Surgical Problems in Primary Care - UCSF Medical …€¢ 42 year old woman with right upper quadrant pain • Worse with eating • Nausea, no vomiting • No fever • Exam: –

Surgical Problems in Primary Care

Ronald H. Labuguen, MD Clinical Professor

UCSF Department of Family and Community Medicine -o-

UCSF Family Medicine Board Review Course March 7, 2017

Faculty Disclosure

I have nothing to disclose

The closest Ill get to being a surgeon

Road Map for Our Journey Gastrointestinal Problems/Acute Abdominal Pain Preop/periop/postop care, wounds, and infections Other surgical specialties:

Trauma surgery Vascular surgery Thoracic surgery Otolaryngology/head and neck surgery Urology Neurosurgery

Top 30 High Yield Items

GASTROINTESTINAL PROBLEMS ACUTE ABDOMINAL PAIN

Right Upper Quadrant Pain

42 year old woman with right upper quadrant pain

Worse with eating Nausea, no vomiting No fever Exam:

Tender to palpation in the RUQ Murphys sign: reproducible pain & halts

breathing on inspiration on palpation at right costal margin at the midclavicular line

RUQ Ultrasound = Test of Choice

Heilman J. File:Gallstones.PNG [Wikimedia Commons Web site]. March 18, 2011. Available at: http://commons.wikimedia.org/wiki/File:Gallstones.PNG.

Cholangiocarcinoma

Cholangiocarcinoma

Treatment: complete surgical resection Generally poor prognosis

Only 10% present at an early enough stage to consider curative resection

5-year survival rate up to 40% for patients with completely resected tumors

Cholangiocarcinoma: Klatskin tumor

Hellerhoff. File:Klatskintumor-ERC.jpg [Wikimedia Commons Web site]. July 15, 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-ERC.jpg .

Klatskin tumor: Palliative stent placement

Hellerhoff. File:Klatskintumor-Stents.jpg [Wikimedia Commons Web site]. July 15, 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-Stents.jpg.

RIGHT LOWER QUADRANT PAIN

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

History Periumbilical for 3 days, then right lower quadrant

for 2 days

Physical exam Tenderness to palpation at McBurneys point

McBurneys Point (#1)

Fruitsmaak S. File:McBurneys_point.jpg [Wikimedia Commons Web site]. September 24, 2006. Available at: http://commons.wikimedia.org/wiki/File:McBurney%27s_point.jpg.


5 day history Periumbilical for 3 days, then right lower quadrant

for 2 days

Physical exam Tenderness to palpation at McBurneys point (-) psoas, (+) obturator signs

Labs Normal

Physical Diagnosis

McBurneys point tenderness LR+ 3.4 Peritonitis:

Rigidity LR+ 3.6 Abdominal wall tenderness LR+ 0.1

LR+ 10.0 = +45% probability LR+ 0.1 = -45% probability McGee S, Evidence-Based Physical Diagnosis, 4th ed. Philadelphia: Elsevier, 2018, pp. 449-453

Labs

no WBC cutoff has sufficient sensitivity or specificity to rule out appendicitis

25% of appys have normal WBC Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007 Jul 25; 298(4): 438-51 Cartwright SL, Knudson MP. Evaluation of Acute Abdominal Pain in Adults. Am Fam Physician 2008, Apr 1;77(7):971-8

Alvarado (MANTRELS) Score

Migration (1 pt) Anorexia (1) Nausea and vomiting (1) Tenderness RLQ (2) Rebound tenderness (1) Elevation of temperature (1) Leukocytosis WBC > 10 (2) Shift to the left > 75%

neutrophils (1)

Score 7 LR+ 3.1 4 LR+ 0.1

Better to help rule out

appendicitis than to diagnose it

McGee S, Evidence-Based Physical Diagnosis, 4th ed. Philadelphia: Elsevier, 2018, pp. 449-453

Appendicitis on CT

Heilman J. File:Appy4.jpg [Wikimedia Commons Web site]. April 24, 2010. Available at: http://commons.wikimedia.org/wiki/File:Appy4.jpg.

Imaging: ACR appropriateness criteria

Classical presentation CT abd/pelv w/ contrast (8 usually appropriate) CT abd/pelv w/o contrast (7 usually appropriate) RLQ US (6 may be appropriate)

Atypical presentation CT abd/pelv w/ contrast (8 usually appropriate) X-ray abd, RLQ US, pelvic US, CT abd/pelv w/o

contrast (6 may be appropriate) American College of Radiology. ACR Appropriateness Criteria: Right Lower Quadrant Pain - Suspected Appendicitis. Available at https://acsearch.acr.org/docs/69357/Narrative/. Accessed 24 February 2017.

Bottom Line: Diagnosis of Appendicitis

H&P and labs low sensitivity and specificity by themselves

CT and MRI have better sensitivity/specificity compared to H&P and labs; ultrasound slightly less sensitive than CT/MRI (studies varied widely)

No single lab or clinical test has superior sensitivity or specificity. Specific cutoffs could not be defined.

Few studies evaluating clinical decision aids Dahabreh IJ, Adam GP, Halladay CW, et al. Diagnosis of Right Lower Quadrant Pain and Suspected Acute Appendicitis AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. Report No. 15(16)-EHC025-EF (Review) PMID: 27054223


What is the most appropriate treatment for this patient?

A. Appendectomy B. IV broad spectrum antibiotics C. PO antibiotics D. Watchful waiting

Appe

ndec

tomy

IV br

oad s

pectr

um an

tibi...

PO an

tibiot

ics

Watc

hful w

aiting

71%

9%9%12%


Appendectomy is historically the treatment of choice


Conservative treatment with antibiotics and watchful waiting? Historically, reports of cases treated successfully with antibiotics Coldrey E. Treatment of acute appendicitis. Br

Med J 1956;2(5007):1458-1461 471 pts treated Mortality 0.2% Recurrent appendicitis 14.4%


Conservative treatment with antibiotics and watchful waiting? Antibiotics not definitively non-inferior to

surgery

Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008359.

Uncomplicated Appendicitis: Antibiotics vs. Surgery

APPAC Did not demonstrate noninferiority of

antibiotics: 27% in Antibiotics group had surgery within 1 year of presentation (cutoff for noninferiority 24% )

Surgery group had higher rate of complications 20.5% vs. 7.0% in Antibiotics group

Salminen P, Paajanen H, Rautio T et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340-2348.

