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Pestana Audio Notes

[Audio 1]: Trauma

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A: If expanding hematoma on neck (or SQ emphysema): answer is intubate with orotrachal or nasotracheal
intubation to establish airway even if pt is still talking (along with rapid anesthetic induction with pulse oximetry)
Airway indication: unconscious!! (the MC reason for intubation in trauma) and dont need anesthesia
o If neck broken but unconscious, airway still comes first before neck xray also use nasotracheal
intubation (over orotracheal intubation)
Awake but gurgling from bloody facial fractures: need airway but cant go thru nose or mouth b/c of multiple
fractures go thru neck directly DO NOT pick ER tracheostomy; instead: cricothyroidotomy also, do NOT pick
little catheter with high freq ventilation esp if there is also head injury b/c need lots of ventilation if head injury
B: BS b/l (see chest trauma for when breathing needs to be helped)
C:

o Shock reasons:
blood loss (empty veins),
PT, or
pericardial effusion (last two have to be chest trauma, and big distended veins (high CVP)); PT
interferes with breathing and pericardial effusion does not.
o Management: first stop bleeding then LR and blood
o Injury to pelvis bleeding out: not tourniquet, not blind clamp, but DIRECT PRESSURE
o Route for fluid: 2 IV 16 gauge line in arms, or femoral vein or ankles.
Monitor fluid needs: 1) hour urinary output and 2) CVP
o Peripheral lines failed in child, next option: intraosseous cannulation in prox tibia with LR bolus
20ml/kg
o If CT: can still give fluid while making window to get in and drain (even thou distended neck veins its not
the same thing as CHF where you DONT give it)
o PT: no tests, just immediately decompress: needle/bore cath thru 2nd intercostal space to be followed by
chest tube put under suction and under-water seal.
o Fixed dilated pupils has closed head injury; but if in shock too, its NOT from the head!!!
o Other reasons for shock w/o trauma:
GI bleed:
Cardiogenic shock: distended veins, high CVP; tx as having MI (dont give fluid)
Vasomotor shock: loss of peripheral vascular tone
Bee sting: warm and flushed, low CVP
PCN allergy: warm and flushed, low CVP
Spinal anesthesia block too high: warm and flushed, low CVP
Tx for all: vasoconstrictors, volume replacement
Review of trauma from HEAD to TOE
o Head:
Impaled foreign body (anywhere): dont remove until in OR with pt anesthetized ]]]
LINEAR skull fracture plus scalp lac: suture and clean in ER
Comunuted, depressed skull fracture + scalp lac: OR for repair
Base of skull fracture:
Raccoon eyes: ecchymoses around eyes after head trauma (pt would be in coma)
Clear fluid dripping out of nose/ear in coma (CSF)
Ecchymoses by ear (name?)
Management? Airway, CT scan (looking for hematoma that may need to be evacuated and
identify fracture at skull fracture base but no tx is really needed for it CSF leak stops
on own), also look at neck (CT or xray) since this was severe trauma.
Lucid phase: epidural hematoma (same side as dilated pupil)
Tx: CT showing midline shift with lens shape, then emergency OR craniotomy of clot, Px:
excellent
Subdural hematoma: massive trauma, and can be similar to events leading to epidural, can wake up
a little but NO lucid phase.
Lg SD: Tx: CT shows biconcave semilunar, crescent with craniotomy and decompression;
Px: not good

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Small SD: Tx if SD w/o lateralizing Sx or deviation of midline: nothing b/c its small (but
brain can swell! so give hyperventilation, avoid fluid, fureosmide, mannitol, without
losing cranial perfusion, plus ICP monitoring)
Diffuse axonal injury: blurring of the gray-white junction w/punctate hemorrhages
Tx: no OR, centered on ICP and monitoring ICP just like in small SD
Chronic SD hematoma: in eldery or alcoholic
A fall a few wks ago followed by slow loss of brain function; Tx: craniotomy with
hematoma evacuation

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[Audio 2]: Trauma continued

Neck: all GSW to middle neck go to OR even if stable!

Also if stab or GSW to neck with hemo instability: always operate
Pt coughing up blood or expanding hematoma from GSW/SW OR (it is to a vital organ, then must operate)
Stab wound to neck can have more discretion
Exception: GSW upper neck (not friendly surgical territory): Tx is angiogram and embolization (dont have to
worry about GI up this high, just vessels)
Exception: GSW to nect base: tests before OR: arteriogram, esogoscopy, bronchoscopy, etc. b/c its at a border of
neck and chest so we need to know where to put the incision
Stab wounds
o aSx in middle of neck (with normal vitals and no hematoma/coughing blood): dont have to operate (had it
been GSW operate b/c mid of neck!)
SC injuries
o Central cord syndrome: neck hyperextension, closer to center go to arms with burning sensation in arms
and normal in legs.
o Best way to look at SC: MRI
o High dose steroids given asap after SC injury: shows better outcomes (first thing to do b4 neurosurg gets
involved)
Chest trauma:
o Rib fracture: local nerve block to take away pain and still be able to breath w/o narcotic
o SW causing PT: CXR first b/c hemodynamically stable; then chest tube (no needle) goes in 2nd intercostal
space in front of chest (if emergency, then needle followed by chest tube)
o SW causing hemothorax w/ hemo stable: CXR first; then chest tube goes at base
If 120 cc from lung (no thoracotomy)
If lots of blood (1200cc) with low BP from a systemic vessel (intercostal?) therefore, then
MUST do thoracotomy to control bleeding
Keeps draining 300cc of blood over 4 hrs eventually thoracotomy [rule: if adds up to 600 cc over
6 hrs thoracotomy]
o Both PT and hemothorax: either 2 chest tubes, or one that extends up to drain air and blood
o Blunt trauma to chest 3 issues:
Obvious injury: show up later
Pulm contusion: show up later
Myocardial contusion: monitor cardiac enzymes, b/c shows up later
Aorta transection: severe deceleration injury must look: at CXR to see if wide mediastinum, then
spiral CT, then arteriogram of aorta to be certain (can be a risky test)
o Flap wound on chest: inspire air goes in, expiration flap closes = PT = sucking chest wound
Tx: Vaseline gauze taped on 3 sides to get air out
o Flay chest: chest wall shows paradoxical bleeding
Tx: if in pulm distress its from pulm contusions more than the flay chest so tx is for underlying
pulm contusions; fluid restriction and monitoring blood gasses
If goes on respirator b/c breathing so difficult: MUST PUT CHEST TUBE b/c PEEP
causes leak thru holes from rib fractures, which causes tension pneumo
o Sternum fracture: must monitor heart b/c can show up as myo contusion Tx for contusion is just like
MI Tx
o Emphysema causes: perforation of esophagus (i.e. from endoscopy), tension pneumo, major tracheal-
bronchial injury (needs bronchoscopy w/then surgical repair)

