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< Back Anal Fissure What is an anal fissure? Patient information: Anal fissure [American College of Colon and Rectal Surgeons] Patient education: Anal fissure (Beyond the Basics) [UpToDate] Trauma from hard stool (constipation) creates a tear in the anoderm distal to the dentate line. Pain leads to internal sphincter spasm, setting up a vicious cycle! Symptoms- severe pain during and immediately following a bowel movement ("like pooping glass", "passing a razor blade"), blood on toilet paper with wiping. This often leads to fear of having bowel movements. Pain leads to muscle spasm→ higher pressure→ vicious cycle. Diagnosis- classic history is almost enough, but pain with effacement of the buttocks and visualization of a tear in the anoderm confirms. Don’t torture them with a digital rectal exam! On exam, typically seen in the posterior midline. If a fissure is seen in a different location, consider IBD, trauma, infection (Tuberculosis, sexually transmitted diseases), cancer. Source: UpToDate Images: Anal Fissure Anatomy What is conservative management for an anal fissure? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for an anal fissure. See patient handouts below. The majority of patients with an acute fissure heal with conservative management. If a fissure has been present for a long time, it is less likely to heal with conservative therapy. Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day. Topical compounds- nitrates, calcium channel blockers→ relax muscle→ improved blood flow→ allows healing. Local anesthetics can also improve symptoms during the healing process. Avoid suppositories, Tucks pads, and Preparation H. These would be painful and won’t treat the disease. This is why diagnosis is vital. Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management for an anal fissure? For the few patients who fail a trial of conservative therapy, surgical intervention can provide relief. Botulinum toxin (Botox) blocks neuromuscular function leading to muscle relaxation. Yes, this is the same Botox that is used to treat wrinkles. Low risk of complications. Lateral internal sphincterotomy is the treatment of choice for chronic fissures that have failed to resolve with other interventions. More successful healing compared to other interventions. Risk of incontinence (inability to control the passage of gas and stool). If incontinence occurs, the inability to control gas is more common than the inability to control liquid stool, which is more common than the inability to control solid stool. Previous Next