Uncomplicated Appendicitis: Antibiotics vs. Surgery Meta-analyses

Higher rate of complications in surgery group Antibiotics group: 8.2% had surgery at 1 mo 22.6% had recurrence at 1 yr No difference in hospital length of stay or incidence

of complicated appendicitis Sallinen, V., Akl, E. A., You, J. J., Agarwal, A., Shoucair, S., Vandvik, P. O., Agoritsas, T., Heels-Ansdell, D., Guyatt, G. H. and Tikkinen, K. A. O. (2016), Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg, 103: 656667. doi:10.1002/bjs.10147 Rollins KE, Varadhan KK, Neal KR, et al. Antibiotics Versus Appendicectomy for the Treatment of Uncomplicated Acute Appendicitis: An Updated Meta-Analysis of Randomised Controlled Trials. World J Surg. 2016 Oct;40(10):2305-18. doi: 10.1007/s00268-016-3561-7. (Review) PMID: 27199000

Non-operative treatment of uncomplicated appendicitis in children Preliminary reports of ongoing studies

indicate: Success rates 89.2% at 30 days 75.7% at 1 year Lower incidence of complicated appendicitis (2.7%

vs. 12.3%) Fewer disability days Lower costs

Minneci PC, et al. JAMA Surg. 2016;151:408-415

Antibiotic treatment post appendectomy in children

Extended-spectrum antibiotics not superior to narrow-spectrum antibiotics re: 30 day readmission rates of children

Kronman MP, Oron AP, Ross RK, et al. Extended- Versus Narrower- Spectrum Antibiotics for Appendicitis. Pediatrics. 2016;138(1):e20154547

Appendicitis: Red Flags

Signs of rupture Change in condition:

Fever Increased pain Abdominal rigidity

Could see improvement in pain (think of a walled-off ruptured abscess) until peritonitis more fully develops

Appendicitis: Red Flags

Higher proportion of patients with ruptured appendicitis at the extremes of age (early childhood, elderly) May be due to lower

incidence, because absolute rate of rupture is constant across ages

Psychopoesie. File:Grandma&me_at_my_cousins_wedding.jpg [Wikimedia Commons Web site]. October 31, 2011. Available at: http://commons.wikimedia.org/wiki/File:Grandma%26me_at_my_cousin%27s_wedding.jpg .

Chan Ho Park

Meckels Diverticulum

Meckels Diverticulum: Rule of 2s

2% prevalence 2 years of age at presentation 2 feet from the ileocecal junction 2 inches in length 2 types of common ectopic tissue

Gastric Pancreatic

2% symptomatic 2 times more symptomatic in boys

LEFT LOWER QUADRANT PAIN

Diverticulitis

Typical story: Acute constant abdominal pain in LLQ Fever Can also see nausea, vomiting, constipation,

diarrhea, sympathetic cystitis (dysuria and frequency caused by bladder irritation from inflamed colon)

Typical physical exam findings: LLQ tenderness, guarding, rebound

Which one of the following is NOT associated with complications of diverticulitis?

A. NSAIDs B. Opioids C. Corticosteroids D. Recurrences of diverticulitis

NSAID

s

Opioi

ds

Corti

coste

roids

Recu

rrenc

es of

divert

iculiti

s

27% 27%30%

15%

Diverticulitis

Risk factors: Smoking, obesity Negative risk factor: Increased physical activity Associated with complications:

Yes: NSAIDs, opioids, corticosteroids No: Recurrences

Recurrences are uncommon (13.3%) & not clustered

Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid Diverticulitis: A Systematic Review. JAMA. 2014;311(3):287-297.

Diverticulitis

Diagnostics: CBC (leukocytosis) Urinalysis CT of abdomen and pelvis with contrast (US, MRI

acceptable alternatives) Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

Diverticulitis

Heilman J. File:Diverticulitis.png [Wikimedia Commons Web site]. June 2, 2011. Available at: http://en.wikipedia.org/wiki/File:Diverticulitis.png.

Treatment of diverticulitis with antibiotics has been shown to reduce which of the following?

A. Complications B. Need for surgery C. Recurrence D. Median length of inpatient stay E. None of the above

Comp

licatio

ns

Need

for s

urge

ry

Recu

rrenc

e

Media

n len

gth of

inpa

ti...

None

of th

e abo

ve

16%

30%

41%

10%

3%

Uncomplicated Diverticulitis: Treatment

Stable, tolerating oral fluids: outpatient Cochrane review best available data do not support abx No effect on complications, need for surgery, recurrence, median length of inpatient stay 1st episode observation decreased hospital LOS, no effect on complications or recovery time

Older or ill pts, not tolerating fluids: admit IV fluids, bowel rest/NPO, ? Antibiotics

Daniels L, Unlu C, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017 Jan;104(1):52-61. Chabok A, Pahlman L, Hjern F et al. Randomized clinical trial of antibiotics for acute uncomplicated diverticulitis. Br J Surg 2012;99(4):532-539. Shabanzadeh DM, Wille-Jorgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012 Nov 14;11:CD009092.

Diverticulitis: Treatment

Complicated (sepsis, perforation, abscess, fistula, obstruction) stabilize, IV fluids, antibiotics, surgical consultation,

percutaneous drainage, intraperitoneal lavage

Broad-spectrum antibiotics to cover anaerobes, gram negative rods

Diverticulitis: Treatment

Indications for surgery Sepsis, acute peritonitis No improvement with medical therapy, percutaneous

drainage, or both Trend toward minimally invasive surgical techniques

(laparascopic preferred in American Society of Colon and Rectal Surgeons guideline)

Consider after complicated episode

Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic Review. JAMA Surg. 2014;149(3):292-303. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

AGA Recommendations: Diverticulitis For

Selective use of abx Colonoscopy after

resolution to r/o CA Fiber ASA, seeds, nuts,

popcorn OK Vigorous physical

activity

Against Elective colon resection

after 1st uncomplicated episode

NSAIDs Mesalamine Rifaximin Probiotics

Stollman N, Smalley W, Ikuo Hirano I, and AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of

Acute Diverticulitis. Gastroenterology 2015;149:19441949.

Which of the following is the most common cause of lower GI bleeding?

A. Hemorrhoids B. Diverticulosis C. Inflammatory bowel disease D. Colon polyps E. Ischemic bowel

Hemo

rrhoid

s

Divert

iculos

is

Inflam

mator

y bow

el dis

ease

Colon

polyp

s

Ische

mic b

owel

72%

23%

0%2%3%

Causes of lower GI bleeding Diagnosis Frequency (%) Diverticulosis 30 Hemorrhoids 14 Ischemic 12 Inflammatory Bowel Disease 9 Post-polypectomy 8 Colon cancer/polyps 6 Rectal ulcer 6 Vascular ectasia 3 Radiation colitis/proctitis 3 Other 6

Source: UCLA-CURE Hemostasis Research Group database. Ghassemi KA, Jensen DM. Lower GI Bleeding: Epidemiology and Management. Curr Gastroenterol Rep (2013) 15:333.