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Large air leak from CT: placed from tension pneumo, lots of air coming out of CT, no lung expansion =
bronchial injury!!! = do bronchoscopy w/surgical repair
o Air embolism: injury to major bronchus and vessel next to one another = sudden cardiac arrest from air
embolism
Supraclavicular node biopsy w/hissing sound pt drops dead
Removal of central line while sitting up pt drops dead
o Fat embolism tx: respiratory support, monitoring blood gasses
Abdominal trauma:
o Every GSW below the nipple is the ABDOMEN therefore, ex-lap
o SW showing omentum sticking out ex-lap
o SW to obese woman attacked with switch blade no peritonitis, no penetration seen no ex-lap but finger
probe instead
o Blunt trauma causing Shock: 1.5L, lungs can hold that but seen on CXR, arms cant, so pelvic, femur, and abd
are left.
Pelvic: would be fractured; femur: would be fractured
But no ex-lap right away need imaging first:
DPL: only gives yes or no answer (unstable)
CT scan: excellent way for finding blood (where it is coming from b/c shows injury)
o But must be stable; may eventually not need OR
FAST (unstable)
o Spleen injury: will try to repair before trying to remove!!!!
Have to remove though if shattered
Or salvageable but so many other injuries that need to remove quickly instead of repair
o Coagulopathy: from getting LOTS of blood! (10-12 units)
Give FFP and platelet packs
o Hypothermia: stop surgery pack, close up temporarily, and return later
o Compartment syndrome: swollen organs during surgery after lots of blood and fluids
Tx: temporary closure
Can also have compartment syndrome later on, and the skin cuts thru the sutures decreased
urine output, decreased respiration tx: temporary closure w/re-opening with sheet or mesh
o Pelvic hematoma: tx if non-expanding w/o Sx: do not touch!
But w/fracture: rectum and urinary bladder (and vagina in women, and urethra in men) must be
evaluated proctoscopic/pelvic exam & cystoscopy to rule out rectal and bladder and vaginal
injuries
Pelvic fracture w/hemo-instability (and no abd bleeding) that does NOT respond to fluids
source of bleeding is symptomatic pelvic bleeding (must stop bleeding)
Tx: external fixation of the pelvis (b/c embolism is difficult)
Urological injury
o Blood in urine is Sx from kidneys, bladder, or urethra (males only)
o Kidney: broken ribs, no pelvic fracture, blood in urine
o Bladder: bl in urine and pelvic fracture (and also add urethra if male)
o Ex: GSW just above pubis with blood in urine injury is to bladder and do ex-lap
o Ex: blunt trauma with blood at meatus retrograde urethrogram (DO NOT PUT FOLEY)
o Ex: high riding prostate and the urge to urinate retrograde and dx: posterior urethral injury
Posterior urethral injury = defer repair; anterior urethral injury = emergently repair
o Ex: pelvic fracture with gross blood in urine and more after foley inserted: BLADDER
Dx: retrograde cystogram
If injury to trigone (lower bladder): empty bladder and take another picture
o Kidney injury: Dx with CT; Tx: MOST injury to kids do not require surgical repair
Kidney injury that wasnt repaired, but 2w later: shortness of breath and flank brewry AV fistula
Dx: arteriogram, Tx: surgical repair
Kidney injury w/sudden onset HTN prob ischemia to kidney due to stenosis of one of vessels
Kidney injury later: microscopic hematuria in adult it doesnt matter, in children it matters (esp
if magnitude of trauma doesnt justify hematuria) congenital anomaly of urinary tract
urological evaluation
o Scrotal hematoma: sonogram to determine if testicular fracture (if yes, needs surgical repair)
o Penile shaft hematoma w/normal glans: fracture of tunica alboginea tx: prompt surgical repair
Extremity injury: the question is about big vessels being damaged or not
o GSW: bullet can stay if not in bad location i.e. antero-lateral thigh (far from femoral)
o GSW to ant-medial of upper thigh, normal pulses, no hematoma, femur intact on XRAY: however, femoral A
near entrance wound tx: arteriogram even though pulses to determine cut
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If hematoma, then no arteriogram

Hematoma, no DPs, shattered bone: first tx bone, then vascular, then nerve repair
Forearm and lower leg = most likely to be site of compartment syndrome
Can be caused by prolonged ischemia followed by reperfusion
Tx: vascular repair and then fasciotomy last
Tissue damage from GSW: proportional to velocity squared and mass
High velocity bullet: wide debridement and prob amputation
Crush injury 2 concerns
Myoglobinuria & Hyperkalemia (alkanylize urine to protect kidneys from myo), plus use fluids &
osmotic diuretics too
Muscles swelling can lead to compartment syndrome

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Burns:
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Biggest goal here is MASSIVE IRRIGATION

