Lee's revised cardiac risk index
6 points:
High risk surgery = 1
CAD = 1
CHF = 1
Cerebrovascular disease = 1
DM 1 on insulin = 1
Creat greater than 2 = 1
1 = low risk
2 = moderate risk
3 = high risk
SCIP pre-operative infection measures
- Prophylactic antibiotics should be received within 1 h prior to surgical incision
- be selected for activity against the most probable antimicrobial contaminants
- be discontinued within 24 h after the surgery end-time
Postoperative infection reduction methods
- pre-op hair removal (clippers)
- wash hands
- normothermia
- maintain euglycemia
- urinary catheters are to be removed within the first two postoperative days
Osteoarthritis: what, incidence
Slow destruction of bones/ joint followed by production of replacement collagen which causes inflammatory changes
- older than 60
- more female after 55
- more black than white women
- men and women equal risk between 45 - 55
- abnormal height or weight (obesity)
- repetitive movement
- prior trauma (sprains/ dislocations)
- diabetic neuropathy
- genetic
Osteoarthritis findings and diagnostics
- Pain in weight bearing joints
- stiffness after sitting, gets better when arising
- feeling of instability on stairs
- fine motor skills deficit
- larger affected joints
- Heberden nodules (bony bumps on the finger joint closest to the fingernail)
- Bouchard's nodules (bony bumps on the middle joint of the finger)
- limited ROM with crepitus
- xr shows narrowing of joint space (need anteroposterior and lateral knee films bilaterally)
- synovial fluid is clear and without WBC
Osteoarthritis treatment
Goal is to relieve symptoms, maintain/ improve function, and avoid drug toxicity
Hand OA:
- rest/ joint protection, with splinting
- heat/ cold therapy
- topical capsaicin
- topical NSAID (trolamine salicylate) (especially for older than 75)
- Oral NSAIDS, incl COX2 inhibitors such as celecoxib (Celebrex) (may cause cardiac problems)
- tramadol
- no opioids
Hip/ knee OA:
- weight reduction, cardiovascular exercises
- transcutanous external nerve stimulator
- acetaminophen
- Topical NSAIDS (knee)
- intraarticular corticosteroid injections
- surgery (joint replacement)
Rheumatoid arthritis: what, who
chronic, systemic autoimmune disease that causes inflammation of connective tissue, first that of jionts them other soft tissues (renal, cardiovascular, pulm). TNF-alpha plays a big role
- more women than men
- unknown cause
- Epstein Barr virus
Rheumatoid arthritis: Findings and diagnostics
- symmetric joint/ muscle pain, worse in the morning then gets better
- weakness, fatigue
- anorexia, weight loss
- generalized malaise
- swollen joints/ boggy feeling of joints with deformity of joints
- warm, red skin on affected joints
later:
- pleural effusions and pulmonary nodules
- inflammation of sclerea (scleritis)
- pericarditis, myocarditis
- splenomegaly (Felty's syndrome)
- anemia (hypochromic, microcytic) with low ferritin
- possibly: positive rheumatoid factor
- XR: joint swelling, later cortical and space thinning
- synovial fluid: yellow, thick with elevated WBC up to 100.000
Felty's syndrome
rheumatoid arthritis, splenomegaly, neutropenia
Rheumatoid arthritis treatment
- early treatment better than stepwise
- early referral rheumatologist
- disease-modifying anti-rheumatic drugs (DMARDs):
- methotrexate ( no alcohol, monitor renal and liver, give with folic acid)
- cyclosporine
- Gold preparations (can cause thrombocytopenia)
- Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor)
- sulfasalazine, moderate RA
- Leflunomide, moderate to severe RA
- Etanercept
- monitor liver function with DMARDs
- screen for TB (skin test) and Hep B
- surgery: joint debridement, joint replacement
Gout: what, who
Inflammatory disorder in response to high uric acid production/ levels in blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean)
- impaired renal function which causes excess uric acid
- foods high in purine, such as dairy, red meat, shellfish, beer
Gout findings, diagnostics
- acute painful joint, often great toe (warm, swollen)
- pain at night
- flank pain because of renal calculi
- fever
- leukocytosis
- elevated erythrocyte sedimentation rate
- tophi (bump under skin) on ear
- limited joint motion
- elevated serum uric acid (greater than 7mg/dl)
- urate crystals seen with joint aspiration
- xr: joint erosion and renal stones
Gout treatment
- NSAIDS: naproxen, ondomethacin, sulindac
- Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also for prophylaxis
- Corticosteroids, if NSAIDS and colchicine not tolerated
- 24hr urine for uric acid
- Allopurinol after flare is over (100mg PO daily)
- Biological modifiers of disease (BMD): Pegloticase. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid
ANA. Tests in rheumatic disease: what, normal level, abnormal with.
