surgery shelf contradictions

[kokonut]

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This is driving me crazy!

In CaseFiles it says in bold, "The best initial diagnostic test for an esophageal rupture is a water-soluble contrast esophagogram ... water-soluble contrast is preferred b/c it causes less mediastinal irritation than barium"

and then in A&L, it says, "The esophagogram should not be conducted with Gastrografin because of its deleterious effects if aspirated into the lungs. Either an esophagoscopy or barium swallow should be used to r/o esophageal injury."

???

And then for traumatic rupture of the aorta, CaseFiles says no one uses aortogram b/c of it's invasiveness and it requires a separate team -- we should use spiral CT to diagnose, and then A&L says we should use an aortogram.

What the heck? Anyone else encountering stuff like this? 😕

I have my shelf in two weeks, wish me luck 🙄

 

[colbgw02]

This is driving me crazy!

In CaseFiles it says in bold, "The best initial diagnostic test for an esophageal rupture is a water-soluble contrast esophagogram ... water-soluble contrast is preferred b/c it causes less mediastinal irritation than barium"

and then in A&L, it says, "The esophagogram should not be conducted with Gastrografin because of its deleterious effects if aspirated into the lungs. Either an esophagoscopy or barium swallow should be used to r/o esophageal injury."

???

And then for traumatic rupture of the aorta, CaseFiles says no one uses aortogram b/c of it's invasiveness and it requires a separate team -- we should use spiral CT to diagnose, and then A&L says we should use an aortogram.

What the heck? Anyone else encountering stuff like this? 😕

I have my shelf in two weeks, wish me luck 🙄

1) if any sort of rupture is suspected, i don't know a single radiologist that would use barium. i would go with the gastrografin.

2) if you suspect a traumatic aortic rupture, i don't think you'd bother to take the time to do an aortogram since it's typically a surgical emergency. i'd go with spiral CT. hell, if it's really an emergency, then i'd say just scan the patient and protocol and contrast be damned.

 

[Anka]

Surgery A&L has a reputation for having a lot of errors, at least at my school.
Best,
AJ

 

[dentate_gyrus]

1) if any sort of rupture is suspected, i don't know a single radiologist that would use barium. i would go with the gastrografin.

2) if you suspect a traumatic aortic rupture, i don't think you'd bother to take the time to do an aortogram since it's typically a surgical emergency. i'd go with spiral CT. hell, if it's really an emergency, then i'd say just scan the patient and protocol and contrast be damned.

Right on.
1. GG for Boorhave's/traumatic or iatrogenic rupture for sure, otw wind up with mediastinitis if extravasation. Aspiration you can fix, mediastinitis = bad bad news. Barium is supposed to be inert, so aspiration is not a "big deal" unless it has gastric contents with it. Don't forget that cervical crepitus on the CXR though.
2. Greenfield says CXR has high sensitivity and low spec. Aortogram is ideal. Next is CT Angiography with high both. Next is CT alone (only used when already doing CT for another reason). My guess would be that the shelf quetion would ask about controlling the BP anyway. IMHO.

I'm probably getting some of this wrong.
Someday I'm going to write a decent surgery clerkship question book. I've looked at Pretest, A&L, Blueprints and CF. They are all either too easy (BP, CF) or chock full of errors and unimportant horsesh*t (A&L and Pretest). Oddly Lawrence seems to be as good as it gets for basic principles of surgery questions.

 

[Tater]

Gastrograffin will cause a severe pneumonitis if aspirated.
Barium will cause a severe peritonitis if it enters the peritoneal cavity.

To diagnose an esophageal rupture/perforation: First use gastrograffin. However, it has a 10% false negative rate. Therefore, if the gastrograffin study is negative...use thinned barium. It apparently can detect smaller perforations not detectable with gastrograffin.

 

[kokonut]

Thanks guys for clearing that up!!

Does anyone know how relevant it is to know stuff like anesthesia drugs, or the more esoteric types of hernias (lumbar, Spigelian, Pantaloon, etc?)

I hate studying without having a reliable source to know what's important 🙁

 

[Tater]

sorry, double posted

 

[Tater]

Thanks guys for clearing that up!!

Does anyone know how relevant it is to know stuff like anesthesia drugs, or the more esoteric types of hernias (lumbar, Spigelian, Pantaloon, etc?)

I hate studying without having a reliable source to know what's important 🙁

Oh no, no, no! 😱 For the most part, what the surgeons pimp you on in the operating room is not what is on the surgery shelf.


Everyone who is taking the surgery shelf, hear me now.

1. Perioperative care. Let me say it again, perioperative care. This is a huge chunk of the surgery shelf and the reason everyone says "it is all medicine". It is not medicine. It is perioperative care. Every surgical textbook has a section regarding this subject. Do yourself a favor and read it.
2. Medical diseases in surgical patients. Again, another reason this shelf is "all medicine". This, again, is another chapter in many surgical textbooks. Read it. I don't remember this being quite as important as perioperative care. But I do remember questions like: "Pt A undergoing cystoscopy. Pt A has history of bacterial endocarditis. Which antibiotic regimen do you suggest for Pt A if they are allergic to penicillins?"
3. Don't forget breast disease and endocrine disease. Most forsake these subjects for the abdomen. Do not forsake them!
4. Grab yourself any Step 2 question book (i.e. Kaplan, or NMS) and do the surgery questions. These are your shelf exam questions...the format, the information, etc. (Wash, rinse, repeat for all your shelf exams. It is an invaluable study source for shelf exams of which many do not take advantage.)

Personally, I used the NMS book to study for the shelf (the Step 2 question book and the surgery book).

Go, my little grasshoppers, go!