Ex: go to ER? NO must first wash before leaving for ER (sooner the better for irrigation)
Ex: drinks alkaline sln: swallow diluted vinegar, OJ, lemons to neutralize
Electrical burn: more tissue destruction than appears; can get cataracts and demyel later; common
injuries include: posterior dislocation of bones and vertebral compression fractures
o Inside burns (i.e. with firemen): respiratory burn is confirmed w/bronchoscopy
Tx: decide tx by blood gasses and if compromised, then give resp support.
Also monitor carboxyhemoglobin (CO poisoning)
o Circumferential burns: third degree produces edema and eschar of skin leads to cut-off circulation
Monitor: Doppler study of bl flow, pulses, etc
Tx: escharotomies w/o need for anesthesia (esp when circumferential around chest)
o [Audio 4] Fluid resuscitation: judge by response of urinary output, central venous pressure
o Percent of body burns: head 9%, ea upper ex 9%, trunk 4 9s, each lower 2 9s
Child: head: 2, upper ex: 1 each, lower extremities get 3 total, trunk is 4
Kg body weight * percent of body burned up to 50% (b/c thats the max) *4ccs = number of ccs
of the balanced electrolyte sln (LR) that pt needs in first 24h with given in first 8h, the other
in next 16h (dont use glucose b/c causes osmotic diuresis that skews urinary output)
Second day: of first day requirement; third day: no more fluids b/c get diuresis since fluid in
burn returns BACK to the pt
If 20% burn, start with 1,000 cc/h and then monitor UO to fine-tune in the adult (for total use
formula above)
o If getting too many fluids, reduce it! Ex) man 70kg putting out 270 cc/hr should be up to 140 which
would be 2cc/hr (more to protect kidneys), but >200 is way too much
o Ex) on 3rd day of burn, has 200-300 cc/hr even after IVF were d/c this is OK b/c diuresis from burn
edema returning to body (this is NORMAL)
o FLUID RESUSITATION: 2-4 in adults, 4-6 in kids
o Other burn care: any burn that breaks skin, must give tetanus prophylaxis
Silver sulfadiazine
Dimaphenide acetate: good for deeper burns (deeper penetration) or if cartilage is involved (but
can hurt and produce acidosis)
Eye burns: triple antibiotic ointment
Pain: must do IV meds (not SQ/IM)
Grafts: after 2-3w
Nutritional support: high calorie, high nitrogen
Rehab: day 1
o If very small, limited 3rd degree burns: early excision & graft
Ex) leather, white, anesthetic (aka 3rd degree) small area from hot iron: early excise & graft
Bites & stings
o Dog bite or caught animal: dont need shots b/c too painful and can just watch animal
o If animal not caught: immunoglobulin + vaccine
o Snake bite: up to 1/3 dont get venimation not unless pain and discoloration at site of bite (present in
30m), is there venimation (just observe)
If venimation: anti-venom at least 5 viles; also bl for typing and cross-matching, coag studies and
renal studies (b/c venom can affect these)
If in child: still lg amount of anti-venom (dont change dose for child)
o Bee hive anaphylaxis: tx: epinephrine w/stinger removal
o Spider bites
Black widow: severe musc cramps; tx: IV calcium gluconate (or musc relaxants)

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Brown recluses spider (painful bite): ulcer w/necrotic center w/halo of erythema; tx: local excision
of ulcer and maybe skin graft eventually; dapsone may help
Human bite: worst bite for bacteriology
Tx: massive irrigation and debridement in OR by ortho

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[Audio 5]
Orthopedics
o Developmental dysplasia of the hips: sonogram, abduction splitting with palvik harness
o Septic hip: age 3 febrile illness before
o Avascular necrosis: age6, hip/knee pain, ataxic gait; dx: XRAY; tx: casting containing the femoral head w/in
the acetabulum w/crutches
o Slipped fatty: fat boy around age13, flex hip and rotates externally and cant be rotated medially; dx: XRAY;
tx: surgical pins to put femoral head back in place
o Browndes dz: cont bow leg >3yo; disturbance of medial prox tibial growth plate; tx: surgery
o Pain in knee w/o swelling: no problem with tendons
Swelling of knee is poor mans MRI of the knee
o Osgood-schlatter dz (osteochondrosis) of tibial tubercle: pain over tibial tubercle; tx: cast 4-6 wks
(extension or cylinder cast); first try RICE
o Club foot (talipes equinovarus): at birth; tx with serial casts starting at birth
Adduction of forefoot treat first
Inversion of foot next treat (varus)
Plantar flexion of ankle and internal tibia rotation lastly treated (equinus)
respond quickly in 6mos, then if no response, surgery btwn 6-8mos but before the age of 1yo
o Scoliosis: continues until skeleton has reached maturity (at menarche, 80% mature), so if still hasnt gotten
period, then dz will continue to progress and needs brace.
o Broken bones in children (angulation): dont do ANYTHING unless w/supracondylar fracture or growth
plate.
o Supracondylar fracture of humerus in children: high incidence of neurovascular compromise must
monitor DPs, cap filling, or Doppler studies.
o Growth plate in two pieces: open reduction and internal fixation needed (unlike if only in 1 piece)
o If bone tumor in kids: REFER!
o Only bone tumor in adults that is primary: MM!
If mets: women its breast, men its lung b/c prostate is blastic
If soft tissue sarcoma (just on side of bone): MRI first best dx test (DO NOT pick an answer that is
invasive needs a big open biopsy done by an EXPERT!)
o Pt jumps from window and fractures joint: get AP and lateral of joint above and below, plus xray of lumbar
spine (cld have been compressed)
o Clavicular fracture: figure 8 device keeps the shoulder back
o Ant dislocation of the shoulder: holding arm but externally rotated as if to shake hands; damages
axillary N; dx: Xray AP & lateral; tx: reduction
o Posterior dislocation (less common): caused by all muscles contract at same time (ie electrical burns,
epileptic seizures), cant dx w/regular XRAYs instead need axillary or scapula-lateral views of XRAY
repeat XRAYs of shoulder is correct ans; tx: reduction of shoulder
o Colles fracture: dinner-fork deformity of distal radius; osteoporotic woman; tx: closed reduction and long-
arm cast
o Monteggia fracture: prox ulna fracture and ant dislocation of radial head = open reduction and internal
fixation for ulna and close reduction of dislocated radius
o Galeazzi fracture: opposite of above
o Scaphoid (carponavicular) fracture: notorious for negative XRAYs
If very displaced/angulated that is shows up on XRAY: open reduction with internal fixation is
preferred b/c nonunion is highly likely
o Displaced femoral neck fracture (from hip fracture): due to blood supply area, low likelihood fem head
will survive is low so OR, remove head, replace w/metal prosthesis
Vs: intertrochanteric fracture (from hip fracture): these can heal so open reduction and
internal fixation w/immobilization + POST-OP ANTI-COAGULATION
Femoral shaft tx: intramedullary rod; if bleeding to cause shock, then ex-fix
Posterior dislocation of hip: shortened and internally rotated, caused by dashboard hit of knees
driving femur backwards; ER due to bl supply of femoral head!; tx: reduction ASAP
o Collateral ligament tears tx: hinge cast unless more injuries too surgery
o ACL tear for sedentary lifestyle tx: immobilization & rehab (athlete): surgery)
o Tibia/fibula fracture tx: casting for those that are easily reduced; intramedullary nailing for those not
easily aligned