Antinuclear antibody (ANA).
Normal: Titer 1.32
POsitive with: Sjogren's (SS), SLE (lupus),
C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with.
Determines hemolytic activity which speaks to level of inflammatory response
Normal: men: 12-72. Women: 13-75 mg/dl
Increased with: inflammatory disease
Decreased with: RA, lupus, SS
The radioallergosorbent test (RAST). Tests in rheumatic disease: what, normal level, abnormal with.
measures presence/ increase antigen IgE
normal: 0.01 - 0.04 mg/dl
Increased with allergic reaction
Erythrocyte sedimentation rate (ESR). Tests in rheumatic disease: what, normal level, abnormal with.
rate at which RBC settle out of unclotted blood in 1 hr
Normal: men: 0-7mm/hr, women: 0 - 25 mm/hr
Increased with inflammation
CRP. Tests in rheumatic disease: what, normal level, abnormal with.
C-reactive protein, a non-specific antigen antibody
Normal: trace to 6mg/ml
Increased with infection and inflammation, RA. Decreased with succesfull RA treatment
RF. Tests in rheumatic disease: what, normal level, abnormal with.
Rheumatoid factor. antibody against IgG.
Positive RF in most people with RA
Corticosteroids and arthritis: what does it do and adverse effects
Not for maintenance
Use lowest dose
Suppresses flares
nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections
NSAIDS and arthritis: what and adverse effects
analgesic and anti-inflammatory
give PPI concurrently to prevent GI complication
Headache, htn, fluid retention, n/v, ulcers/ bleeding, abnormal liver function tests, rash, renal insufficiency
Celebrex and Arthritis
Analgesic and anti-inflammatory
Fewer ulcers than with other NSAIDS
Not recommended in renal or liver failure
Screen for sulfa allergy
May cause cardiovascular thrombotic event
May cause GI adverse event
subluxation: what, cause
partial dislocation of a joint. Common sites: shoulder, elbow, wrist, hip, knee, patella, ankle, spine
trauma, blunt force
neuromuscular disease
inflammatory joint disease, RA
Loose ligaments
Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital)
Findings and diagnostics subluxation
Pain over affected area
previous subluxation
swelling around joints
loss of ROM
XR, CT, MRI show subluxation
Increased WBC (stress response)
Management of subluxation
Early reduction, many spontaneously
immobilization (splint, sling)
PT
NSAIDS for pain/ swelling
Dislocation: what, cause
Complete displacement of bone end and position in joint. Common sites: shoulder, elbow (nurse maid), wrist, hip, knee (emergency if loss of integrity of ACL and PCL), ankle/ foot
high energy blunt force trauma
congenital
neuromuscular disorder
inflammatory joint disease, RA
Loose ligaments
younger than 35 often, due to sports
Often associated with fracture
Findings and diagnostics dislocation
severe pain over affected area
hx of mechanism of injury
numbness/ tingling distal to injury
joint deformity
shortened limb
contusion/ laceration over affected joint
decreased pulses distal to joint
decreased rom
decreased sensation distally due to nerve damage
WBC elevated due to stress
Hgb may be low due to bruising
xr: dislocation (should get anteroposterior)
CT scan for pelvic trauma to rule out hip/ pelvic fracture
Order ultrasound for posterior knee dislocation: high incidence of popliteal artery injury
McMurray test, Lachman Test, straight leg test
McMurray: turn foot and bend knee. Positive with Meniscus injury
Lachman test: Hold upper and lower leg, around knee, stretch. Hyperstretch: ACL injury
Straight leg test: Pain when raising leg, while supine. Positive for herniated disk.
Dislocation management
Early reduction is essential: closed/ manual if no fracture. If fracture then may need surgery.