Diverticulosis

Typical story: abrupt onset of painless voluminous bleeding (arterial)

Diagnostics: nuclear bleeding scan, angiography, colonoscopy

Treatment: colonoscopy; may require surgery

Diverticulosis

Hellerhoff. File:Sigmadvivertikulose CT axial.jpg [Wikimedia Commons Web site]. December 23, 2010. Available at: http://commons.wikimedia.org/wiki/Sigmadivertikulose_CT_axial.jpg.

Diverticulosis

Case: 53 yo woman with hemorrhoids

Hemorrhoids

WikipedianProlific. File:Hemorrhoid.png [Wikimedia Commons Web site]. September 12, 2006. Available at: http://commons.wikimedia.org/wiki/File:Hemorrhoid.png.

Volvulus

Midgut volvulus from malrotation of the gut Sigmoid volvulus

Midgut Volvulus: Malrotation of the Gut

Typical story: 1st month of life: bilious vomiting, feeding

intolerance, sudden onset of abdominal pain, upper abdominal distention

Older children: More vague (chronic, unexplained) abdominal pain, irritability, anorexia, nausea/vomiting, failure to thrive

Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children BMJ 2013;347:f6949


Diagnostics Physical exam: normal, or subtle findings Abdominal x-ray: double bubble sign (gastric and

duodenal dilatation); lack gas in lower GI tract; pneumatosis coli (ominous sign)

UGI contrast w/ birds beak, spiral, corkscrew signs of duodenal obstruction

Sensitivity 96%, false negative rate 3-6% Ultrasound scanning of the mesenteric vessels

Sensitivity 86.5%, specificity 75%, positive predictive value 42%, negative predictive value 96%


Treatment: Ladds procedure

(1) untwist the intestine, (2) divide any adhesive bands, and (3) widen the mesentery to result in the bowel being in a safe non-rotated position

Sigmoid Volvulus

Older patients Typical story sx of bowel obstruction/ischemia:

Abdominal pain, distention, inability to pass stool or flatus (obstipation), history of constipation

Vomiting may be late presenting feature Diagnostics: abdominal x-ray shows distended

sigmoid colon Treatment: sigmoidoscopy/rectal tube placement;

resection & primary anastomosis

Sigmoid Volvulus

Hellerhoff. Files:Sigmavolvulus_Roentgen_Abdomen_pa.jpg, Sigmavolvulus_Roentgen_Abdomen_LSL.jpg [Wikimedia Commons Web site]. 22 September 2014.

EPIGASTRIC PAIN

Case: 34 yo man with epigastric pain

Ransons criteria at admission: GA LAW Glucose > 200 AST > 250 LDH > 350 Age > 55 WBC > 16

Ransons criteria at 48 hours: Cal(vin) & HOB(BE)S Calcium < 8 Hematocrit drop > 10 % pts pO2 < 60 BUN incr > 5 after fluid hydration Base deficit > 4 (Base Excess < -4) Sequestration of fluid > 6 L

Grey Turners Sign

Fred H, van Dijk H. Images of Memorable Cases: Case 21 [Connexions Web site]. December 3, 2008. Available at: http://cnx.org/content/m14942/1.3/.

Cullens Sign

Fred H, van Dijk H. Images of Memorable Cases: Case 120 [Connexions Web site]. December 8, 2008. Available at: http://cnx.org/content/m14904/1.3/.

Pancreatitis

Surgery indicated for infected necrosis 80% of deaths from acute pancreatitis caused by

infection of dead pancreatic tissue Pancreatic pseudocysts

Endoscopic drainage as effective as surgery, both more effective than percutaneous drainage

Johnson MD, Walsh RM, Henderson JM, et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol 2009 Jul;43(6):586-90.

Peptic Ulcer Disease

Surgery rarely needed Vagotomy Gastrectomy

Surgical Treatment for GERD

Surgical Treatment for GERD

Unresponsive to aggressive antisecretory therapy (proton pump inhibitors)

After surgery, some patients still require antisecretory therapy

Potential obstructive complications of Nissen: dysphagia rectal flatulence inability to belch or vomit

Right Inguinal Hernia

Hernia Inguinal

Inguinal Hernia

16th Century Hernia Surgery

21st Century Hernia Surgery

Hernia Surgery

Indications for surgery Emergent

Strangulated hernias Nonreducible bulge with pain, sometimes

after heavy lifting Urgent

Incarcerated hernias

Hernia Surgery

Indications for surgery Elective

Inguinal hernias watchful waiting recommended

Femoral hernias higher risk of strangulation Ventral hernias Umbilical

Normally resolve without intervention by age 5

Umbilical Hernia

Hernia Surgery: What about mesh?

Fewer recurrences 5-7% absolute risk reduction

More long-term complications requiring surgical intervention 3-5% absolute risk reduction

Scott N, Go PM, Graham P, McCormack K, Ross SJ, Grant AM. Open Mesh versus non-Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD002197. DOI: 10.1002/14651858.CD002197. Kokotovic D, Bisgaard T, Helgstrand F. Long-term recurrence and complications associated with elective incisional hernia repair. JAMA 2016 Oct 18; 316:1575.

Case: 6 year old boy with severe abdominal pain in the Peds ED

Small Bowel Obstruction

Heilman J. File:SBO2009.JPG [Wikimedia Commons Web site]. November 8, 2009. Available at: http://commons.wikimedia.org/wiki/File:SBO2009.JPG.

Large Bowel Obstruction

Heilman J. File:LargeBowelObsUp2008.jpg [Wikimedia Commons Web site]. August 28, 2008. Available at: http://commons.wikimedia.org/wiki/File:LargeBowelObsUp2008.jpg. Heilman J. File:LargeBowelObsFlat2008.jpg [Wikimedia Commons Web site]. August 28, 2008. Available at: http://commons.wikimedia.org/wiki/File:LargeBowelObsFlat2008.jpg.

A 48-year-old male presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 oclock position.

The most appropriate initial treatment would be topical: A. Botulinum toxin B. Clobetasol (Temovate) C. Capsaicin (Capzasin-HP, Zostrix) D. Nitroglycerin

Botul

inum

toxin

Clobe

tasol

(Temo

vate)

Caps

aicin

(Capz

asin-H

P, Z..

.

