Kaplan USMLE - Step 2 CK Lecture Notes 2017- Surgery

USMLE Step 2 CK λ Surgery

object. They do not have any incontinence during the night. Examination will show a weak pelvic floor, with the prolapsed bladder neck outside of the “high-pressure” abdominal area.

•For early cases, pelvic floor exercises may be sufficient.

•For advanced cases with large cystoceles, surgical repair of the pelvic floor is indicated.

•For extreme cases, surgical reconstruction of the pelvic floor may be needed.

STONES

Passage of ureteral stones produces the classic colicky flank pain, with irradiation to the inner thigh and labia or scrotum, and sometimes nausea and vomiting. Most stones are visible on non-contrast CT scan. Although there is an array of fancy gadgetry available to deal with urinary stones, intervention is not always needed.

•Small stones (≤3 mm) at the ureterovesical junction have a 70% chance of passing spontaneously. Such cases can be handled with analgesics, plenty of fluids, and watchful waiting.

•On the other hand, a 7-mm stone at the UPJ only has a 5% probability of passing. Intervention will be required.

The most common tool used is extracorporeal shock-wave lithotripsy (ESWL). Sometimes ESWL cannot be used (pregnant women, bleeding diathesis, stones that are several centimeters large). Other options include basket extraction, sonic probes, laser beams, and open surgery. Although there is specific therapy for the prevention of recurrences in defined types of stones, abundant water intake is universally applicable.

MISCELLANEOUS

Pneumaturia is almost always caused by fistulization between the bladder and the GI tract, most commonly the sigmoid colon, and most commonly from diverticulitis (second possibility is cancer of the sigmoid, and cancer of the bladder is a very distant third). Workup starts with CT scan, which will show the inflammatory diverticular mass. Sigmoidoscopy is needed later to rule out cancer. Surgical therapy is required.

Impotence can be organic or psychogenic.

•Psychogenic impotence has sudden onset, is partneror situation-specific, does not interfere with nocturnal erections (which can be tested with a roll of postage stamps), and can be effectively treated with psychotherapy only if it is done promptly.

•Organic impotence, if caused by trauma, will also have sudden onset, specifically related to the traumatic event (after pelvic surgery, because of nerve damage, or after trauma to the perineum, which involves arterial disruption).

––Because of chronic disease (arteriosclerosis, diabetes), organic impotence has very gradual onset, going from erections not lasting long enough, to being of poor quality, to not happening at all (including absence of nocturnal erections).

––Sildenafil, tadalafil, and vardenafil have become first choice therapy in many cases, but there are many other options, including vascular surgery (well-suited for those with arterial injury), suction devices (can be used on almost everybody), and prosthetic implants.

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Organ Transplantation 1300

Chapter Title

Learning Objectives

Describe the policies related to waiting lists for organ transplantation

Describe the common complications in organ transplantation

Selection of donors has been liberalized tremendously to help alleviate the acute shortage of organs. Virtually all brain-dead patients are potential candidates, regardless of age. Donors with specific infections (e.g., hepatitis) can be used for recipients who have the same disease. Even donors with metastatic cancer can donate corneas.

The general rule for regular physicians is that all potential donors are referred to the harvesting teams, and they will exclude the few that cannot be used at all.

A positive HIV status is the only absolute contraindication to organ donation, though recent reports of donating to HIV+ recipients may change that policy.

Transplant rejection can happen in 3 ways: hyperacute, acute, and chronic rejection.

Hyperacute rejection is a vascular thrombosis that occurs within minutes of reestablishing blood supply to the organ. It is caused by preformed antibodies. It is prevented by ABO matching and lymphocytotoxic crossmatch, and thus it is not seen clinically.

Acute rejection (most common) occurs after the first 5 days, and usually within the first 3 months. Episodes occur even though the patient is on maintenance immunosuppression. Signs of organ dysfunction suggest it, and biopsy confirms it.