Postreduction immobilization (splint, cast, sling)
surgical repair of ligaments
PT/ OT
NSAIDS
Muscle relaxant for muscle spasms
Narcotics for short term use
Soft tissue injury: definition, classifications, incidence
Injury to non-bony tissue, such as muscle, ligament, tendon, bursa, cartilage, skin
Classification:
- Closed injury: contusion, hematoma, crush, strain (muscle), sprain (ligament, first to third degree), rupture (muscle and ligaments: instability, inability to move)
- Open injury: laceration, abrasion, penetrating/ puncture, amputations
trauma
exercise/ overuse
autoimmune (RA, SLE)
obesity
age (skin tear elderly)
Findings and diagnostics soft tissue injury
pain
swelling
feeling of instability of joint
Ruptures/ muscle tear: decreased ROM, immediate swelling and hematoma, abnormal contour muscle, instability of joint, pain/ guarding, watch neurovascular integrity
Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign)
Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding
Cartilage: swelling, click during McMurray's test (would indicate meniscus tear), pain/ guarding
Bursa: swelling with boggy feeling, erythema over bursa, decreased ROM
Skin: abrasion, laceration, puncture
Soft tissue injury findings and diagnostics
WBC increased, especially with bursitis
Hgb decreased with massive hematoma
Synovial fluid aspiration: WBC with inflammation, RBC with bleeding into joint, crystals with gout
Xr will reveal swelling
MRI (knee/ shoulder) location and degree of injury
Soft tissue injury management
PRICE (protection, rest, ice, compression, elevation)
possible immobilization
surgery, if rupture, grade III ligaments sprain, septic bursa, wound closure
PT
NSAIDS
Muscle relaxant
Opioids - short term
Broad spectrum ab's (cephalexin, cefazolin)
Fracture Classification - Gustillo
- Closed
- Open:
Type 1: wound smaller than 1cm
Type 2: wound larger than 1cm, moderate contamination
Type 3: high degree of contamination, severe fracture instability, soft tissue damage. T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone, T3C: open fracture with arterial injury
- Incomplete or complete
- stress
- traumatic/ pathologic
- displaced/ non-displaced
Type of fracture lines
Transverse
Spiral
Oblique
Comminuted
Logtitudinal
butterfly
segmental
impacted
Salter-Harris Fracture Classification
Concerns growth plate
S: straight across growth plate
A: Above growth plate
L: BeLow growth plate
T: Through growth plate
R: ERaser of growth plate (Rammed)
Cause of fractures
Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders
Findings and diagnostics of fractures
Pain
History of traumatic event
Neuromuscular dystrophy: headache (autonomic dysreflexia)
Deformity of limp
Diminished/ absent pulses
ecchymosis and swelling
xr, always order anteroposterior and lateral
CT scan for pelvic and spinal fractures
MRI for suspected spinal cord injury
Mortise view (leg inward) for ankle to check talus bone
oblique films for humerus, femur, ankle
DEXA scan to determine degree of osteoporosis
Acute Fractures Management
- ABC care (Airway, breathing, circulation), musculoskeletal second survey
- fluid resuscitation
- early reduction of fracture
- cover open wounds
- surgical irrigation and debridement for open fracture
- Ab's: Cefazolin for gram pos. Clindamycin for tetani infection
- pain: opioids
- tetanus shot of unknown
- calcium upon discharge for osteoporosis
- cement injection in bone with vertrebroplasty
Fractures: Reduction
- Orthopedic surgeon referral
- buddy-tape toe fracture for immobilization
- radius/ ulna: splint with ace-wrap, unless open
- post reduction xr
- check neurovascular function pre and post reduction
- intramedullary rodding for closed femoral and tibial fracture
- external fixation for open fracture
Compartment syndrome: what, who
Increased pressure in tissue limits the circulation and function of the contents within that space (compartment: bone, blood vessel, nerves, muscle, soft tissue). Most often in arms and legs (most compartments), also abdomen
Men under age 35
stemming from fracture of tibia
stemming from splint, cast, scar
increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/ surgery, burn, bite
Compartment syndrome finding and diagnostics
pain out of proportion to injury
hx of trauma
paresthesia
heaviness in affected extremity
Six P's:
Pain on passive stretch
Paresthesia
Paralysis of affected limb (late finding)
Pulses, bounding first then pulseless later
Pallor of affected limb
Polar/ poikilothermia (ice cold limb)
Elevated WBC
Hyperkalemia (tissue necrosis)
CPK and LDH elevated
Myoglobin in urine
Elevated compartment pressure (normal 0-8)
Clinical diagnosis, MRI may confirm
Acute renal failure (due to myoglobinuria)
Compartment syndrome management
Non surgical:
- limb at heart level (do not elevate)
- remove bandages/ immobilizers
- diuretic
- neurovascular checks
- CRRT/ dialysis to treat ARF
- intracompartmental pressure monitoring
Surgical:
- fasciotomy, with delayed closure of wounds (negative pressure wound vac)
- skin grafting
- amputation if septic from necrotic tissue
Restorative:
- functional splinting
- ROM
- early prostethic fitting post amputation
Low back pain - four major syndromes
1. Back strain
2. Disk herniation
3. Osteoarthritis/ disk degenration; osteophyte (bone spur)
4. Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment
Specific findings for back pain
- numbness
- saddle anesthesia (CA, mass)
- bowel, bladder dysfunction (emergency surgery)
- pain worse at rest (CA, tumor, infection)
- Discitis, epidural abcess (IV drug use)
- Decreased rom
- Radiculopathy (pain down leg), not with OA
- Crossover straight leg test: herniated disk
- back, buttock, leg pain when ambulating (neurogenic claudication with spinal stenosis). Also positive straight leg raise test with spinal stenosis
xr anteroposterior, to rule out scoliosis, bone spur
MRI for soft tissue structure, bulging disk
CT for bony imaging
Cauda Equina Syndrome
Spinal cord compression from metastatic lesion to spine. Causes: gradual to sudden weakness and inability to move/ lift legs, bowel/ bladder incontinence, diminished sensation in legs: saddle. Surgical emergency!