Nitro

glyce

rin

2%

71%

3%

24%

Anal Fissure

Anal Fissure Nonsurgical measures that are proven effective in

relaxing the sphincter: Topical nitroglycerin ointment Diltiazem, nifedipine (topical preparations usually

have to be compounded by a pharmacist) Botulinum toxin injected into the internal sphincter Corticosteroid creams may decrease the pain

temporarily Surgery: internal sphincterotomy Fargo MV, Latimer KM: Evaluation and management of common anorectal conditions. Am Fam Physician 2012;85(6):624-630.

Pilonidal Cyst

GiggsHammouri. File:Pilonidal cyst.JPG [Wikimedia Commons Web site]. April 1, 2010. Available at: http://commons.wikimedia.org/wiki/File:Pilonidal_cyst.JPG.

PREOP/PERIOP/POSTOP CARE WOUNDS INFECTIONS

Preoperative Workup

Source #1: 2014 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2007 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation. 2014;130:e278-e333

Preoperative Workup

Source #2: Feely MA, Collins CS, Daniels PR, et al. Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations. Am Fam Physician. 2013 Mar 15;87(6):414-418.

Free App: Joshua Steinberg

Preoperative Workup

No routine/indiscriminate testing Base testing on H&P, perioperative cardiac risk

assessment, clinical judgment Not required for cataract surgery

Preoperative Workup

EKG: Signs/symptoms of cardiovascular disease Consider in elevated-risk procedure,

patients with cardiac risk factors Not needed for low-risk procedures

Preoperative Workup

Noncardiac Surgery Risk of Cardiac Death or Nonfatal MI: Elevated ( 1%) Low (< 1%)

Ambulatory, breast, endoscopic, superficial, cataract

Preoperative Workup

Risk factors: Cerebrovascular disease Congestive heart failure Creatinine level >2.0 mg/dL Diabetes mellitus requiring

insulin Ischemic cardiac disease *Suprainguinal vascular

surgery, intrathoracic surgery, or intra-abdominal surgery

RFs % Risk major cardiac event (95% CI) 0 0.4 (0.05 to 1.5) 1 0.9 (0.3 to 2.1) 2 6.6 (3.9 to 10.3) 3 11 (5.8 to 18.4)

Revised Cardiac Risk Index (RCRI)

Preoperative Workup

Elevated cardiac risk and poor or unknown functional capacity

Only if a positive test would change management

Stress Tests

Preoperative Workup

CXR: New or unstable

cardiopulmonary signs or symptoms

Increased risk of postop pulmonary complications if results would change management

UA: Urologic procedures Implantation of foreign

material (e.g., heart valve or joint replacement)

Preoperative Workup

BMP: At risk of electrolyte

abnormalities or renal impairment (based on history, medications)

Glucose, A1c: Signs/symptoms or very

high risk of undiagnosed diabetes, if abnormal result would change periop management

CBC: At risk for anemia Significant blood loss

anticipated

Coags: On anticoagulants History of abnormal

bleeding At risk for coagulopathy

(e.g., liver disease)

Perioperative Areas of Focus

Anticoagulation management Venous thromboembolism (VTE) prevention Beta-blocker therapy Antibiotic prophylaxis Chronic disease

Anticoagulation Stop ASA 7-10 days (3 days?) pre-op (unless benefit

preventing ischemia outweighs bleeding risk), restart 8-10 days post-op

Stop warfarin 4-5 days pre-op Stop heparin

LMWH 12 hrs pre-op UFH

IV 4-6 hrs pre-op SQ 12 hrs pre-op

Devereaux PJ et al for the POISE-2 Investigators. Aspirin in Patients Undergoing Noncardiac Surgery. N Engl J Med 2014;370:1494-503.

Venous Thromboembolism

Assess risk Check renal function Consider prophylaxis Bridge therapy (treat w/ LMWH after holding

warfarin) for patients with mechanical heart valve, h/o VTE

BRIDGE trial: Do patients w/ atrial fibrillation on warfarin need bridge therapy with LMWH when warfarin is held pre-op?

Placebo was noninferior to LMWH with respect to preventing atrial thromboembolism

More bleeding complications in LMWH group Excluded patients: stroke, mechanical valves Relatively low risk population (only 13% high-

risk by CHADS2)

Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-33

In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?

A. Nonfatal MI B. Stroke C. Death D. Hypotension E. Bradycardia

Nonfa

tal M

I

Strok

eDe

ath

Hypo

tensio

n

Brad

ycardi

a

75%

5%0%0%

20%

In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?

A. Nonfatal MI RR 0.69 B. Stroke RR 1.76 C. Death RR 1.30* D. Hypotension RR 1.47 E. Bradycardia RR 2.61

INCREASED risk *excluding DECREASE trial data

Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative Beta Blockade in Noncardiac Surgery: A Systematic Review for the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):2246-64

Beta Blockade

Stay on them if already on them Modify or discontinue based on clinical

picture Assess risk (Revised Cardiac Risk Index) If administering perioperative beta blockers:

Start well in advance of surgery (2-7 d preop) Do not start on day of surgery

Perioperative Beta blockade? Not routinely in pts w/ uncomplicated HTN Increased incidence of CV death, nonfatal

ischemic stroke, nonfatal MI NNH 140 for pts > 70 yo 142 for men 97 for pts undergoing emergency surgery Jorgensen ME, Hlatky MA, Kober L, et al. beta-Blocker-Associated Risks in Patients With Uncomplicated Hypertension Undergoing Noncardiac Surgery. JAMA Intern Med. 2015 Dec;175(12):1923-31.

Perioperative Diabetes Management

Best if A1c < 7 Tight glycemic control controversial

140-180 may be adequate

Statins

Stay on them if already on them Consider initiating in selected high-risk

patients

Postoperative Care

Monitor cardiovascular, pulmonary, fluid status

Pain management Complications

Postop fever

Non-evidence based workup: 5 (or 6) Ws

Wind atelectasis Water UTI Wound wound infection Walk (Wegs) deep venous thrombosis Wonder drug drug fever Winnebagos (or upside down W) Mastitis

Postop fever

Recommendations for Evaluation of Fever Within 72 Hours of Surgery

O'Grady NP, Barie PS, Bartlett JG et al., American College of Critical Care Medicine, Infectious Diseases Society of America. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med 2008 Apr;36(4):1330-49.

Postop fever

Recommendations for Evaluation of Fever Within 72 Hours of Surgery CXR, UA, UCx not mandatory if fever is only

indication UA, UCx in febrile patients w/ indwelling catheter

> 72 hrs High level of suspicion for VTE in at-risk patients Open & culture incisions w/ signs of infection

Care of Surgical Wound

Sterile dressing 24-48 hrs Minor surgical wounds can be allowed to get

wet in the first 48 hours without increasing risk of infection

Extremity wounds may be covered with a clear film dressing (reduced rate of blistering, exudates)

Case: 23 yo man with swelling, redness, pain, pus from thigh

I & D of Skin Abscesses

Antibiotics after I & D? I & D alone is usually sufficient for uncomplicated

abscesses Indications: Large abscess > 10 cm, cellulitis,

immunocompromised, multiple or recurrent abscesses, extremes of age, failure of I&D alone

Singer HJ, Thode Jr. HC. Systemic antibiotics after incision and drainage of simple abscesses: A meta-analysis. Emerg Med J 2014;31:576-578.