Compartment syndrome first sign: Pain with passive extension of toes; tx: ER fasciotomy (in leg, open all
four compartments through 2 incisions)
Loss of pulses isnt always common b/c you can have compartment syndrome w/less than drop of
30mmHg and that still brings in pulses
Achilles repair: open repair for fast, or casting in tip-toe (equinus) position for several months
Ankle fracture: if displaced open reduction and internal fixation
Open fracture: ER, need OR
Gas-gangrene: high dose IV penicillin, surgical debridement, hyperbaric O2 to deactivate toxin
Radial nerve: groove of humerus, cant dorsiflex wrist, injured during mid-shaft humerus break
Tx: reduce fracture to see if nerve function returns
If was reduced and then lost nerve function nerve entrapment need to operate with open
reduction
Posterior dislocation of knee injures: popliteal artery must chk pulses, Doppler, maybe arteriogram;
tx: immediate reduction in order to not press upon popliteal A (bad collaterals)
Ex: pt falls on feet must look for compression fractures of spine
Ex: MVA w/chest trauma & facial lac must chk knees from dashboards posterior dislocation of hip (an
ortho ER since head of femur has feeble bl supply) do hip XRAYs to look for hip dislocation
Ex: MVA with closed head injury must chk cervical spine

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AUDIO 6: starts with compartment syndrome and continues to orthopedic trauma

Open fracture: close and fix within 6hours

Hip hit dashboard with knees: Shortened, adducted and internally rotated leg = posterior dislocation in the hip
o Ortho ER due to femoral head tenuous bl supply (Dx with hip XRAY)
Gas gangrene tx: IV penicillin, surgical debridement, hyperbaric O2 to deactivate the toxin
Posterior dislocation of knee blood supply: popliteal artery leg gets ischemic so do arteriogram, Doppler, and
immediately reduce the dislocation to restore bl flow
Hand problems:
o Carpel tunnel: dx: XRAY, tx: splints and anti-inflammatories; if surgery do electromyography before
o Trigger finger: females, flexed, Tx: steroid injections, then surgery if it doesnt work
o De quervians tenosynovitis: wrist flexed with simultaneously thumb extention; pain reproduced by holding
thumb into fist and ulnar deviation simultaneously; tx: steroid injection is the best!
o Pulp of finger abscess = felon; tx: immediate surgical drainage and decompression
o Game keepers thumb: injury of ulnar collateral ligament of thumb (i.e. when falling when skiing); tx:
casting b/c can lead to more injury
o Jersey finger: ring finger doesnt flex; tx: splinting; Mallot finger: Cannot extend middle finger; tx: splinting
o Finger amputated: wrap in saline moistened gauze, wrap in plastic bag, place bag on bed of ice
Back pain:
o Lumbar disc herniation: Electrical shock shoots down leg, keeps flexed, positive straight leg test; peak age is
45; its L4-5 if by big toe and L5-S1 if by little toe b/c of dermatomes; tx: bed rest; if getting weaker =
surgery; if sphincter defect = caudal equine syndrome, then its surgical ER
o Metastatic malignancy to back: worse at night, get bone scan (radionucleide scan of bone most sensitive
to detect early mets, but also positive if fracture so get tracer xray after to rule out fracture if positive)
Ulcers:
o Management: control of DM, keep leg horizontal
o Vs ulcer a/w PAD in smoker/high cholesterol
o Venous stasis ulcer: above medial malleus with hyperpigmentation (use stockings, and if bad: surgery)
o SCC from chronic draining sinus in lower leg: looks like dirty ulcer, with heaped up tissue growth around
edges (from chronic osteomyelitis draining, or from third degree burn that was never cured) AKA
marjolins ulcer; dx: biopsy heaped up tissue on edge; tx: wide resection
Foot pain:
o Plantar fasciitis: Heal pain, overweight, worse in morning, xray: bony spur, tenderness on PE over spur
Tx: not surgical excision of bony spur, but supportive management and pain meds so you step on
whole foot; usually goes away
o Mortons Neuroma: Forefoot pain with btwn 3 and 4 toes from High heel shoe-wearer; inflmm of common
digital nerve; tx: conservative by wearing better shoes; or excise neuroma
o Gout: Swelling redness and pain at first metatarsal joint; dx: serum uric acid or tap joint

AUDIO 7: starts with pre-op and post-op care

Do surgery after 6mos out from MI

Needs abd aorta an surgery, and has angina so first get coronary revascularization before surgery
High risk for surgery: all related to smoking due to inability to ventilate properly
o Operate when? Cessation of smoking for 8weeks, plus rehab -> better to operate
Liver risk: need a functioning liver to use anesthesia for operation
o If severe cirrhosis: dont operate
Death occurs via high CO heart failure w/low PVR in liver failure
Nutritional risk:
o Judge: weight loss exceeds 20% of TBW, albumin <3, anergy to skin test antigen, transferrin <200
o Above have higher mortality rate when undergoing surgery
o Tx: brief period of nutritional support: 4-5d preoperatively, preferably 7-10d gets feedings tube into GI
tract
Metabolic complications:
o No surgery in diabetic ketoacidosis (i.e. in acute cholecystitis) 1st fix metabolic abnormality

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Post-op fever:
o Malignant hyperthermia: After anesthetic exceeding 104F; plus met acidosis and hyperCa; due to lack of
enzyme to break down succinylcholine; tx: IV dantrolene
o Bacteremia: 45 min after cystoscopy, chills and fever spike of 104F; tx: blood cultures X3, empiric ABs
o Post-op d1 fever: most likely due to atelectasis; dx: CXR; tx: improving ventilation, and ultimate therapy
would be bronchoscopy to get into brachial tree and take out plug that is causing the atelectasis
o Post-op d1 fever lasting until post op d3: pneumonia developed from atelectasis
o Post-op d3 first fever: UTI
o Post-op d5 first fever: DVT
o Post-op d7 first fever: wound infection
o Post-op d10 fever: wonder where? Abscess; or wonder drugs
Post-op chest pain:
o Severe chest pain: either MI or PE differ based on when happened
o MI: post op day 1-2; tx: dont use clot busters
o PE: longer than 1-2 days; no hypercarbia which is more indicative of resp failure; tx: heparin, or IVC filter
o Aspiration from emesis: bronchoscopy for lavage; then bronchodilators and resp support, also steroids
o Pulmonary TB pt gets surgery: damaged lungs, pt declines during surgery, was getting positive pressure
ventilation must have gotten a tension PT (BP dropping and CVP going up)
Post-op Altered mental status:
o First thing to chk is blood gas most likely hypoxic
o From ARDS: in a pt who has had lots of complications with pulm infiltrates with low pO2 and no congestive
heart failure; Tx: PEEP and mechanical resp support; also chk for abscess (CT scan)
o Alcoholic with hallucinations: DTs post-operatively, tx: IV alcohol
Post-op Urinary complications:
o Urinary retention esp those in lower abs surgeries, 6hr post-op; tx: catheter in and out, if continues, then
make indwelling
o No urine with catheter: not from low fluids, not from renal failure (would be at least a small amt); so think
of mechanical problem; tx: check catheter (it must be mechanical)
o Oliguria: prb low fluids or renal failure; dx: bolus IV fluid to tell difference if no increase in urine, due to
RENAL FAILURE; OR measure urine Na concentration (will be HIGH if RENAL FAILURE, >40, VS <20, also
measure FENA); tx for RF: fluid restriction
Post-op Abd distention:
o Paralytic ileus: Post-op d4 ex-lap, abd distension without BS, XRAY dilated loops w/o air-fluid levels, lab
tests? Serum K b/c hypoK can make ileus worse
o SBO: if longer than post-op d4 (d6-7), no bowel sounds, no gas mechanical! Dx: barium study w/serial
XRAYS will eventually make it down if ileus, but will STOP if SBO. Tx: re-operation
o Olgovies syndrome: massive colonic dilation, elderly pts who are not active and immobilized by surgery
that isnt even abd, then gets massive distension of colon (similar to ileus); tx: colonoscopy to suck out gas,
also to rule out CA, then leave in rectal tube to allow continued exit of gas