Low back pain management
Nonsurgical:
- rest
- ice/ heat (alternate)
- NSAIDS
- antispasmodics (diazepam, flexeril)
- opioid short-term, to promote mobility
- anticonvulsants and antidepressants for neuropathic pain
- PT
- weight loss
- epidural steroid injection
Surgical:
- Foraminotomy or diskectomy
- spinal fusion
Herniated disk: what, who
Bulging or protrusion of nucleus through a defect in the annulus of spine, may cause nerve entrapment
- Trauma
- Obesity/ sedentary lifestyle
- Age 35 - 45
- Often located at L4- L5, L5 - S1
Herniated disk findings and diagnostics
- Decreased/ absent reflexes
- Atrophy of muscles
- limp
- possible straight leg raise test/ radiculopathy
- limited rom spine
- xr anteroposterior and lateral of spine
- CT with and without dye: detects bony defects
- MRI: detects soft tissue defects
- myelogram
- EMG (tests nerve innervation)
Herniated disk L4 root finding (disk between L3 and L4)
- quadriceps weak, difficulty extending quadriceps (have pt squat and rise)
- pain and numbness radiating into medial malleous
- diminished/ absent knee jerk
Herniated disk L5 root finding (disk between L4 and L5)
- dorsiflexion of great toe and foot weak (have pt walk on heels of feet)
- pain and numbness into lateral calf and between first toe web space
Herniated disk S1 root finding (disk between L5 and S1)
- weakness of plantar flexion of great toe and foot (have pt walk on toes)
- pain along buttock, lateral leg and lateral aspect of foot and posterior calf
- diminished achilles calf
Herniated disk management
Non surgical:
- functional bracing
- rest
- PT for muscle strengthening
- heat/ ice alternate
- weight loss
- transcutaneous electrical nerve stimulator
- NSAIDS
- antispasmodic
- Narcotics for short-term use
- epidural steroid injection
Surgical:
- Laparoscopic diskectomy
- hemilaminectomy
- total disk replacement arthroplasty
HIV and age
- Can live beyond 50 years, but survival decreases after 45 yrs, unless tested.
- Antiretroviral meds are approved for younger than 50yrs, so older pt's need close monitoring
HIV etiology
Africa/ Asia: heterosexually acquired
Western nations: men who have sex with men, iv drug user, congenital spread
Pathophysiology of HIV
- HIV infects cells with CD4 receptor (macrophages, Tcells). Acute infection (high viral load) then latent (lower viral load). When CD4 is less than 200 AIDS and viral load increases again, this immunodeficiency
- HIV is chronic and prgressive:
HIV - acute retroviral syndrome, symptoms
fever, chills
fatigue
diffuse erythematous rash
HIV test may be negative, based on how long since infection
HIV viral load increased, CD4 within normal range
HIV - latent phase
- asymptomatic
- may have persistent lymphadenopathy
- HIV load and CD4 load variable (ultimately HIV load high, CD4 low)
Symptomatic HIV disease
Symptoms: fever, chills, diarrhea, weight loss
- infections: candidiasis/ thrush (oral, mucocutaneous, vaginal), shingles (herpes zoster), frequent bacterial infections
AIDS, definition and diagnosis
acquired immune deficiency syndrome
CD4 low, below 500 and infection with opportunistic organism
Or:
CD4 below 200
Common oppertunistic organism in AIDS
Pneumocystis jiroveci
Cryptosporidium
Candida albicans
Advanced HIV infection: definition, symptoms, prognosis
CD4 below 50
Wasting, fevers, fatigue
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