I & D of Skin Abscesses

Slight benefit using trimethoprim-sulfamethoxazole after I&D of uncomplicated abscesses Increases cure rate by 7% (NNT = 14) Already high cure rates in control group 80-85%

Talan DA, Mower WR, Krishnadasan A, et al. TrimethoprimSulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016;374:823-832

Time Out

OTHER SURGICAL SPECIALTIES: TRAUMA SURGERY VASCULAR SURGERY THORACIC SURGERY OTOLARYNGOLOGY/HEAD AND NECK SURGERY UROLOGY NEUROSURGERY

TRAUMA SURGERY

Primary Survey: ABCDE

Airway Breathing Circulation Disability Exposure/Environment

Secondary Survey

Vital Signs Repeat Primary Survey Review patients history Physical exam: Fingers or tubes

in every orifice

Shock Classification

Signs of Basilar Skull Fracture

Periorbital ecchymosis (raccoon eyes) Mastoid ecchymosis (Battles sign) Hemotympanum

Raccoon Eyes (Periorbital Ecchymoses)

Clearing C-spines: NEXUS Criteria

When a significant mechanism of injury is present, a cervical spine is stable if: No posterior midline cervical tenderness No evidence of intoxication Patient is alert and oriented to person, place,

time, and event No focal neurological deficit No painful distracting injuries (e.g., long bone

fracture)

Clearing C-spines: Canadian C-Spine Rule

Only applies to GCS=15 and stable trauma Not applicable for:

GCS


X-ray if ANY of the following High Risk factors: Age >65 years Dangerous mechanism

fall from elevation 3 feet / 5 stairs axial load to head, e.g. diving MVC high speed (>100km/hr), rollover, ejection motorized recreational vehicles bicycle struck or collision

Parasthesia in extremities


If ANY Low-Risk factor present, assess clinically with ROM testing (If all NO: x-ray) Simple rear-end MVC which DOES NOT include the

following pushed into oncoming traffic hit by bus / large truck rollover hit by high speed vehicle

Sitting position in ED Ambulatory at anytime Delayed onset of neck pain Absence of midline C-spine tenderness


(If at least 1 low-risk factor present) Able to actively rotate neck 45 degrees left and right? If able then NO x-ray needed If unable, X-ray.

Clearing C-spines: Which is Better?

Sensitivity: Canadian 99.4% vs. NEXUS 90.7% Specificity: Canadian 45.1% vs. NEXUS 36.8%

Stiell IG, Clement CM, McKnight RD et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003; 349:2510-2518

C-Spine Films: Lateral

Monfils L. File:C1-C2 Lat.JPG [Wikimedia Commons Web site]. March 13, 2011. Available at: http://commons.wikimedia.org/wiki/File:C1-C2_Lat.JPG.

C-Spine Films: Odontoid

Monfils L. File:C1-C2 AP.JPG [Wikimedia Commons Web site]. March 13, 2011. Available at: http://commons.wikimedia.org/wiki/File:C1-C2_AP.JPG.

C-Spine Films: Flexion & Extension

Lamiot F. File:Cervical XRayFlexionExtension.jpg [Wikimedia Commons Web site]. November 10, 2010. Available at: http://commons.wikimedia.org/wiki/File:Cervical_XRayFlexionExtension.jpg.

VASCULAR SURGERY

Peripheral Vascular Disease


Intermittent claudication (many may not have classic symptoms)

Late symptoms: rest pain, ulcers, gangrene Risk Factors = CAD, esp. smoking Diagnosis: ABI, PE pulses, bruits, hair loss

(watering the plants), poor nail growth, dependent rubor, ulcers


Treatment: modify risk factors, exercise, meds (ASA, clopidogrel, cilostazol)

Ticagrelor no better than clopidogrel Hiatt WR, Fowkes FG, Heizer G, et al. Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease. N Engl J Med. 2017 Jan 5;376(1):32-40.


Surgery: not enough evidence to favor bypass surgery over angioplasty

Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002000. DOI: 10.1002/14651858.CD002000.pub2.

Medical vs. Surgical Management: Asymptomatic Carotid Artery Stenosis

No evidence clearly favoring: Carotid endarterectomy vs. carotid artery

stenting Surgery vs. medical management

Low rates of ipsilateral stroke in patients managed medically 1.68% all studies, 1.18% newer studies

Raman G, Moorthy D, Hadar N, et al. Management Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158:676-685.

THORACIC SURGERY

Aortic Aneurysm

Ruptured Aortic Aneurysm

Heilman J. File:CTRupturedTA.PNG [Wikimedia Commons Web site]. January 19, 2011. Available at: http://commons.wikimedia.org/wiki/File:CTRupturedTA.PNG.

USPSTF Recommendation for Ultrasound Screening for AAA

One time screening in men aged 65-75 who have ever smoked (B recommendation)

No recommendation for or against screening in men aged 65-75 who have never smoked (C recommendation)

Recommends against routine screening in women (D recommendation)

Coronary Artery Disease

Hggstrm M. File:Coronary arteries.png [Wikimedia Commons Web site]. January 19, 2011. Available at: http://commons.wikimedia.org/wiki/File:Coronary_arteries.png .

Indications for CABG

Disease in left main, or all 3 coronary vessels (L Cx, LAD, RAD)

Diffuse disease not amenable to PCI Severe CHF, diabetes

Valvular Surgery: Stenotic vs. Regurgitant Lesions

Stenotic: can be monitored until symptoms appear

Regurgitant: may require surgery even if asymptomatic carefully monitor LV function by echo

Aortic Stenosis: Bicuspid Aortic Valve

Lynch PJ. File:Heart_bicuspid_aortic_valve.svg[Wikimedia Commons Web site]. December 23, 2006. Available at: http://commons.wikimedia.org/wiki/File:Heart_bicuspid_aortic_valve.svg.

