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< Back Vent Mgmt #1: Basics The goal of ventilatory support is to maintain appropriate O2 and CO2 in the blood while offloading the work of the respiratory muscles and minimizing iatrogenic lung damage. Understanding this principle will help guide your ventilator management. Many variables can be manipulated on the ventilator, but there are a few key variables that truly control oxygenation and ventilation. While there is not one ideal setting for every scenario, there are a few basic principles that cover the majority of ventilator management. Basic Ventilator Settings First, it is important to understand what the ventilator does. The ventilator can push air into patients. You can control how much air is pushed in (tidal volume), the number of breaths per minute (respiratory rate, RR), and the concentration of oxygen molecules in the air itself (fraction of inspired oxygen, FiO2). It's also possible to control how quickly air is pushed in (flow)- but we will get to that later. It is important to note: the ventilator does NOT generate pressure- it only monitors pressure to prevent damage from elevated pressures (barotrauma). Breathing is controlled by three variables. Trigger- this determines when a breath starts. Either time, flow, or pressure. Time trigger is utilized when the patient is not generating any spontaneous breathing (ie mandatory breaths). Flow and pressure triggers are utilized if the patient has spontaneous respiratory activity. When the patient attempts to inhale, there is a change in flow and/ or pressure. This is sensed by the ventilator, and a breath is delivered. Limit- this sets the maximum value a parameter can reach during a breath. For example, volume-limited indicates that a breath can't exceed a certain max mL and pressure-limited indicates that the pressure monitored by the machine can't exceed a certain max cm H2O. For a graphic representation, please refer to the image in the section on Limit Variables in Deranged Physiology. Limits impact the shape of the waveform. Volume limited- flow ceases when the set/ target volume is delivered. Pressure limited- a large portion of the TV delivered at the beginning of the breath until the set/ target pressure is reached and then the flow tapers, slowly delivering the remainder of the volume until the breath is time or flow cycled (see next) Cycle- this determines the end of a breath. Time cycled- inspiration ceases at the end of a set time duration. Used in mandatory breaths. Flow cycled- inspiration ceases when flow drops below a certain level. Used in spontaneous breaths. Volume and pressure are not currently used to cycle breaths. The goals of mechanical ventilatory support are O2 delivery (oxygenation) and CO2 removal (ventilation). Effective oxygenation and ventilation are measured by an arterial blood gas- PaO2 indicates the partial pressure of O2 and PaCO2 indicates the partial pressure of CO2. Oxygenation is a function of the concentration of O2 delivered to the patient (fraction of inspired O2, FiO2) and the surface available for O2 exchange. Positive pressure maintains open airways, which maintains the surface available for O2 exchange. Mean airway pressure (MAP) is the parameter that indicates the average pressure measured in the lungs throughout inspiration (inspiratory pressure) and expiration (positive end expiratory pressure, PEEP). Expiration is usually 2-3 times longer than inspiration, so MAP is often simplified to PEEP when trying to optimize oxygenation. However, increasing inspiratory time can improve MAP without adjusting PEEP. Ventilation is controlled by minute ventilation (total volume of air exchanged every minute). Minute ventilation is respiratory rate multiplied by tidal volume. Therefore, respiratory rate (RR) and tidal volume (TV) are the two parameters that can optimize ventilation. Lung-Protective Ventilation Minimizing iatrogenic lung injury is also important when caring for patients receiving ventilatory support. Different types of trauma, including barotrauma (excess pressure), volutrauma (excess volume), and atelectrauma (repetitive opening and closing of alveoli), can damage lungs that are already diseased. The risk of barotrauma can be minimized by monitoring airway pressures (peak and plateau pressures). Volutrauma can be minimized by low tidal volume. Historically, larger tidal volumes were standard (10-12 mL/kg). Currently, the most commonly recommended volume is 6-8 mL/kg (there are some exceptions). Decreased TV leads to ↓minute ventilation and ↓CO2 clearance (↑PaCO2). This is the basic physiologic principle behind "permissive hypercapnia" during mechanical ventilation for ARDS. Atelectrauma can be minimized by maintaining PEEP, which keeps alveoli open. Additional References 1. Respiratory Therapy Pocket Reference Card Previous Next