AUDIO 8: post-op care

Wound complications

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Wound dehiscence: Salmon soaking dressings, skin intact, other deeper layers have healed, pink fluid is
peritoneal fluid; complications: evisceration; tx: careful protection of wound, keeping ab wall together; later
repair abdominal wall
o Evisceration: cover bowel with warm, moist, saline-soaked dressings and then rush to ER for repair
o Infection: AB tx for skin flora; if pus, must drain, if fluctuant, must drain (abscess); dx: US
o Fistula: bowel content draining from bowel, afebrile (not leaking); most eventually heal!!! Esp if from
sigmoid to ab wall b/c not taking away water or nutrients really; dont pick colostomy!
o Fistula high in GI tract: not leaking necessarily, but need to manage b/c HIGH in GI tract; tx: NOT
emergent OR, but: start with fluid and electrolyte replacement, enteral nutritional replacement distal to
fistula or parenteral, protect abd wall with ileostomy bag, znOxide, suction device, not necessarily surgery
Fistula NEEDS surgery when: FETID: foreign body, epithelialization (wont close), tumor (when
fistula occurs thru tumor & not healthy tissue), Infection/irradiated tissue/IBD, Distal obstruction
Hypernatremia: if occurred over short period of time, can correct quickly (i.e. was in coma; if occurred over long
time like 5d, change serum Na slowly or will kill pt (i.e. pt was NOT in coma) but put volume back in without
changing tonicity split rate of correction i.e. D5W w/1/2 NS to replace vol w/o quickly correcting tonicity
o If occurred over long period of time tx: isotonic fluids if slightly alkalotic, NS>LR
o Short period of time: 3% saline
hypoK: can give 20mEq/hr to correct (i.e. diabetic ketoacidosis)
hyperK: the best thing to use is IV Ca gluconate b/c it works fastest
Met acidosis from lactic acidosis Tx: LR!!!! For volume expansion b/c you want to correct the underlying
problem.
Met acidosis from loss of bicarb (fistula): can now give bicarb; in IV fluids, bicarb given last minute in fluid or
give in fluids as precursor as acetate or lactate
Met alk (vomit): saline >LR, and hydrogen donor, or give 5-10 mEq/hr KCl to enable kidney to use Cl for retrieval
of Na and not bicarb/H ions. ******KCl only with functioning kidneys!!!!!******

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AUDIO 9: General surgery

GI
Barretts: can do Nissan fundoplication vs. long-term proton-pump inhibitors
o Before doing surgery, do a lot of eso & stomach studies beforehand
Achalasia: more common in women, a functional problem, learn to sit up straight so liquids can pass
o Manometry best b/c its a motility problem
o Tx: dilations, heller myotomy, etc.
Eso CA dx: barium swallow endoscopy w/biop CT for operative or not tx: Transhiatal esophogectomy
Mallory-weiss: tear that affects ONLY the mucosa of the esophagus tx: endoscopy
Borhaves syndrome: leukocytosis, extreme pain, this is perf of lower esophagus **bleeding isnt a main part of the
presentation; dx: gastrographing swallow (using water-soluble medium to demonstrate leak); then barium if
negative, followed by immediate surgical repair
Eso perforation is MC as iatrogenic!!
SBO: if no gas in colon (complete ob) then wait 24h only before surgery; if gas (partial ob) then wait 3-4d before
surgery; complication: strangulation (the 5 things to worry about)
o SBO due to hernia: operate right away (unlike w/adhesions)
o **If severely dehydrated, or electrolyte problem, do NOT first OR even if bad must first rehydrate pt
Appendicitis:
o ER OR always get before it perforates; if needs Dx study: either US or CT

AUDIO 10: General surgery

GI continued
R-sided CRC: bigger lumen, usu NO obstruction, usu BLEEDS, but pt usually cant see = anemia presents instead
L-sided CRC: obs!!!, if bleeds, its not occult but overt
CD surgery? Only for chronic bleed, obstruction, fistula, perforation
UC surgery?
o Toxic megacolon, UC for >20y, excessive hospitalizations, interferes with nutritional status, long-term on hi
dose steroids
o **rectal mucosa always has to be removed**
C-dif Dx: toxin identification in stool; Tx: stop AB, NO anti-diarrheal meds, Flagyl, vanco, OR replace gut flora
Ano-rectal dz:
o Management always begins with ruling out CANCER
o Hemorrhoids: rectal exam and proctosigmoidal exam to r/o CA
Internal hem Tx: rubber band ligation, laser

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External hem Tx: former surgery w/anesthesia b/c of pain