Aortic Stenosis

Classical presentation: asymptomatic, then angina, exertional syncope, dyspnea

After symptoms develop Average survival 2-3 years 75% die w/in 3 yrs w/out valve replacement

Aortic Stenosis: Workup

Echocardiogram mild/moderate AS q2-5 yrs severe AS annual (to check LV function)

Critical stenosis: Valve area < 0.8 cm2 or gradient > 50 mm Hg

CXR, EKG CT (thoracic ascending aortic aneurysm) NO stress testing

Transcatheter vs. Surgical Aortic Valve Replacement

Clear mortality benefit in high-risk pts w/ severe aortic stenosis (NNT = 20 to avoid 1 death at 1 year)

Similar benefit in intermediate-risk patients at 2 years

Popma JJ, Adams DH, Reardon MJ et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014 May 20;63(19):1972-81. Adams DH, Popma JJ, Reardon MJ et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis. N Engl J Med 2014;370:1790-8. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2016 Apr 28;374(17):1609-20.

Mitral Stenosis

Symptoms mimic CHF Atrial fibrillation, pregnancy bring out

symptoms

Mitral Stenosis: Treatment

Mild disease: diuretics Atrial fibrillation: rate control Surgery: > mild symptoms, or pulmonary

hypertension Balloon valvotomy, open commisurotomy, MV

reconstruction, MV replacement

Aortic Regurgitation

Causes: endocarditis, rheumatic fever, collagen vascular disease, aortic dissection, syphilis

Typical presentation: Initially asymptomatic, then subtle initial signs (decreased functional capacity or fatigue), then sx of L-sided heart failure

Aortic Regurgitation: Treatment

AV replacement even in asymptomatic patients before EF < 55 % or end systolic dimension

reaches 55 mm

Severe AR + normal LV function: afterload reduction w/ vasodilators, especially

nifedipine, can delay surgery

Mitral Regurgitation

Causes: infectious endocarditis, mitral valve prolapse, rheumatic fever

Surgery: if > mild sx If asymptomatic but EF < 60%, or end-systolic

dimension approaches 45 mm Usually MV repair preferred over replacement

What about Mitral Valve Prolapse?

Typical symptoms: chest pain, dyspnea, anxiety, palpitations

Treatment: reassurance no need for surgery

OTOLARYNGOLOGY HEAD AND NECK SURGERY

Otitis Media with Effusion

Descouens D. File:Tympan-normal.jpg. [Wikimedia Commons Web site]. November 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:Tympan-normal.jpg. welleschik. File:Trommelfell_Paukenerguss.jpg. [Wikimedia Commons Web site]. November 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:Trommelfell_Paukenerguss.jpg.

http://upload.wikimedia.org/wikipedia/commons/3/38/Trommelfell_Paukenerguss.jpghttp://upload.wikimedia.org/wikipedia/commons/3/38/Trommelfell_Paukenerguss.jpg

Otitis Media with Effusion Candidates for surgery

persistent hearing loss or other signs and symptoms recurrent or persistent OME in at-risk children regardless

of hearing status structural damage to the tympanic membrane or middle

ear Shared decision-making re: surgery Tympanostomy tube insertion is the preferred initial

procedure (+/- adenoidectomy in children 4 yo) Rosenfeld RM, Shin JJ, Schwartz SR et al. Clinical Practice Guideline: Otitis Media with Effusion Executive Summary (Update). OtolaryngologyHead and Neck Surgery 2016:154(2):201214

Indications for Functional Endoscopic Sinus Surgery (FESS)

Failed medical therapy for chronic rhinosinusitis

Nasal polyps

Luong A, Marple BF. Sinus surgery: indications and techniques. Clin Rev Allergy Immunol. 2006 Jun;30(3):217-22.

http://www.ncbi.nlm.nih.gov/pubmed/16785592

Epistaxis

Pressure Silver nitrate cauterization (only 1 side of nasal

septum at a time) Packing

Anterior: F/U w/ ENT w/in 2-3 days, avoid ASA & NSAIDs but can continue warfarin

Posterior: Admit Management of Acute Epistaxis. Author: Ola Bamimore, MD; Chief Editor: Steven C Dronen, MD, FAAEM http://emedicine.medscape.com/article/764719-overview#showall. Accessed February 24, 2017.

http://emedicine.medscape.com/article/764719-overview#showallhttp://emedicine.medscape.com/article/764719-overview#showallhttp://emedicine.medscape.com/article/764719-overview#showallhttp://emedicine.medscape.com/article/764719-overview#showall

For which of the following patients with recurrent pharyngitis/tonsillitis is tonsillectomy indicated?

A. History of peritonsillar abscess B. 2 episodes in each of the last 3 years C. 4 episodes in each of the last 2 years D. 7 episodes in the past year E. Allergies to or intolerance of multiple

antibiotics

Histo

ry of

perit

onsill

ar a..

.

2 epis

odes

in ea

ch of

the .

..

4 epis

odes

in ea

ch of

the .

..

7 epis

odes

in the

past

year

Allerg

ies to

or in

tolera

nc...

6%0%

13%

56%

24%

Tonsillectomy in Recurrent Pharyngitis/Tonsillitis: Paradise Criteria

At least 7 episodes in past year, or 5/yr x 2yrs, or 3/yr x 3 yrs Each episode: sore throat + one of the following:

T>38.3, cervical adenopathy, tonsillar exudate, Group A beta hemolytic strep test +

Episodes of strep throat properly treated with antibiotics Each episode documented OR subsequent observance by the

clinician of 2 episodes Modifying factors

allergies to or intolerance of multiple antibiotics, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), history of peritonsillar abscess

Ref: Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310:674-683.

Peritonsillar Abscess

Heilman J. File:PeritonsillarAbsess.png [Wikimedia Commons Web site]. May 13, 2011. Available at: http://en.wikipedia.org/wiki/File:PeritonsilarAbsess.jpg.

UROLOGY

Urinary Retention

Hellerhoff. File:Harnverhalt.jpg [Wikimedia Commons Web site]. January 8, 2010. Available at: http://commons.wikimedia.org/wiki/Harnverhalt.jpg.

Urinary Retention: Treatment with Catheterization

Look out for: hematuria, hypotension, postobstructive diuresis

How long to leave in? Unknown in pts with known or suspected BPH Alpha blocker at time of catheter insertion x 3 d. can

increase chance of returning to normal voiding Urinary retention from BPH: at least one trial of voiding

without catheter before considering surgical intervention Long-term treatment with 5-alpha reductase inhibitors can

prevent acute urinary retention in men with BPH

Kidney and Ureter Stones: Indications for Surgery

No passage after reasonable period of time Constant pain Hydronephrosis Damaging kidney tissue Constant bleeding Ongoing urinary tract infection Too large to pass on its own or stuck Growing larger Ref: National Kidney & Urologic Diseases Information Clearinghouses. Kidney Stones in Adults. http://kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/

http://kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/

Kidney and Ureter Stones:Treatment

Extracorporeal shock wave lithotripsy (ESWL)

Percutaneous nephrolithotomy Large stone Location does not

allow effective use of ESWL

Ureteroscopic Stone Removal

Case: 53 year old man with gross hematuria

Renal Cell Carcinoma: Risk Factors Men African Americans Exposure to household & industrial chemicals Hypertension Family history of RCC Occupational exposure to cadmium Dialysis patients w/ acquired cystic disease of the

kidney (30x) Hysterectomy (2x)

Higgins JC, Fitzgerald JM. Evaluation of Incidental Renal and Adrenal Masses. Am Fam Physician. 2001 Jan 15;63(2):288-295.