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How to play nice in the sand box...and why it matters Consults < Back How to play nice in the sand box...and why it matters The department of Acute Care Surgery and Emergency Medicine frequently interact to discuss consults. Unfortunately, several factors predispose to an adversarial relationship between the ER provider and the consultant.(1) I won't pretend that I didn't contribute to some of the negative interactions I've had while responding to consults. However, I'm grateful that my years of experience have provided me with insight and perspective that reframed my thoughts about the consultation process. What are the different types of consults? #1 The patient requires something that is beyond the scope of practice of the emergency provider. This includes everything from hospital admission, surgical or procedural intervention (appendectomy, stop the bleeding from a penetrating neck wound, cardiac catheterization), or a plan for close follow-up. How to Respond? This is why we chose our specialty, and our business is patient care. If a consultant is not responsive, it might be because they are caring for more urgent clinical issues. It's also possible that they are a generally unpleasant person, and it has no relation to the nature of the consult..some people can be difficult regardless of the scenario. Admittedly, it might also be 2 am, and they just fell back asleep after their last page. As much as I hate to admit, it's harder to be pleasant on the phone when you're absolutely exhausted. #2 The unclear diagnosis. The patient is presenting with a complex issue, or the diagnosis may be outside the provider's experience. This could be the first time they encounter a particular clinical scenario or an unusual presentation of a common diagnosis. How to Respond? Depends on the scenario. If that patient requires emergent assistance, prioritize their needs. If no emergent need, but further workup is needed, provide whatever recommendations you can regarding the next steps of the diagnostic workup. If the patient's case falls under your specialty, refer back to #1. #3 The emergency room provider doesn't know who the appropriate consultant is, or they have had no luck reaching them. How to Respond? It's easy to brush off a call when the primary provider called the wrong service. This might occur if the provider cannot reach a particular specialist, and you are the next best option (example- plastic surgeon doesn't respond for a consult on a patient with a wound complication). Please, if you know how to reach that provider, lend a hand. Or, if they call the wrong service, take the time to give a little guidance about whom they should have called. They aren't trying to waste your time- they are likely also busy, and calling multiple consultants is not the best way to spend their time either. Whatever assistance you can provide is best for the patient. #4 The controversial consult. In my experience, during years of working with surgeons and emergency physicians, probably one of the most contentious consultations is the consultation for something that the consultant considers inappropriately simple or unnecessary. The surgeon may think that the issue is trivial or the need is non-existent and feel that the provider should be capable of resolving the issue without calling a surgeon. This disconnect might be the key patient interaction that can set the tone for the relationship between departments. How to Respond? First, and most importantly, please don't be dismissive when someone calls you for a consult. If you are receiving a call, it's because the person on the other end of the phone (and therefore the patient they are caring for) needs your help. Surgeons, along with other specialists, have extensive specific expertise, so it's easy to lose perspective and presume that the knowledge in our head is universal. It's become almost intuitive in our minds, so we might forget that the primary provider does NOT have the same specialization. We each chose our respective specialties, and our training and biases are quite divergent. It is unreasonable to expect ER physicians to share the same depth of knowledge in each of the many specialties, just as each of the specialists would not have the same ability to deftly juggle the wide array of clinical scenarios managed in the ER. I remember the plastic surgeon who showed me how to do a scar revision on a young woman's face. He spent his career training and practicing to perform plastic surgery. It was simple in his hands, but that doesn't mean the woman would have a similar outcome if the needle driver was in my hand. Please, think of the patient's best interest. Yes, the primary provider may be "an idiot" or "lazy" or whatever. But consider the other possibilities. I prefer to give my colleagues the benefit of the doubt and avoid automatically assuming incompetence. Regardless of the underlying issue, whether it's a flaw of the provider or its truly beyond their capability, the patient needs someone to take care of them. Do the right thing for the patient- in the end, that's what matters. 1. Koo A, Bothwell J. Tips for Working with Consultants. ACEP Now. Nov 2017. Previous Next