Anal Fissure: young women MC, pain on defecation, blood streaks; Dx/Tx: rectal exam/endoscopy, stool
softeners, topical agents; also, things to change tight sphincter: nitrates, lateral internal sphincterotomy,
forceful dilation, Botox injections to paralyze sphincter
o Ischioanal abscess: if in diabetic! Then it could be the beginning of necrotizing fasciitis part of correct
answer would include CLOSE F/U after drainage of abscess
o Fistula-in-ano: previously had anal abscess that was drained b/c drain was thru skin so fistula formed over
that; tx: fistulotomy with unroofing
o SCC of anus: more common in HIV+, homosexuals, HPV of anus; mets to LN of groin! And abdomen
(adenocarcinoma of rectum mets to LN of only abdomen)
Tx: first shrink (NIGRO protocol) w/chemo and radiation followed by surgery
GI bleeding dz:
o Upper GI bleed dx: endoscopy
o Ex) Dark Red Blood in stool, and dont want to do endoscopy, pt is active bleeding based on vitals, hes
young so its from UGI bleed do NG tube to recover blood and prove its upper GI even thou bl is thru
lower GI then do endoscopy finally
o Ex) Active bleeding, blood in stool, NG tube shows NO blood, vital unstable; if fluid is white, bleed from duo;
if fluid green, then its NOT upper GI
So r/o upper now either colon or SB bleed
If active bleed, wouldnt be smart to do colonoscopy b/c blood obscures field
Do anoscopy to see if hemorrhoids
2cc/min+: arteriogram w/potential embolization or tagged red cell
<2cc/min: watchful waiting, colonoscopy after bleed stops
<2cc but >0.5: tagged/labeled red cell study
o Ex) Melena last occurred 2d ago: dx is with upper and lower endoscopy b/c cant see with NG tube since its
been 2d
o Ex) 7yo boy with blood BM: meckels, dx: radiolabeled technecium scan to find gastric mucosa
o Ex) ICU pt vomiting a lot of BRB: stress ulcers in gastric mucosa; every pt in ICU gets Nexium; tx:
arteriography w/embolization
Acute abdomen:
o Due to: perforation (constant pain, pain everywhere, not wanting to move), obstruction (colic pain),
inflammation (gradual and builds up, localized to area, ie appendicitis, cholecystitis)
o Tx for acute abd: ex-lap after lots of tests to r/o pneumonia or MI
o Tx for acute abd w/ascites: gram stain ascites fluid and treat medically b/c its SBP
o Tx for perforation: ex-lap
o Urethral stone: IVP, ultrasound, CT scan, sx inc pain that radiates to groin, blood in urine, etc.
o Diverticulitis: fever, leukocytosis, palpable mass, pain in LLQ
o Volvulus tx: protosigmoidal exam to release air and untwist, leave long rectal tube to prevent twisting
again; may need sigmoid resection if repetitive episodes; Dx: parrots beak showing dilation in RUQ
o Mesenteric ischemia: ex-lap to resect bowel & assess damage

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AUDIO 11: General Surgery
Hepatobiliary
o Hepatic adenoma: young woman on OCPs, presents suddenly with signs of intra-abd bleeding and
unstable vitals; dx: CT scan; tx: surgical resection
If sudden bleed during preg (7mos.): bleeding aneurysm of smaller artery i.e. hepatic
o Acute cholangitis causing hepatic abscess: drain percutaneously
o Amebic abscess in liver: Flagyl; if refractory, then DRAIN!
o Hemolytic jaundice labs: elevated indirect bili, everything else normal
o Hepatitis labs: hepatic jaundice, elevation of both types of bili, high ALT/AST (in thousands), moderate
elevation of alk phos
o Obstructive jaundice labs: hi direct, very high alk phos (6X UL), transaminases are high but not in
thousands
o CA that cause obstruction: head of panc tumor, cholangiocarcinoma, adenocarcinoma of duodenum that
begins at the ampula vater (occludes biliary tract); dx: CT
***If cant see on CT: ERCP***
Ampullary CA: wld also cause anemia, occult bl in stool; DONT do CT scan b/c these tend to be
small; do endoscopy (dont even need ERCP)
o US for acute cholescystits shows 3 things: stones in GB, pericholecystic fluid, thickened GB wall
Operate later after antibiotics and inflmm cools down
Operate sooner if pt doesnt get better, or if diabetic male ER choly

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Acute ascending cholangitis: IV ABs and ER ERCP or PTC or surgery ; presentation: worse fever, worse
white count, very high alk phos
o Biliary pancreatitis: US, conservative therapy first followed by elective choly b/c MOST STONES PASS; if
doesnt work, then do ERCP w/sphincterotomy
o If US ever inconclusive: can use HIDA scan to show acute cholecystitis diagnostic if doesnt fill GB
Pancreas
o Acute panc eval of urinary vs serum amylase/lipase: if 3-4d post onset, get urinary
o Distinguish btwn edematous panc or hemorrhagic panc: look at HCT/HGB high if edematous, lo if hem.
Edematous Tx: NPO, IV fluids, rest
Hemorrhagic Tx: will get panc abscesses, so look daily w/CT and drain immediately; can show up
as late as 10d later
o Ransons criteria: prognosis of panc based on presentations; they include
Low HCT, elevated bl glucose, high WBC, low Ca = bad Px
At 48h: BUN going up, meta acidosis, low pO2 = very bad Px
o Panc pseudocyst: from acute panc or from trauma, 5w later, collection is located in lesser sac; get US/CT
4 courses: resolves (w/in 1st 6w), ruptures, erode into bl vessels & hemorrhage, turns into abscess
& sepsis (after 6weeks) therefore, first few wks post dx, OBSERVATION w/CTs. If persists >6w,
cystogastrostomy in the old days, or percutaneous radiological drainage, OR endoscopic internal
drain by hooking together posterior wall of stomach to panc pseudocyst
o Chronic panc pain tx: ERCP to look for surgical solution to pain
Exceptions to hernia repair: usu repair electively, but do NOT repair if
o Child <2yo w/umbilical hernia (closes by itself)
o aSx inguinal hernia: treat!
o Long-standing non-reducible hernia: elective surgery
o Short-standing non-reducible hernia: ER surgery
o

AUDIO 12: General Surgery
Breast
o Phylloides: requires tissue diagnosis; necessitates removal
o Intraductal papilloma: must get mammo to see if underlying malignancy, also get ductogram or retro-
aerolar exploration to remove duct
o Abscess: only in lactating women otherwise, would be cancer
o Pregnancy limits tx for CA: no radiation therapy, no chemo in first trimester; no need to end preg.
o Trauma to breast: doesnt exclude b. CA b/c trauma is usu how breast CA is brought to pt 10ttn..
o Inflmm CA of breast: need to do rad/chemo before resection
o Even though lobular can occur bilat, same management as ductal, no need for double mastectomy
o DCIS: no need for axillary sampling; other tx includes mastectomy, or lumpectomy and radiation
o Systemic tx for: pre-meno, post-meno use hormonal, also use systemic for positive nodes, also for distant
mets
o Bone mets best test: Bone scan! (better than xray), or MRI; tx: radiation therapy, ortho stabilization; like the
pedicles of the veterbra
Endocrine
o Mass? FNA followed by surgery if positive for tumor or indeterminate
o Indicators of CA: male, single nodule, hx of radiation to head/neck, older age
o Signs of hyperT with lump dx: hormone levels, followed by uptake scan
o Thyroid in LN: represents mets from follicular CA of the thyroid
o Glucagonoma: measure glucagon and CT to look for tumor