< Back Don't mess with the Pancreas A 47-year-old female with epigastric abdominal pain and nausea presents to the ER for evaluation. She is an otherwise healthy female, with no prior surgical history. On further questioning, her pain started 3 days ago and radiates toward her back. It has persisted and wasn't relieved with over-the-counter Tums, Gas-X, and Pepcid. She has had nausea but no vomiting. She has had minimal appetite over the past few days. Her history is otherwise unremarkable with no prior similar symptoms. On exam, she is uncomfortable but not in acute distress. HR 112, BP 112/63, T 99.1, O2 sat 99% on room air. Her abdominal exam is notable for focal tenderness in the epigastrium. What is on your differential and what is your initial workup? Peptic ulcer disease, esophagitis, hepatobiliary pathology (cholecystitis, hepatitis), pancreatitis, bowel obstruction, GERD, and bowel perforation. Labs- CBC, amylase, lipase, lactate. Imaging- acute abdominal series, possibly CT scan. Her labs are notable for a WBC of 11K, markedly elevated lipase, normal bilirubin and normal renal function. Her acute abdominal series shows non-specific bowel gas pattern with minimally dilated loops of small bowel. Right upper quadrant ultrasound revealed gallstones without evidence of acute cholecystitis. Based on the patients clinical presentation and lab findings, she is diagnosed with acute gallstone pancreatitis and was admitted to the surgical service. What are your initial goals of management? Pain control, IV fluid resuscitation. NPO until pain is improving. NGT if nauseated/ vomiting. Monitor vitals and organ function (urine output, labs). On her second hospital day, she developed worsening nausea/ vomiting, so an NGT was placed to decompress her stomach. Over the next few days, she has ongoing low grade sinus tachycardia, and then she developed intermittent low grade fever and mild leukocytosis. At that point, a CT scan is obtained. CT abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_7d78015ba7b5430bb996145d60f8b0d6/360p/mp4/file.mp4 The scan reveals peripancreatic inflammation with peripancreatic stranding, gland edema and hypoperfusion. There is also simple appearing peripancreatic fluid. Over the next few days, the patient developed worsening pain and an uptrend in her leukocytosis. She is mildly hypotensive and she is urinating less frequently. When a Foley catheter is placed, she has a small volume of concentrated urine in the collection bag. She is transferred to the ICU and a Dobhoff tube was placed for post-pyloric enteral feeding. Over the next two days, she develops fevers, an increasingly oxygen requirement and persistent pain. A repeat CT scan was obtained. Follow-up CT abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_e3134e03b3f242a291efd6dbc2e187e2/360p/mp4/file.mp4 There is evidence of progression of her pancreatitis. There are bilateral pleural effusions as well as worsening intra-abdominal free fluid. There is evidence of non-perfusion of the midportion of her pancreas, consistent with pancreatic necrosis. She remained in the ICU over the next several days. She did not clinically deteriorate and her pain slowly resolved. She had persistent high-volume output from her NGT. Why would she have high volume output in her NGT? Gastric outlet obstruction from peripancreatic fluid collection or necrosis. Ileus from ongoing intra-abdominal inflammation. Her distension improved with NGT decompression, and she continued to have bowel function. She was started on post-pyloric enteral feeds via a nasojejunal tube, and this was continued for the next month, awaiting for the acute necrosis to wall-off and develop a rind. Management of Acute Pancreatitis Etiology Gallstones and alcohol account for the vast majority of cases of pancreatitis. Other causes include hypertriglyceridemia, medication, ERCP, and hypercalcemia. Diagnosis Clinical presentation- epigastric pain, sometimes radiating to the back or shoulder. Nausea/ vomiting. Labs- elevated amylase/ lipase at least 3x normal Radiology- peripancreatic inflammation on contrast CT of abdomen. CT scan is not always mandatory on admission, but its commonly obtained for patients who have significant enough disease that they warrant a surgical consult. CT is also useful to rule out other pathology if the diagnosis is unclear. Clinical Course Most patients (about 80%) with acute pancreatitis suffer only mild disease and have resolution of symptoms without sequalae. The remaining 20% progress to moderate or severe pancreatitis, which is defined by the development of peri-pancreatic fluid collections or necrosis (sterile= moderate, infected= severe), or organ failure (transient= moderate, persistent= severe). Patients with organ dysfunction require ICU admission. Initial management Fluid resuscitation and ensuring adequate pain control. Nutritional support is also important, and patients are allowed to eat. Enteral nutrition should be initiated if the patient doesn't have adequate intake over the first few days. Close monitoring for development of sequalae. Patients are at risk for ARDS, abdominal compartment syndrome and infection. Assessment of Disease Severity Ranson's Criteria: Classic criteria for estimating pancreatitis severity[1] Admit data: WBC >16K, age >55, glucose >200, AST >250, LDH >250 48 hours: ↓Hct >10%, ↑BUN >5, Ca <8, PaO2 <60, Base deficit >4, >6L IVF. CT Severity has also been used to grade pancreatitis- inflammation, fluid collections and necrosis.