Favorite Websites and Apps < Back Kitchen Hacks #4 Favorite Websites and Apps How Sweet Eats Eating Well (previously Cooking Light) Cooking Substitutions Previous Next

< Back GERD What is GERD? Gastroesophageal Reflux Disease (GERD), more commonly known as heartburn, is caused by acid from the stomach moving into the esophagus, which causes a burning pain in the middle of the chest. Anatomy After swallowing, food moves down the esophagus and into the stomach. The lower esophageal sphincter (LES), which is at the connection between the esophagus and stomach, prevents stomach contents from moving back into the esophagus. The lower esophageal sphincter is located below the diaphragm, where pressure from the abdominal organs helps keep the sphincter closed. There are different causes of GERD, but the lower esophageal sphincter is key to preventing reflux. See below for more details about why GERD occurs. Source: UpToDate Images: Gastroesophageal Reflux (GERD) Causes of GERD Decreased pressure of the lower esophageal sphincter- if the lower esophageal sphincter is too loose/ relaxed, stomach contents move more easily into the esophagus. This can be a pre-existing condition but it can also be caused or worsened by lifestyle habits. For example, tobacco and certain foods such as alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods, can also decrease the pressure of the sphincter. Eating too much/ too fast→ overfilling the stomach leads to increased pressure, causing stomach contents to be pushed into the esophagus Laying flat- when you are standing or sitting upright gravity helps avoid reflux by keeping food in the stomach, but when laying flat, stomach contents can move into the esophagus more easily. This is why symptoms are often more severe at night or first thing in the morning. Hiatal hernia - when the lower esophageal sphincter is able to move into the chest, it no longer has the external pressure normally present when it’s in it’s correct position, and it more easily allows stomach contents to move into the esophagus. See link for image. Obesity or pregnancy- increased pressure on the abdomen from excess weight can put pressure on the stomach and allows stomach contents to move into the esophagus for easily. GERD: Symptoms and Causes [Mayo Clinic: Patient Care & Health Information] Diagnosis Symptoms are often adequate to diagnosis GERD. A swallow study can provide further information. This study is performed in radiology, and involves drinking contrast material and having x-ray images taken to evaluate the esophagus and stomach while you swallow. This study can diagnose esophageal problems, such as poor muscle function leading to swallowing difficulty. In addition, a hiatal hernia can be identified. John Hopkins Medicine: Barium Swallow An esophagogastroduodenoscopy (EGD), also known as an upper endoscopy (see link) can be used to assess the inner lining of the esophagus, stomach and the first part of the small intestine (duodenum). There are many things that can be identified on an EGD, but specifically related to GERD, damage to the lining of the esophagus and the presence of a hiatal hernia can be identified with an EGD. Patient education: Upper endoscopy (Beyond the Basics) [UpToDate] Upper Endoscopy [Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)] Additional testing can be performed based on symptoms, results of initial testing and response to treatment. Esophageal manometry- a study to evaluate the muscle function of the esophagus ( pH test- a study to evaluate how much acid the esophagus is exposed to, which is one measure of the severity of GERD. GERD: Diagnosis and Treatment [Mayo Clinic: Patient Care & Health Information] Treatment Lifestyle Modifications [ Patient Handout: Anti-Reflux Diet and Lifestyle Modifications ] Eat slowly, avoid eating large meals and stop eating before you feel full. Avoiding alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods. Avoid lying down for at least 2-3 hours after meals. Don't snack after dinner/ before bed. Elevating the head of the bed by 6-8 inches. This is NOT done by placing multiple pillows under your head- multiple pillows would actually increase pressure in the abdomen (like doing a sit-up or crunch). For more information, see this guide from the Kingsley clinic. Lose weight. Stop smoking. Avoid tight-fitting clothing. Medication Over the counter antacids Prescription medication Surgery Depending on how well medication and lifestyle modifications improve your GERD symptoms, and depending on the results of your other studies, such as your swallow study, esophageal manometry and pH testing, surgery may be an option for GERD. UpToDate Patient Education Patient Education: Gastroesophageal reflux disease in adults (Beyond the Basics) Previous Next