AUDIO 13: General Surgery

Surgical HTN
o Conns syndrome: measure ratio
o Also see Pheo, coarctation of aorta
o Coarctation of aorta: CXR to see intercostal vessel affect on ribs, also, can do TEE, spiral CT, or MRI angio to
view
o Flank brewery/upper abd: renovascular HTN
Young women: fibromuscular dysplasia; dx: duplex or arteriogram; tx: dilate w/stents
Older pts: plaque from occlusive disease
Pediatric Surgery
o Birth-24hrs

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Esophageal atresia: Sx excessive salivation; dx: NG tube w/baby-gram (XRAY) showing NG tube
coiled backwards w/air in GI tract (MC: blind pouch at upper end and fistula btwn eso and
trachea); tx: first do other tests b4 OR = VACTER (echo for heart, US for kidneys)
Imperforate anus: if fistula, then less urgency; if none, then determine how high blind pouch is
(XRAY with upside down baby); if very close, simple repair immediate; if far, then diverting
colostomy for surgery that is more intense later (before toilet training age)
Bowel hernia thru diaphragm: always on left, baby tachypnic; usu born to mom w/o prenatal
care; tx is NOT immediate OR they need 2-3 d to develop pulm function since compressed lung is
small on respirator (ECMO = extra-corporeal membrane oxygenation)
Gastroschisis: no membrane, bowel had been in amniotic fluid, normal cord, defect to right of cord
Tx: get venous access in addition to repair for TPN b/c bowel is not going to work for 1mo
since had been sitting edematous in amniotic fluid
Omphalocele: membrane with bowel/liver inside, cord goes to sac
Tx: construction of a silastic silo to house and protect bowel, and ea day squeeze bowel in;
then close defect
Extrophy of the urinary bladder: pubic symphisis didnt close & bladder didnt close;
**urgency** - repair in first day-2 of life
Duodenal Atresia: Vomit green fluid after first feed, double bubble sign on XRAY w/no gas in rest
of bowel, plus baby has Downs
Could also have malrotation or annular pancreas
Malrotation: some air filled loops of bowel beyond duodenum
Tx: bypass the area that is occluded
The worst of the 3 is malrotation b/c of ischemia **urgency** - repair asap
o Test for sure with barium swallow (riskier, but more diagnostic) or enema (safer)
Intestinal atresia: many air-fluid levels, not an issue w/genes, due to vascular accident in utero
**no need to look for other congenital abnormalities**
1-2 months of life
NEC key is starts when feeding starts: 4d old pre-me, feeding intolerance, ab distention; tx: stop
feeds, IV fluids and nutrition, broad-spec ABs; surgery only if bowel DIES shown by ab wall
erythema, pneumoperitoneum, air in biliary tree
Meconium ileus due to CF: 3d old full term w/feeding intolerance and billous vomit; XRAY:
dilated loops of SB & ground-glass in lower abd born to mom with CF; dx: gastrographing enema
makes diagnosis to show micro-colon b/c feces never got in + helps dissolve meconium b/c draws
fluid into lumen!!!!
Malrotation later in life: 3 wk, billous vomit, trouble feeding, double-bubble w/normal gas
pattern in rest of bowel (malrotation?)
Pyloric stenosis: 3 week projectile vomiting; dx: US b/c barium will make child vomit; tx: dont
jump to surgery b/c babies are dehydrated correct that first! then randsted pylorotomy
Biliary atresia: HIDA scan 1 week after phenobarbital therapy; 1/3 cant be repaired and need
liver transplant
Hirschsprugs: 1 mo, rectal exam is explosive, constipation with xray showing gas and dilated
loops of bowel; can be long or short so presentation varies; if exam shows full rectal vault and child
sometimes soils (its psychological); dx: full thickness biopsy of rectal mucosa
Later in life:
Intussception: colicky pain, comes and goes, right side b/c term ileum goes into asc colon

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AUDIO 14 & 15: Cardiothoracic

Congenital

o Vascular ring: trouble swallowing, resp distress; dx: barium swallow showing extrinsic compression,
bronchoscopy showing segmental tracheal compression (also r/o tracheal malasia); tx: surgery dividing the
smaller of the 2 aortic arches
o VSD: IF located LOWER in membranous septum: WATCHFUL WAITING b/c more likely to close
o PDA: use indomethacin in pre-me but cant use if baby in CHF need surgery then
o Tetralogy of Fallot: able to last until 5, 6, 7yo as blue kid
o AS: surgery for: gradient >50mmHg, or first indication of CHF, syncope, angina
o AR: surgery for: ventricle starts to dilate; can also get acute if endocarditis from drug abuse Tx: ER valve
replacement, IV ABs, and continued ABs for long time
o MS: surgery usu when pt very Sx; prefer to REPAIR>replace (repair with comissurotomy)
o MR: surgery usu when pt very Sx; prefer to REPAIR>replace (repair w/anuloplasy)
Coronary Dz:
o Intervene when progressive, unstable, no longer responding to medical management: get cardiac cath

70% occlusion of 3 arteries, 65% EF, good distal vessels = ideal candidate for surgical CABG
if was just 1 artery = balloon dilation
Chronic constrictive pericarditis: surgery