Renal Cell Carcinoma: Diagnosis

Classic triad in 10-15%: hematuria, flank pain, abdominal mass

Often diagnosed incidentally at asymptomatic stage

Imaging Sensitivities: CT 94%, ultrasound 79% MRI better than CT at distinguishing benign

lesions

Renal Cell Carcinoma

Treatment Nephrectomy Doesnt respond well to

XRT or chemo

Incidental Adrenal Mass

Depends on size Refer >6 cm for surgery (high incidence of cancer)

Incidental Adrenal Mass

>3 cm < 6 cm: MRI, additional endocrine eval

Bladder Carcinoma

Demographics: older Caucasian male smokers > 60 years old (80%) men 3x > women Caucasians > African Americans mortality higher in African Americans because of

delayed diagnosis Ref: Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder Cancer. Am Fam Physician. 2009 Oct 1; 80(7):717-723

Bladder Carcinoma

Risk factors: smoking 4-7x > nonsmokers Occupational exposure (aromatic amines

chemical dyes and pharmaceuticals; gas treatment plants)

Schistosoma haematobium Radiation treatment to pelvis Cytoxan Arsenic in well water Chronic infection

Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder Cancer. Am Fam Physician. 2009 Oct 1; 80(7):717-723

Bladder Carcinoma: Presentation

Painless hematuria Irritative symptoms (dysuria, frequency) Urinary obstructive symptoms Symptoms of advanced disease

lower extremity edema, renal failure, suprapubic palpable mass

Bladder Carcinoma: Diagnostics

Urine cytology 66-79% sensitive, 95-100% specific

Cystoscopy, bladder wash cytology Evaluate upper urinary tract CT preferred Metastatic workup

CBC, chemistries (alkaline phosphatase, LFTs), CXR, CT or MRI, Bone scan if alkaline phosphatase is elevated or other symptoms suggest bone metastases

Bladder Carcinoma

Treatment: Non-muscle invasive: transurethral

resection +/- intravesical chemotherapy (mitomycin) or immunotherapy (intravesical BCG)

Muscle-invasive: radical cystectomy +/- chemotherapy

Metastatic: chemotherapy

NEUROSURGERY

Case: 30 year old man with progressive sciatica

Herniated Disc

Edave. File:L4-l5-disc-herniation.png [Wikimedia Commons Web site]. April 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:L4-l5-disc-herniation.png.

When do patients need surgery for low back pain?

Severe or progressive neurologic deficits Serious underlying conditions are suspected Persistent low back pain and signs or symptoms of

radiculopathy or spinal stenosis Only if they are potential candidates for surgery or

epidural steroid injection (for suspected radiculopathy) MRI (preferred) or CT Chou R, Qaseem A, Snow V et al, Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007 Oct 2;147(7):478-91

Herniated Disc

Which patients need neuroimaging (noncontrast head CT) for headaches?

Emergent: headache and new abnormal neurologic findings

(e.g., focal deficit, altered mental status, altered cognitive function)

new sudden-onset severe headache (thunderclap) HIV-positive patients with a new type of headache

(consider) Urgent:

Patients > 50 years old w/ new type of headache but normal neuro exam

Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008 Oct;52(4):407-36.

Which patients need neuroimaging for headaches?

Atypical headaches and change in headache pattern (CT)

Unexplained focal neurological findings and recurrent headache (MRI)

Unusual precipitants Exertion, cough, Valsalva (MRI) Standing (MRI w/ gadolinium) Lying down (CT, MRI)

Late onset (> age 50), no other red flags (CT) Toward Optimized Practice. Guideline for Primary Care Management of Headache in Adults. Edmonton (AB): Toward Optimized Practice, 2012 Jul. 71 pp.

Which patients need lumbar puncture for headaches?

Sudden-onset, severe headache + negative noncontrast head CT (rule out subarachnoid hemorrhage)

Who needs neuroimaging before LP? Adult patients with headache and signs of increased intracranial pressure papilledema, absent venous pulsations on

funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation

Can this patient w/ HA go home?

Patients with a sudden-onset, severe headache who have negative findings on a head CT normal opening pressure negative CSF findings do not need emergent angiography can be discharged from the ED with follow-up

When do you order head CT in patient with mild traumatic brain injury (TBI)?

headache vomiting age greater than 60 years drug or alcohol

intoxication short-term memory

deficits

physical evidence of trauma above the clavicle

posttraumatic seizure Glasgow Coma Scale

(GCS) score less than 15 focal neurologic deficit coagulopathy

With loss of consciousness or posttraumatic amnesia only if one or more of the following is present:

Jagoda AS, Bazarian JJ, Bruns JJ Jr et al, American College of Emergency Physicians, Centers for Disease Control and Prevention. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008 Dec;52(6):714-48.

When do you order head CT in patient with mild traumatic brain injury (TBI)?

age 65+ yrs GCS < 15 focal neurologic deficit vomiting severe headache physical signs of a basilar

skull fracture

coagulopathy dangerous mechanism of

injury ejection from a motor

vehicle a pedestrian struck fall from a height of

more than 3 feet or 5 stairs

Consider in patients with no loss of consciousness or posttraumatic amnesia if there is

Can this patient w/ mild TBI go home?

Isolated mild TBI + negative head CT May be safely discharged from the ED However, inadequate data to include patients

with a bleeding disorder receiving anticoagulation therapy or antiplatelet

therapy; or had previous neurosurgical procedure

Inform about postconcussive symptoms

Phew!

Questions?