11 Made to Stick Why Some Ideas Survive and Others Die 6 Principles of Sticky Ideas - Simple - Unexpected- crash at the end of the car commercial. - Concrete - Credibility- the ability to test. Before you vote ask yourself if you are better off today than you were 4 years ago- Reagan. - Emotions - Stories Curse of knowledge- we find it hard to imagine not knowing what we have learned. Can’t imagine what it’s like not to understand a certain concept that we accept as fact Previous Next

< Back The Trauma Bag Why was there a need for a trauma bag in the hospital? As an acute care surgeon responding to trauma activations, airway emergencies, and a variety of other hospital surgical emergencies, there are a handful of supplies that I always have with me. The two basics are a scalpel for surgical airways and trauma shears (classically used to remove clothes in the trauma bay, but I seem to find more uses all the time). Eventually, I added a Kelly clamp to my armamentarium- handy for disconnecting or unscrewing a wide variety of impossibly tight connections or securing something in place. During the COVID Pandemic, numerous changes were made in our hospital to minimize infection transmission. Unfortunately, several of the modifications had unintended negative consequences. When we stopped wearing white coats, we lost our pocket space for stashing scalpels and shears. We also carried more gear, including eye protection and N-95 masks (carried in a brown bag when not worn). Many surgeons adapted by using an assortment of bags, such as sling backpacks or CamelBak cases. My own choice is this fanny pack , which draws many compliments! The next challenge was the relocation of supplies from the wall of our trauma bay onto shelves in the hallway. Team members had to leave the trauma bay, locate which cart the item was on, and then scan for the item, which created delays. This disrupted communication as well because team members missed changes when they were outside the room. Another hurdle that existed even before the pandemic was the array of different names for the same item. Most people who place cotton-tipped applicators in their ears after their shower call them by the brand name “Q-tip”…they are actually called “cotton tip applicators” or “CTA”. **Note- don’t use Q-tips in your ears!** Drop the Q-tip! Why ENTs are begging you to leave your ears alone. The surgeon might ask for 4x4s, which is what we call gauze in the operating room. Some say "Quik-Clot” while others know the product by the name “Combat Gauze”. Sutures are a whole other bag of worms…do you use silk or Ethibond to secure your chest tube? Curved or straight needle? Countless times, the trauma chief is managing the trauma and when someone calls for a suture, their attention is often diverted to advising the person reaching into the suture box on the wall.…"no, the one to the left, top row." It’s not always easy to tell from the box what the suture and needle look like. In addition to the elimination of white coats, relocation of commonly used supplies outside the trauma bay, and different names for supplies, I noticed that several key items were frequently used and they seemed to be unreasonably challenging to locate in a timely fashion. Combat Gauze, Coban, specific suture on a specific needle, etc. Therefore, I created a backpack of supplies that I carry when on call. What does this bag do? This bag was created from my perception of a necessity to ensure specific supplies are readily available when responding to surgical emergencies. A Level 1 trauma center is equipped with the highest level of resources and personnel to manage the most complex patients, and our resources and patient population dictate what supplies are needed on a routine basis. My focus was on supplies that are (1) frequently used, (2) unique and not readily available in all locations where they are used, and when they are required, (3) delays in employment are remarkably morbid, and (4) portable. Why didn’t I include tourniquets? They’re frequently used and delays in employment are morbid, but patients typically have them in place on arrival and if not, they are readily available in the trauma bay. Why didn’t I include chest tubes? They are frequently used and delays in employment are morbid, but they are relatively widely available. In addition, the life-threatening physiology of hemothorax or pneumothorax can be resolved with a finger thoracostomy using a scalpel and Kelly (essentially the same process as placing a