•In the case of the liver, technical problems are more commonly encountered than immunologic rejection. Thus, the first goal when liver function deteriorates posttransplant (rising g-glutamyltransferase [GGT], alkaline phosphatase, and bilirubin) is to rule out biliary obstruction by U/S and vascular thrombosis by Doppler.

•In the case of the heart, signs of functional deterioration occur too late to allow effective therapy, thus routine ventricular biopsies (by way of the jugular, superior vena cava, and right atrium) are done at set intervals. The first line of therapy for acute rejection is steroid boluses. If unsuccessful, antilymphocyte agents (OKT3) have been used though their high toxicity is a problem. Newer anti-thymocyte serum is tolerated better.

•Efforts are underway to come up with cellular MRI as a non-invasive way to diagnose rejection, without the need for biopsy. The field of allotransplantation is in continuous flux.

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USMLE Step 2 CK λ Surgery

Chronic rejection is seen years after the transplant, with gradual, insidious loss of organ function. It is poorly understood and irreversible. Although we have no treatment for it, patients suspected of having it have the transplant biopsied in the hope that it may be a delayed (and treatable) case of acute rejection.

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SECTION II

Surgical Vignettes

Trauma 001

Chapter Title

PRIMARY SURVEY: THE ABCs

Airway

1.A patient involved in a car accident is fully conscious, and his voice is normal.

A very brief vignette, but in terms of the airway, the airway is fine.

2.A patient with multiple stab wounds arrives in the ED fully conscious, and he has normal voice, but he also has an expanding hematoma in the neck.

3.A patient with multiple stab wounds arrives in the ED fully conscious, and he has a normal voice, but he also has subcutaneous air (emphysema) in the tissues in the neck and upper chest.

The airway may be fine now, but it is going to be compromised soon. Intubation is indicated now before an emergency situation develops. Orotracheal intubation with rapid-sequence anesthetic induction and pulse oximetry (or topical anesthesia) is preferred in the setting of a trauma center. Blind nasotracheal intubation is often performed by paramedics in the field. The patient with subcutaneous emphysema requires fiberoptic bronchoscopy (more details follow).

4.A patient involved in a severe car accident has multiple injuries and is unconscious. He is breathing spontaneously but his breathing sounds gurgled and noisy.

Altered mental status is the most common indication for intubation in the trauma patient. Unconscious patients with Glasgow coma scale ≤8 may not be able to maintain or protect their airway. Orotracheal intubation would be preferred here, but no anesthetic is needed.

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USMLE Step 2 CK λ Surgery

5.An unconscious patient is brought in by the paramedics with spontaneous but noisy and labored breathing. They relate that at the accident site the patient was conscious, but was complaining of neck pain and was unable to move his lower extremities. He lost consciousness during the ambulance ride, and efforts to secure a nasotracheal airway were unsuccessful.

Although it is obvious that the patient has a cervical spine injury, his airway has to be managed first. Orotracheal intubation can still be performed with manual in-line cervical immobilization or over a flexible bronchoscope. Some prefer nasotracheal intubation in this setting if facial injuries do not preclude it.

6.A patient involved in a severe automobile crash is fully awake and alert, but he has extensive facial fractures and is bleeding briskly into his airway, and his voice is masked by gurgling sounds.

Securing an airway is mandatory, but the orotracheal route may not be suitable. Cricothyroidotomy is probably the best choice under these circumstances (except in the pediatric population because of the high-risk of airway stenosis in children, in whom a tracheostomy should be performed because the cricoid cartilage is much smaller than in the adult).

Breathing

7.An unconscious trauma patient has been rapidly intubated in the ER. He has spontaneous breathing and bilateral breath sounds, and his oxygen saturation by pulse oximetry is above 95.

As far as breathing is concerned, he is moving air (physical examination) and getting oxygen into his blood (oximetry). Deterioration could occur later, but right now we are ready to move to C in the ABCs.