o
Lung:
o Lung CA dx: broncoscopy w/biopsy for central, and transthoracic need biopsry for peripheral
If not sufficient: thoracotomy w/wedge resection
Must do PFTs first also if going to do a pneumonectomy needs FEV1 at least 800 after surgery
Also do V/Q scan to see what percent that lung contributes to pulm function
If liver mets, other lung mets, carina mets = NO surgery!
Ex) if same lesion 1-2 years ago = NOT CA no further workup needed
Ex) Peripheral lesion: sputum cytology and CT or percutaneous biopsy
Calcified mass is more likey benign than not calcified mass
Surgery ONLY if non-small cell (sm cell gets rads and chemo, NO surgery)
Vascular
o One exception to legs as mainly arteriosclerotic the arms: subclavian steal syndrome = plaque right
before take-off of vertebral A; sx: during arm use, difficulty speaking, vertigo, tingling arm; dx: arteriogram
that demonstrates retrograde flow thru the vertebral artery; tx: bypass to bring blood to arm w/o stealing
o AAA: 6cm or bigger = must operate; if 4cm or less = watchful waiting
Dx: US
Symptomatic (i.e. tender): will rupture in 1-2d
Back pain & low BP: retroperitoneal rupture
Can treat w/stents: need at least 2.5cm neck
o Intermittent claudication: only surgery when it interferes with life severely
Dx: Doppler study for pressure gradients
No gradient: dz in small vessels = no surgical soln
Gradient: arteriogram to show stenosis = surgery after
Tx: long segment occluded = bypass; short segment = angioplasty with stent
o Emboli to leg: from a-fib, pulseless, pale, cold leg
Dx: Doppler
Tx: embolectomy with folgarty catheter; if incomplete, could bust clot medically; if had for 6-8hrs,
get prophylactic fasciotomy to avoid compartment syndrome
o AD: sounds like MI, enzymes negative, widening mediastinum
Dx: spiral CT (also MRI angio, TEE)
Tx: asc aorta: surgery, desc aorta: medical management
Dermatology
o SCC: goes to LNs (BCC do not)
o Dx: full thickness biopsy inc normal skin
BCC Tx: small margins
SCC Tx: .5-2cm margins; may need to do LN dissection
o Melanoma
Tx: <1mm, 1inch margins; >1mm, larger borders, >4mm has very bad Px
can mets very late i.e. melanoma of toe nail removed and mets to liver yrs later
Ophthalmology
o Kids:
White reflex, amblyopia (permanent after 7yo), strabismus (must be surgically corrected, the
sooner the better); strabismus later in life (5yo) = severe refraction problem b/c crossing eyes to
see near things (tx: glasses)

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AUDIO 16: General Surgery

Ophthalmology Continued
o Adults
Chemicals in eye: what to do before pt is d/c? test pH of eye
Floaters during day? retinal detachment also with flashes of light, dark cloud at top
Halos around lights? acute angle glaucoma
CRAO tx on way to hospital: pushing eye in and out, plus breathing into paper-bag to dilate
ENT
o Thyroglossal cyst surgical tx: remove cyst, middle segment of hyoid bone and track that lead to base of
tongue; sometimes radionucleotide scan before to find normal thyroid location
o Can do FNA of head/neck CA or of supraclavicular nodes
o Cystic hygroma: must do CT scan first to show infiltration into mediastinum

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Bells palsy: treat with antiviral and steroids

Facial N tumor: gradual Bells palsy; tx: Gadolinium-enhanced MRI
Pleomorphic adenoma: benign, sx include no pain, no pain of facial nerve; tx is NOT enucleation of tumor
b/c it will grow back do superficial parotidectomy or complete parotidectomy if tumor is deep to facial N
sparing the N
o Enlarged node of neck from possibly lymphoma: FNA first step; then surgical removal of LN
o Head and neck CA: panendoscopy DO NOT BIOPSY a piece of the mass b/c you may want to remove mass
later on best to have a virgin neck
RF: AIDS and smoking and drinking (multiplicative effect)
o Juvenile nasopharyngeal angiofibroma: benign, in young, growth destroys nearby structures = must
remove
o Nosebleed due to HTN in elderly: not local pressure, no anterior packing, no meds NEEDS posterior
packing or surgery w/ligation of offending vessels
o Spinning/dizziness: rm spinning its inner ear; youre spinning its brain
Neurosurgery
o TIA follow-up? Duplex scan followed by carotid endartarectomy
o tPA: use for both early strokes and MI
o Hi dose steroids dec ICP in brain tumors
o Subarachnoid hemorrhage steps: CT (maybe spinal tap, but should never be done first) arteriogram to
locate aneurysm can surgically clip or radiologically insert endovascular coil
o Prolactinoma therapy: bromocriptine or surgical removal (trans-sphenoidal) who want to get pregnant or
fail to respond to bromo
o Pituitary apoplexy: long-standing presence of pituitary issue (headache, b/l hemianopsia) followed by
sudden onset h/a, loss of remaining vision, b/l pallor of optic nerves, stupor and hypotension (b/c no
ACTH); get MRI or CT and give STEROIDS to help ACTH (cortisol)
o Brain tumor in kids: knee-chest position to relieve dizziness
o Brain abscess: resection is required and has characteristic appearance on CT ( no need for MRI)
o Reflex sympathetic dystrophy: dx with successful sympathetic block; cre: surgical sympathectomy
Urology
o Testicular torision: a surgical ER must untwist and do orchiopexy (then the other side is done after);
orchiopexy is putting the testis back into sac and permanently fixing it there
o Acute epididymitis: US done to r/o torsion b/c very similar; if normal, give ABs
o Obstruction of urinary tract due to stone: another surgical ER; seen with stone passing and sudden onset
of fever spike and chills; tx: IV ABs & decompression with ureteral stent or percutaneous nephrostomy
o Prostatitis: Sx inc urinary freq, dysuria, low back pain and tender prostate; tx: IV ABs and dont repeat
rectal exam b/c causes septic shock
o Posterior urethral valves: dx with voiding cystourethrogram and tx with endoscopic fulguration or
resection
o UTI in children: always leads to urological workup!!!!
o Ureteropelvic junction obstruction: everything is normal until large diuresis induced ie. College kid
drinking beer gets colicky flank pain
o Hematuria in adults: start with CT and end with cystoscopy
o Prostate CA mets to bone: androgen ablation, orchiectomy, LH agonists or anti-androgens like flutamide
o Testicular CA: common in younger; biopsy with RADICAL ORCHIECTOMY THRU INGUINAL ROUTE (b/c
they are never benign); chemo is good for metastatic disease
o Stress incontinence in women: surgical pelvic floor repair in advanced cases with lg cystoceles.
o Stones >7mm: necessitates intervention MC extracorporeal shock-wave lithotripsy (ESWL), cannot be
used in pregnant women, bleeding diathesis, very very large stones (cms); others: basket extraction, sonic
probes, laser beams, open surgery

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UWORLD:
Fractures of 2, 3, 4 metacarpal is rest if still bad, case; fractures of 5th is SURGERY
Sclerotherapy, band ligation and surgery for eso varies are not used for prophylaxis but after the 1st episode of
variceal bleeding; if those ont work, TIPS
o Otherwise, if bleeding from ulcer in stomach from alcoholism, do conservative medical management
Mediastinitis tx: surgical debridement & ABs

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