chest tube, but stopping at the step of a finger sweep in the thoracic cavity, releasing massive hemothorax or tension pneumothorax). Why didn’t I include a REBOA kit? This is a controversial topic. However, in the situation where resuscitative thoracotomy is deferred in favor of REBOA, rapid employment is ideal. However, this device is not frequently used at our facility. Paper clips? In a trauma bag? Yes, paper clips. They are used to mark wounds for creating a road map of the trajectory. What DOESN’T this bag do? This is NOT an all-inclusive bag for responding to all emergencies. It should not be considered a guide for pre-hospital emergency response, non-surgical emergencies, or any situations outside of the specifications reviewed above. There are other response teams in the hospital that have different supplies. For example, we have ICU nurses that respond to rapid response or code blue situations, and they carry critical care transfer bags. I don’t know the list of supplies that they carry, but here is a sample of potential contents of a “transfer bag”. In summary, my trauma bag is focused on specific needs that I perceived based on my daily work at my facility. If you perceive a need for a similar tool at your facility, I would encourage you to develop a supply list tailored to your needs. Trauma Bag- Supply List Personal Protective Equipment Blue gown, non-sterile (2) Medium gloves Mask with eye shield (1) Sterile Supplies for Procedures Pack of blue towels (1) Stapler (1) Sterile gown (1) Small Chloraprep (2) Laceration tray (1) Dressings and Hemostatic Agents Gauze, 4x4 (2) Surgicel, 2 in x 3 in (4) Quik-Clot, 3 in x 4 yds (3) Kerlix, 3.4 in x 3.6 yds (3) Kerlix, 4.5 in x 4.1 yds (1) Coban, 4 in x 5 yds (1) Large Tegaderm (4) Sutures and Instruments #1 Ethibond, curved needle (8) #0 Silk, straight needle (4) #0 Silk, curved needle (1) #2-0 Silk, curved needle (2) #2-0 Vicryl, curved needle (5) Skin stapler (1) Adsons (1) Kelly clamp (2) Needle driver (1) Laceration tray (1) Scalpel #10 (1) Scalpel #11 (1) Miscellaneous Cotton tip applicators (3) Tongue Depressors (2) Paper clips Disclaimer: This was created early in the pandemic, while I was a fellow at a different institution. Previous Next

1st day in radiology: your right is your left, your left is your right Radiologic Dyslexia < Back 1st day in radiology: your right is your left, your left is your right I have recently coined a new phrase. While showing my mom a picture, pointing out someone she had never met before, I commented, "he's the one on the right." Funny story, though- he was actually on the left side of the picture. I had to pause while I talked to my mom and reassure her that I know the difference between my right and my left. While scrolling through Twitter the other day, I was reviewing a question posed about an abdominal x-ray. Another Twitter user added a helpful hint by indicating "the right side of the circle" when pointing out an abnormality. I predicted he meant anatomical right (meaning the image's left side) based on my interpretation. We chuckled about the discrepancy between radiographic laterality and left-right differentiation in real life. I decided to designate this mix-up "radiologic dyslexia." Feel free to use this in the appropriate context! Previous Next

< Back Vent Mgmt #4: All Together Choosing a mode Controlled- patients who aren't generating breaths. PC, VC. Most common mode at initiation of MV. SIMV- patient generating some breaths, but still needs significant mechanical support. Spontaneous- not frequently used at initiation, but can be used for patients with airway obstruction and preserved lung function. How to set initial parameters TV (6-8 mL/ kg predicted body weight) [lung protective ventilation] RR 10-14 FiO2 often start at 100%, but quickly weaned unless severely hypoxic Inspiratory:expiratory ratio typically 1:2 Flow- typically set @ 60L/min, can increase if the patient is in distress or has a high minute ventilation How to adjust parameters based on arterial blood gas results Low PaO2 (low arterial oxygen content)- increase FiO2, increase mean airway pressure Markedly elevated PaO2 (hyperoxia)- decrease FiO2 Low PaCO2 (low arterial carbon dioxide concentration)- decrease TV or RR High PaCO2 (high arterial carbon dioxide concentration)- increase TV or RR *For more details, check out these resources: Lectures: Critical Care: Respiratory Failure Lectures: Critical Care: Vents Other principles of mechanical ventilation VAP bundle- elevated head of bed, oral care Daily awakening and spontaneous breathing trials Previous Next