[2] Management of Complicated Pancreatitis- Fluids Collections, Necrosis, Infection Diagnosis and Classification of peri-pancreatic fluid collections and necrosis [3] Acute interstitial edematous pancreatitis Less than 4 weeks, the fluid collection is an acute peripancreatic fluid collection . After 4 weeks, it becomes walled-off/ encapsulated and is a pancreatic pseudocyst . Acute necrotizing pancreatitis [non-enhancing pancreatic parenchyma] Less than 4 weeks, the fluid collection is an acute necrotic collection . After 4 weeks, it becomes walled-off/ encapsulated and is walled-off necrosis . Infected pancreatic necrosis- diagnosed by air in the necrosis, clinical symptoms consistent with infection and confirmed by aspiration and culture. A negative culture does not definitely rule out infection, so in the appropriate setting of clinical deterioration, there must be a high index of suspicion for infection. Indication for Antibiotics Antibiotics are NOT indicated for severe pancreatitis or pancreatic necrosis as a prophylaxis for infection.[4, 5] They are only indicated in known or highly-suspected infected necrosis. The antibiotics chosen must penetrate pancreatic tissue to be effective- quinolones and carbapenems are both broad-spectrum antibiotics (cover gram positive and gram negative) that penetrate pancreatic tissue. Carbapenems also cover anaerobes. Metronidazole covers gram negatives. Regimen: carbapenem or quinolone + metronidazole. Also consider antifungal coverage in severely ill patients.[6] Diagnosis of Infected Necrotizing Pancreatitis Infected pancreatic necrosis can be a challenging clinical diagnosis because the inflammatory state associated with pancreatitis can present with similar signs and symptoms, including fever, tachycardia, leukocytosis and ileus. CT evidence of air in the pancreatic necrosis is highly suggestive of infection, although absence of air does NOT definitively rule out infection. Fine-needle aspiration (FNA) can be used to obtain a sample for culture. There is a risk of infecting a sterile necrotic collection by performing an FNA, so this requires careful clinical decision-making. Management of Infected Necrotizing Pancreatitis These patients need broad spectrum antibiotics. Some patients may improve with antibiotics alone, but a drainage procedure is often needed. Percutaneous IR drain placement has a low rate of complications, but frequently fails to fully resolve the infection. Upsizing the drain or proceeding to more invasive intervention (see below) is required if that patient deteriorates despite drain placement and antibiotics. Previously, open necrosectomy was the standard. This is a highly morbid procedure, that requires maintaining an open abdomen, repeat washouts, and a prolonged ICU stay. Now, the step up approach is being increasingly utilized to manage these patients less invasively with similar or better outcomes (percutaneous retroperitoneal drainage or endoscopic transgastric drainage, endoscopic necrosectomy, followed by retroperitoneal necrosectomy).[7-10] Management of peri-pancreatic fluid collections [11-13] Enteral nutrition and pain control. A trial of a regular diet is appropriate, but if the patient is able to tolerate a regular diet, supplemental nutrition is required. Enteral nutrition is ideal, as it is associated with improved outcomes compared to TPN. Enteral access distal to the 3rd portion of the duodenum may theoretically avoid stimulation of the pancreas, but there is no evidence that jejunal feeds are superior to gastric feeds. However, depending on the location of the fluid collection, gastric outlet obstruction is a potential complication. Ideally, post-pyloric access would be obtained prior to obstruction, and can be used for long-term feeding while the fluid collection is allowed to resolve/ mature. Most resolve without intervention. As long as the patient is not systemically ill, drainage of pancreatic necrosis should be delayed as long as possible, ideally 6-8 weeks. Goal is to avoid procedural intervention until the fluid/ necrosis have become walled off, and then only intervene if the patient remains symptoms (pain, early satiety). However, if the patient clinically worsens, earlier intervention is necessary. Open pancreatic necrosectomy is associated with significant morbidity and mortality. An algorithm starting with least invasive (percutaneous or endoscopic drainage) and progressing to more invasive if the patient continues to do poorly is associated with decreased morbidity and mortality. References Ranson JH et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. Balthazar EJ et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. Banks PA et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. Dellinger EP et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg. 2007 May;245(5):674-83. Leppanieme A et al. Executive summary: WSES Guidelines for the management of severe acute pancreatitis. J Trauma Acute Care Surg. 2020 Jun;88(6):888-890. Howard TJ. The role of antimicrobial therapy in severe acute pancreatitis. Surg Clin North Am. 2013 Jun;93(3):585-93. van Santvoort HC et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491-502. van Brunschot S et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018 Jan 6;391(10115):51-58. Luckhurst CM et al. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. J Am Coll Surg. 2020 Jun;230(6):873-883. Boxhoorn L et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med. 2021;385(15):1372-1381. Tyberg A et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol. 2016 Feb 21;22(7):2256-70. van Dijk SM et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017 Nov;66(11):2024-2032. Maurer LR et al. Contemporary Surgical Management of Pancreatic Necrosis. JAMA Surg. 2023;158(1):81. Previous Next