Circulation

8.A 22-year-old man arrives in the ED with multiple gunshot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, and anxious. He asks for a blanket and a drink of water. His BP is 60/40 mm Hg, pulse 150/min, and thready.

We recognize the picture of shock. In the trauma setting, shock is most commonly hypovolemic caused by bleeding, but other possibilities are pericardial tamponade or tension pneumothorax. Although each of these could occur with transabdominal gunshot wounds, it is less likely (than a direct thoracic injury), so most likely the source of shock is bleeding.

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Management includes several simultaneous interventions:

•Large-bore IV lines

•Foley catheter

•Preparation of blood products for immediate exploratory laparotomy for control of bleeding

•Fluid and blood administration

The old emphasis on fluid resuscitation first has given way to a preference for control of the bleeding site as the first order of business, particularly when surgery will have to be done anyway. When surgery might or might not be needed as with blunt trauma, fluid resuscitation is still performed first, in part as a diagnostic test (patients who respond promptly and remain stable are probably no longer bleeding).

9.During a bank robbery an innocent bystander is shot multiple times in the abdomen. When the emergency medical technicians arrive, they find him to be in shock. A fully staffed trauma center is 2 miles away from the site of the shooting.

An ambulance can travel 2 miles in 2 minutes—maybe 3. The point of the vignette is that elaborate attempts to start an IV at the site and begin to infuse Ringer’s lactate would waste precious time that would be best spent moving the patient to a place where the urgently needed laparotomy can be done (“scoop and run”).

10.A 19-year-old male is shot in the right groin during a drug deal gone bad. He staggers to the hospital on his own, and arrives in the ED with BP 90/70 mm Hg and pulse 105/min. Bright red blood is squirting from the groin wound.

The point of this vignette is that control of the bleeding by direct local pressure is the first order of business before volume resuscitation is started. Finger pressure is used in the civilian setting, where typically there is a single patient and multiple health care workers. In the military combat setting, where the ratio is reversed, tourniquets are life-saving.

11.A car accident victim arrives at the ED both unconscious and with spontaneous but noisy breathing. His BP is 80/60 mm Hg, pulse 95/min. Head and neck veins are not obviously distended. While the anesthesia team is intubating him, another team is placing a central line for central venous pressure (CVP) measurement, and others are examining his chest and abdomen.

The emphasis on control of bleeding first and fluid replacement later cannot be implemented if we do not know yet where the bleeding is coming from, and whether it might stop spontaneously or not. In a case like this, two large (16-gauge) peripheral lines should be started, and Ringer’s lactate should be rapidly infused.

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USMLE Step 2 CK λ Surgery

At one time central venous lines were deemed essential for fluid resuscitation, but short, wide catheters in peripheral veins work better, and placing them does not interfere with other ongoing therapeutic and diagnostic maneuvers. Central lines should only be used when no other access is available or there is a need for monitoring. Percutaneous femoral vein catheter is an acceptable alternative when peripheral IVs are hard to start. Saphenous vein cut-downs, which were very popular in the 1950s, have also made a comeback as a suitable route.

12.A 4-year-old child has been shot in the arm in a drive-by shooting. The site of bleeding has been controlled by local pressure, but he is hypotensive and tachycardic. Two attempts at starting peripheral IVs have been unsuccessful.

Up to age 6, the access of last resort is intraosseous cannulation in the proximal tibia and femur. The initial bolus of Ringer’s lactate would be 20 ml/kg of body weight.

13.During a wilderness trek, a 22-year-old man is attacked by a bear and bitten repeatedly in the arms and legs. His trek companion manages to kill the bear and to stop the bleeding by applying direct pressure, but when paramedics arrive 1 hour later, they find the patient to be in a state of shock. Transportation to the nearest hospital will take at least 2 hours.