< Back Free Fluid in the Abdomen A 62-year-old male presents following a motor vehicle collision in which he was an unrestrained driver. He was intubated in the trauma bay for decreased mental status. A focused assessment with sonography for trauma (FAST) was performed, which did not reveal intra-abdominal fluid. Computed tomography (CT) of the head demonstrated minimal intra-cranial injury. CT of the abdomen and pelvis (see below) revealed decreased blood supply to the left kidney, small irregularity of the splenic contour, and a moderate amount of free fluid in the abdomen and pelvis. Hounsfield units are consistent with simple fluid. CT of the abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_b03419943e9941d281c3d8f0b800e37f/480p/mp4/file.mp4 What is the differential diagnosis for the free fluid in the abdomen? Free fluid due to trauma can be urine, enteric contents (bowel injury with spillage of succus) or blood. It is possible to have fluid present prior to the trauma, such as ascites from chronic liver disease. In this case, the free fluid in the abdomen had characteristics of “simple fluid,” based on Hounsfield units, suggesting that the fluid was not blood. In females, free fluid in the pelvis can be normal (physiologic fluid). However, free fluid is NOT normal in a male, and it's concerning for hollow viscus injury. What are the possible causes of decreased blood flow to the kidney? The renal artery can be injured in blunt trauma. Blunt injury can disrupt the layers of the artery wall, leading to thrombosis and decreased blood flow beyond the injury. He was admitted to the intensive care unit. A foley catheter was placed and demonstrated pink-tinged urine [NOT frank gross blood/ clots]. What are the possible causes of blood-tinged urine? Bloody urine indicates a traumatic injury to the genitourinary tract, anywhere from the kidneys down to the urethra. A CT cystogram was performed, which did not reveal any extravasation of contrast from the bladder. CT Cystogram https://video.wixstatic.com/video/3b6ff6_119074429b224cc98677d4f101fef666/480p/mp4/file.mp4 Next steps? Based on an unreliable physical exam and a normal CT cystogram, it is necessary to rule out bowel injury. The patient was hemodynamically stable and had normal laboratory values. He remained with a decreased mental status, and therefore serial abdominal exams were not a viable management plan. The patient was taken to the operating room and underwent diagnostic laparoscopy. His small bowel, colon, and mesentery were examined in there entirety and found to be completely normal. There was a small amount of clear thin fluid in the pelvis, but there was no evidence of bile staining or bleeding. After completing the evaluation of the gastrointestinal tract, we repositioned the patient in Trendelenburg. The pelvis was inspected, and it was quickly apparent that the patient in fact had a large defect in the dome of the bladder. We elected to proceed with a low midline laparotomy. The bladder was easily mobilized, and the extent of the defect was defined. The edges were grasped, and the defect was closed in two layers with absorbable suture. Postoperatively, we reviewed the preoperative CT cystogram. In retrospect, there was a suggestion of bladder irregularity. We reviewed the CT cystogram with the radiologist and there was no evidence of contrast extravasation. However, the bladder does not appear to have been completely distended with contrast. It is very atypical that a large bladder wall defect was not associated with contrast extravasation, and this highlights the importance and ensuring complete filling of the bladder with contrast. Evaluation and Management of Bladder Injuries Bladder injuries can occur from blunt or penetrating trauma. For example, bladder injuries can occur when blunt force is exerted on a full bladder or in the setting of a pelvis fracture. Diagnosis Gross hematuria is seen in most patients with bladder injuries. Cystography, either using plain x-ray or CT, is the diagnostic test of choice. Management The management of bladder injuries is based on location. Intra-peritoneal injuries require operative management. This is done in two or three layers with absorbable suture. A decompressive foley catheter is left following repair. Extra-peritoneal injuries can typically be managed non-operatively with a foley catheter for 10-14 days. Exceptions include large bony segments protruding into the bladder wall, associated rectal or vaginal injuries, bladder neck injuries, or an associated pelvic fracture undergoing operative intervention to prevent hardware contamination. Current guidelines recommend a cystogram before foley removal, except for the most uncomplicated injuries. Yeung LL et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;86(2):326-336. Previous Next

< Back Fever...pending Evaluation of Fever Previous Next

3 General Surgery Lectures General Surgery .pdf Download PDF • 152.12MB Anorectal .pdf Download PDF • 1.55MB CT Scan and X-ray .pdf Download PDF • 564KB Vascular .pdf Download PDF • 13.57MB Suture .pdf Download PDF • 4.94MB