< Back Stomach Ulcers UpToDate Patient Information Patient education: Peptic ulcer disease (Beyond the Basics) Patient education: Helicobacter pylori infection and treatment (Beyond the Basics) Patient education: Upper endoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Upper Endoscopy Previous Next

< Back What happens during Surgical ICU (SICU) Rounds? This does NOT reflect the practice pattern of every SICU. All the components must be addressed, but there are many variations on how they are incorporated into the daily routine. Flash Rounds A multi-disciplinary process that includes the charge nurse, respiratory therapist, clinical nutritionist, physical therapists/ occupational therapists, clinical case manager, and a senior member of the team (attending, fellow, APP). Focused on ensuring that each patient has daily goals and a plan from each of the team members, ensuring that key issues are addressed early instead of waiting until after rounds (nutrition, plans for ventilator weaning, disposition planning, etc.). Working Rounds A multi-professional process that includes the bedside nurse, "learners" (broad term to include students, residents, advanced practice provider (APP) fellows), as well as the APPs (nurse practitioners (NP) and physicians assistants (PA)) and a clinical pharmacist. The team is led by the attending physician or critical care fellow. Engagement and communication by all team members are encouraged. After reviewing overnight events, a system-based approach is used to methodically evaluate the patient's current clinical status and then develop a management plan. 1. Systems-Based Rounds- presented by resident or APP - Neurologic- assessment of mental status, including the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), etc. Current sedation and analgesia regimen. Review relevant radiologic imaging. - Cardiovascular- relevant vital signs and hemodynamic monitoring parameters, including trends and ranges. Review current cardioactive medication. - Pulmonary- current ventilator settings, relevant laboratory values (arterial blood gas), relevant radiologic imaging (chest radiograph). - Gastrointestinal- physical exam. Assess nutritional status (tolerating enteral nutrition, contraindication for enteral feeds, plan for parenteral nutrition). Review relevant radiologic imaging (abdominal radiograph). - Genitourinary/ Renal- review intake/ output (I/Os). The total volume of fluid intake (intravenous fluids, nutrition, blood, antibiotics, etc.) and fluid output (urine, stool, drains, etc.). Relevant laboratory values (basic metabolic panel). - Endocrine- review glycemic control. - Hematology- assessment of coagulation status or abnormal blood counts (hemoglobin, platelets). - Infectious Disease- physical exam- fever and evaluation of all possible infection sources (catheters, wounds, respiratory secretions). Review relevant laboratory values (white blood cell count, culture results), review current antibiotic therapy. - Prophylaxis- review needs for venous thromboembolism and stress ulcer prophylaxis. 2. A-F Bundle presentation by bedside nurse [SCCM ICU Liberation Bundle] - Assess, prevent, and manage pain - Breathing (Spontaneous awakening and breathing trials) - Choice of analgesia and sedation - Delirium assessment, prevention, and management - Early mobility and exercise - Family engagement 3. Develop a management plan based on comprehensive patient assessment. Previous Next

Advanced Practice Nurses to begin coming to Code Blues and supervising residents Code Blue: Who's in Charge? < Back Advanced Practice Nurses to begin coming to Code Blues and supervising residents I recently came across this article on Twitter and wrote my reply as soon as I read it. But as I was preparing to post this, I did a little more background research on the article. Let's start with the source- the website is called "MidlevelWTF ". The tagline is- "Exposing midlevel incompetence in the fight to ensure patient safety and preserve physician-led, physician-supervised medicine." The author's user name/ Twitter handle is MidlevelWTF; motto: "an actual doctor, with an actual MD." In light of this, the tone of the article makes much more sense. I'm disgusted to discover that a physician has dedicated their time/ energy to specifically target and defame APPs. Reply I disagree with a policy that formally designates a nurse practitioner to supervise any resident who runs a code. It's not appropriate to assign anyone else the authority to unilaterally overrule the decisions of the code leader. Codes need 1 leader- this is typically not the most junior person in the room, but someone in the middle or upper level of their training- a midlevel or senior resident. This doesn’t mean leaders can’t get recommendations from others. The more senior personnel in the room are welcome to provide advice- if there is egregious incompetence, which I would guess is the exception far more than the rule, someone, such as an attending or fellow or senior resident, can take over the role as leader. Working with the premise that the leader is competent, correcting a mistaken dose, helping develop a differential and general troubleshooting are all in the patient's best interest. These are also integral to closed-loop communication, and shouldn't be considered undermining or met with resistance. Team members should be able to speak up freely without having to worry about being yelled at for correcting another provider who is potentially more senior. The problem with this policy lies in the disruption of the team dynamics- adding another layer of "leadership" by formally assigning someone to have authority over the team leader creates confusion. If there is a contradiction, does the team listen to the leader or the "assigned" supervisor, who could reasonably have less experience than the resident? I've gladly welcomed advice from those with more experience than me during a difficult situation, and I trust them to speak up if they see something amiss. I trust all the non-physicians who care for our patients in my absence, and I trust them to call me if there is any concern; I hope they will feel empowered to do this in a code situation as well. So I support the author's general stance that the policy is inappropriate. However...I take great offense at this article. Implying that nurse practitioners (NPs) are minimally qualified and poorly educated is insulting and severely erroneous. Worst of all, the writer implied that a midlevel might decide to call it quits on a code “because they didn't feel like doing it anymore.” Absolutely inflammatory. Implying that any healthcare professional would be lazy or bored and just give up is preposterous. I have worked with many APPs (advanced practice providers), which includes NPs and PAs (physicians assistants) in the ER, on the inpatient wards, in the operating room, in the ICU, and in clinic. I have found them to be phenomenal teammates, motivated and eager to continually learn about how to best care for patients. Yes, some are less competent than others. But this is equally true of all healthcare professionals. I would gladly have a competent NP run a code if they were at the bedside at felt comfortable/ empowered to do so. While I would never designate a non-physician to oversee a resident running a code, I would similarly never expect a resident to take over the role of team leader from a competent NP or PA. As a fellow, during my time in the ICU, I would gladly let either an APP or a resident run the code, depending on availability and comfort level. I would be readily available and provide input when needed such as when the decision-making process extends past the algorithm of ACLS and into specific patient scenarios. In addition, if the patient needed an emergent/ urgent procedure, I was free to perform or assist while those procedures were being performed, as the NP/PA or resident continued to manage the overall code situation (meds, compressions, US to examine for cardiac activity, calling for MTP, etc). So I disagree with the policy, but I am deeply disappointed in the way the author chose to make petty accusations to undermine APPs and justify their disagreement with the policy. It's disappointing that a professional would stoop low enough to attack the character of our teammates. Previous Next