All the training that paramedics took to enable them to infuse IV fluids has not been wasted. In the urban setting we now prefer rapid transportation to the hospital (“scoop and run”), but in this case prompt and vigorous fluid resuscitation is in order. The preferred fluid is Ringer’s lactate, infusing at least 2 liters in the first 20–30 minutes.

14.A 22-year-old gang member arrives in the ED with multiple gunshot wounds to the chest and abdomen. He is diaphoretic, pale, cold, shivering, anxious, and asking for a blanket and a drink of water. His BP is 60/ 40 mm Hg and pulse 150/min and thready.

Hypovolemic shock is still the best bet, but the inclusion of chest wounds raises the possibility of pericardial tamponade or tension pneumothorax. As a rule, if significant findings are not included in the vignette, they are not present. Thus, as given, this is still a vignette of hypovolemic shock, but you may be offered in the answers the option of looking for the missing clinical signs: distended neck veins (or a high measured CVP) would be common to

both tamponade and tension pneumothorax; and respiratory distress, tracheal deviation, and absent breath sounds on a hemithorax that is hyperresonant to percussion would specifically identify tension pneumothorax.

15.A 22-year-old gang member arrives in the ED with multiple gunshot wounds to the chest and abdomen. He is diaphoretic, pale, cold, shivering, anxious, and asking for a blanket and a drink of water. His BP is 60/40 mm Hg and pulse 150/min and thready. He has distended veins in his neck and forehead. He is breathing okay and has bilateral breath sounds and no tracheal deviation.

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This is clearly describing the presentation of pericardial tamponade. Although the FAST exam or a formal transthoracic echocardiogram could confirm the diagnosis, it is clinically apparent and time is of the essence. Management entails evacuation of the blood in the pericardial space. This could be done by pericardiocentesis or pericardial window. If positive, follow with thoracotomy and then exploratory laparotomy. Fluid administration or blood transfusions would also help the patient with pericardial tamponade, but only as a temporizing measure while preparations are being made to evacuate the pericardial sac.

16.During a domestic dispute a young woman is stabbed in the chest with a 6-inch-long butcher knife. On arrival at the ED she is found to have an entry wound just to the left of the sternal border, at the fourth intercostal space. BP is 80/50 mm Hg and pulse 110/min. She is cold, pale, and perspiring heavily. She has big distended neck and facial veins, but she is breathing normally and has bilateral breath sounds.

There is no question that this is pericardial tamponade, and the location of the entry wound leaves no doubt as to the source: a stab wound to the heart. That will need to be repaired, and performing the median sternotomy will automatically open the pericardial sac and relieve the tamponade. Many trauma surgeons will not bother with previous pericardiocentesis or pericardial window, and will go straight to the OR.

17.A 22-year-old gang member arrives in the ED with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. His BP is 60/40 mm Hg and pulse 150/min and thready. He is in respiratory distress and has big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds.

This vignette describes a tension pneumothorax. Management entails immediate decompression using a large-bore needle or IV catheter placed into the right pleural space, followed by chest tube placement on the right side. Watch out for a trap which offers chest x-ray as an answer choice. Although this would confirm the diagnosis, it is clinically apparent and time is of the essence. Patient will die if sent to x-ray. Exploratory laparotomy will follow.

18.A 22-year-old man is involved in a high-speed, head-on automobile collision. He arrives in the ED in coma, with fixed, dilated pupils. He has multiple obvious fractures in both upper extremities and in the right lower leg. His BP is 70/50 mm Hg, with a barely perceptible pulse 140/min. His CVP is zero.

We have pointed out that shock in the trauma setting is caused by bleeding (the most common source), pericardial tamponade, or tension pneumothorax. This case fits right in, but the presence of obvious head injury might lead you into a trap: the question will offer you several kinds of intracranial bleeding (acute epidural hematoma, acute subdural hematoma, intracerebral bleeding, subarachnoid hemorrhage, etc.) as answer choices, all of which would be wrong. Intracranial bleeding can indeed kill you, but not by blood loss. There isn’t enough

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