[email protected]

Surgical Problems in Primary CareFaculty DisclosureThe closest Ill get to being a surgeonRoad Map for Our JourneyTop 30 High Yield ItemsGastrointestinal problemsacute abdominal painRight Upper Quadrant PainSlide Number 8RUQ Ultrasound = Test of ChoiceCholangiocarcinomaCholangiocarcinomaSlide Number 12Cholangiocarcinoma:Klatskin tumorKlatskin tumor:Palliative stent placementRight Lower Quadrant PainCase: 34 yo man with Right Lower Quadrant Pain in Urgent CareMcBurneys Point (#1)Case: 34 yo man with Right Lower Quadrant Pain in Urgent CarePhysical DiagnosisLabsAlvarado (MANTRELS) ScoreAppendicitis on CTImaging: ACR appropriateness criteriaBottom Line: Diagnosis of AppendicitisCase: 34 yo man with Right Lower Quadrant Pain in Urgent CareWhat is the most appropriate treatment for this patient?Case: 34 yo man with Right Lower Quadrant Pain in Urgent CareCase: 34 yo man with Right Lower Quadrant Pain in Urgent CareCase: 34 yo man with Right Lower Quadrant Pain in Urgent CareUncomplicated Appendicitis: Antibiotics vs. SurgeryUncomplicated Appendicitis: Antibiotics vs. Surgery Meta-analysesNon-operative treatment of uncomplicated appendicitis in childrenAntibiotic treatment post appendectomy in childrenAppendicitis: Red FlagsAppendicitis: Red FlagsChan Ho ParkMeckels DiverticulumMeckels Diverticulum: Rule of 2sLeft Lower Quadrant PainDiverticulitisWhich one of the following is NOT associated with complications of diverticulitis?DiverticulitisDiverticulitisDiverticulitisTreatment of diverticulitis with antibiotics has been shown to reduce which of the following?Uncomplicated Diverticulitis: TreatmentDiverticulitis: TreatmentDiverticulitis: TreatmentAGA Recommendations: DiverticulitisWhich of the following is the most common cause of lower GI bleeding?Causes of lower GI bleedingDiverticulosisDiverticulosisDiverticulosisCase: 53 yo woman with hemorrhoidsHemorrhoidsVolvulusMidgut Volvulus:Malrotation of the GutMidgut Volvulus:Malrotation of the GutMidgut Volvulus:Malrotation of the GutMidgut Volvulus:Malrotation of the GutSigmoid VolvulusSigmoid VolvulusEpigastric PainCase: 34 yo man with epigastric pain Grey Turners SignCullens SignPancreatitisPeptic Ulcer DiseaseSurgical Treatment for GERDSurgical Treatment for GERDRight Inguinal HerniaHernia InguinalInguinal Hernia16th Century Hernia Surgery21st Century Hernia SurgeryHernia SurgeryHernia SurgeryUmbilical HerniaHernia Surgery: What about mesh?Case: 6 year old boy with severe abdominal pain in the Peds EDSmall Bowel ObstructionLarge Bowel ObstructionA 48-year-old male presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 oclock position.The most appropriate initial treatment would be topical:Anal FissureAnal FissurePilonidal CystPreop/periop/postop care woundsinfectionsPreoperative WorkupPreoperative WorkupPreoperative WorkupPreoperative WorkupPreoperative WorkupPreoperative WorkupPreoperative WorkupPreoperative WorkupPreoperative WorkupPerioperative Areas of FocusAnticoagulationVenous ThromboembolismBRIDGE trial: Do patients w/ atrial fibrillation on warfarin need bridge therapy with LMWH when warfarin is held pre-op?In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?Beta BlockadePerioperative Beta blockade? Not routinely in pts w/ uncomplicated HTNPerioperative Diabetes ManagementStatinsPostoperative CarePostop feverPostop feverPostop feverCare of Surgical WoundCase: 23 yo man with swelling, redness, pain, pus from thighI & D of Skin AbscessesI & D of Skin AbscessesTime OutOther surgical specialties: trauma surgery vascular surgery thoracic surgery otolaryngology/head and neck surgery urology neurosurgeryTrauma surgeryPrimary Survey: ABCDESecondary SurveyShock ClassificationSigns of Basilar Skull FractureRaccoon Eyes(Periorbital Ecchymoses)Clearing C-spines: NEXUS CriteriaClearing C-spines:Canadian C-Spine Rule Clearing C-spines:Canadian C-Spine Rule Clearing C-spines:Canadian C-Spine Rule Clearing C-spines:Canadian C-Spine Rule Clearing C-spines: Which is Better?C-Spine Films:LateralC-Spine Films:OdontoidC-Spine Films:Flexion & ExtensionVascular surgeryPeripheral Vascular DiseasePeripheral Vascular DiseasePeripheral Vascular DiseasePeripheral Vascular DiseaseMedical vs. Surgical Management: Asymptomatic Carotid Artery StenosisTHORACIC surgeryAortic AneurysmRuptured Aortic AneurysmUSPSTF Recommendation for Ultrasound Screening for AAACoronary Artery DiseaseIndications for CABGValvular Surgery:Stenotic vs. Regurgitant LesionsAortic Stenosis:Bicuspid Aortic ValveAortic StenosisAortic Stenosis: WorkupTranscatheter vs. SurgicalAortic Valve ReplacementMitral StenosisMitral Stenosis: TreatmentAortic RegurgitationAortic Regurgitation: TreatmentMitral RegurgitationWhat about Mitral Valve Prolapse?OTOLARYNGOLOGYHEAD AND NECK surgeryOtitis Media with EffusionOtitis Media with EffusionIndications for Functional Endoscopic Sinus Surgery (FESS)EpistaxisFor which of the following patients with recurrent pharyngitis/tonsillitis is tonsillectomy indicated?Tonsillectomy in Recurrent Pharyngitis/Tonsillitis: Paradise CriteriaPeritonsillar AbscessUROLOGYUrinary RetentionUrinary Retention:Treatment with CatheterizationKidney and Ureter Stones:Indications for SurgeryKidney and Ureter Stones:TreatmentCase: 53 year old man with gross hematuriaRenal Cell Carcinoma: Risk FactorsRenal Cell Carcinoma: DiagnosisRenal Cell CarcinomaIncidental Adrenal MassIncidental Adrenal MassBladder CarcinomaBladder CarcinomaBladder Carcinoma: PresentationBladder Carcinoma: DiagnosticsBladder CarcinomaneurosurgeryCase: 30 year old man with progressive sciaticaHerniated DiscWhen do patients need surgery for low back pain?Herniated DiscWhich patients need neuroimaging (noncontrast head CT) for headaches?Which patients need neuroimagingfor headaches?Which patients need lumbar puncture for headaches?Can this patient w/ HA go home?When do you order head CT in patient with mild traumatic brain injury (TBI)?When do you order head CT in patient with mild traumatic brain injury (TBI)?Can this patient w/ mild TBI go home?Phew!

Documents

Surgical Problems in Primary Care - UCSF Medical …€¢ 42 year old woman with right upper quadrant pain • Worse with eating • Nausea, no vomiting • No fever • Exam: –