< Back Pancreatitis UpToDate Patient Education Patient education: Acute pancreatitis (Beyond the Basics) Patient education: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics) Source: UpToDate Images: Pancreas Anatomy Previous Next

< Back Pain and Anxiety...pending Management of Pain and Anxiety Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). Previous Next

< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous Next

Common Measurement Conversions < Back Kitchen Hacks #3 Common Measurement Conversions Powdered Milk Reconstitution Use volume of water equivalent to desired milk volume. 1 Cup Milk= 3 Tbsp Powdered Milk= 45 mL 3/4 Cup Milk = 2.25 Tbsp Powdered Milk 2/3 Cup Milk = 2 Tbsp Powdered Milk= 30 mL 1/2 Cup Milk = 1.5 Tbsp Powdered Milk 1/3 Cup Milk = 1 Tbsp Powdered Milk= 15 mL 1/4 Cup Milk = 3/4 Tbsp Powdered Milk Measuring Spoon Conversions 1/2 tsp= 2.5 mL 1 tsp= 5 mL 1 + 1/2 tsp= 1/2 Tbsp= 7.5 mL 2 tsp= 10 mL 3 tsp= 1 Tbsp 6 tsp= 2 Tbsp= 1/8 c Liquid Measurement Conversions 1 fluid ounce= 2 Tbsp= 6 tsp 2 fluids ounces= 4 Tbsp= 1/4 cup 2+2/3 fluid ounces= 5 Tbsp + 1 tsp= 1/3 cup 4 fluid ounces= 8 Tbsp= 1/2 cup 6 fluid ounces= 3/4 cup 8 fluid ounces= 1 cup 16 fluid ounces= 2 cups= 1 pint 4 cups= 2 pints= 1 quart 4 quarts= 1 gallon Substitute dry for fresh spices 1:3 of dry:fresh 1 tsp dry= 1 Tbsp fresh Previous Next

< Back Chicken Enchiladas in Sour Cream Sauce Ingredients 10 small soft flour tortillas 3 Tbsp flour 2 c chicken broth 1 c sour cream 2.5 c shredded cooked chicken 3 c shredded Monterey Jack cheese 3 Tbsp butter 4 oz can diced green chillies Instructions 1. Preheat oven to 350 degrees 2. Combine shredded chicken and 1 cup of cheese. Fill tortillas with the mixture above and roll each one then place in a greased 9x13 pan. 3. Melt butter in a pan over medium heat. Stir flour into butter and whisk for 1 minute over heat. 4. Add broth and whisk together. Cook over heat until it's thick and bubbles up 5. Take off heat and add in sour cream and chilies. Be careful it's not too hot or the sour cream will curdle. 6. Pour mixture over enchiladas and add remaining cheese to top. 7. Bake in oven for 20-23 minutes then you will want to broil for 3 minutes to brown the cheese. The roux, with sour cream and green chilies added Previous Enchiladas covered with sauce Cooked and broiled to brown the cheese Next

3 < Back Acute Care Surgery Clinical Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. SurgicalCriticalCare.Net . Evidence-based guidelines from Orlando Regional Medical Center. Vanderbilt Trauma and Surgical Critical Care Practice Management Guidelines. Evidence-based guidelines developed by Vanderbilt. Covers trauma and surgical critical care topics. Evidence-Based Decisions in Surgery. This does require membership with the American College of Surgeons. General Medical Information UpToDate. The name says it all- evidence-based recommendations based on the most current literature. Subscription required. Previous Next