Killip Classification

This classification predicts risk of mortality after a ST-segment elevation myocardial infarction (STEMI.)

Class 1 – absence of congestive heart failure – 6% risk of mortality.
Class 2 – presence of an S3 murmur and/or bibasilar rales – 17% risk of mortality.
Class 3 – presence of pulmonary edema – 30-40% risk of mortality.
Class 4 – presence of cardiogenic shock – 60-80% risk of mortality.

Sgarbossa Criteria

The presence of a left bundle branch block (LBBB) makes it difficult to determine if there are ischemic changes on an electrocardiogram (ECG.)

The Sgarbossa scoring system can determine with a 90% specificity if cardiac ischemia is present on an ECG in the setting of a LBBB if the score equals 3 or greater.

The criteria are:

1. Elevation of the ST segment of 1 mm or greater that is concordant as the QRS in any lead – 5 points.

2. Depression of the ST segment of 1 mm or greater in any lead from V1 to V3 – 3 points.

3. Elevation of the ST segment of 5 mm or greater that was discordant with the QRS complex – 2 points.

Amaurosis fugax is a classic sign (more often described than actually seen) for an acute embolus to the ophthalmic artery, a branch of the internal carotid artery

It presents as an acute descending blindness in one eye, as if a shade is being pulled down over the eyelid. It is considered an indication for carotid endarectomy (surgical removal of atheromatous plaque in the carotid artery.)

Treatment of Kidney Stones

The development of kidney stones (aka urinary calculi) is a common condition seen by family practice doctors, emergency room physicians, and urologists. There are several considerations when treating kidney stones:

1. Most small calculi (< 4mm) pass spontaneously on their own without intervention.
2. Treatment of stones < 4mm consists of pain medication, vigorous hydration, and straining of the urine.
3. Stones larger than 4 mm but less than 2.5 cm are treated by extracorporeal shock-wave lithotripsy (ESWL).
4. Stones larger than 2.5 cm require percutaneous nephrolithotomy (PCNL).
5. Staghorn calculi require PCNL.
6. Stones that do not pass spontaneously typically obstruct the urinary system at three points: the ureteropelvic junction, the area where the ureter crosses the iliac vessels, and the ureterovesical junction.

Caloric Yield of Basic Nutrients

Adequate surgical nutrition is critically important in recovering from injury or illness. When calculating the energy yield from nutritional substances, the following caloric determinants are used:

Fat – 9 kcal/gm
Protein – 4 kcal/gm
Carbohydrate – 3.4 kcal/gm

The goal in any nutritional therapy is to provide sufficient calories in fat and carbohydrate to prevent protein breakdown.

Criteria For Referring Patients To A Burn Center

Burn wounds are distressingly common and can be dangerous for the patient and difficult to treat. It is generally acknowledged that the following criteria are indications for referral to a burn center:

Inhalation Injury
Burns to the face, feet, hands, or perineum
Electrical burns
Chemical burns
Burns involving more than 10% of total body surface area
Burns in patients with co-morbidities (ex. HIV)

Umbilical Hernias In Infants

Umbilical hernias (aka belly button hernias) are extremely common in infants and toddlers and occur in 10% – 30% of newborns.

Management of the hernia at time of discovery is dependent on the size of defect in the abdominal wall. Small hernias (< 2.0 cm) frequently close on their own and repair should be delayed until age 4.

Defects larger than 2 cm should be repaired at time of diagnosis, although this is typically scheduled on an elective basis as incarceration (i.e., tissue or bowel becoming trapped in the hernia) is rare.

Airway Pressure Release Ventilation (APRV)

This mode of ventilation became commercially available in the United States in the mid 1990s. It uses a different mode of ventilation than other methods.

Conventional modalities use a strategy that begins the ventilation cycle at a lower baseline pressure and with an increase in airway pressure to open the alveoli and produce ventilation.

APRV begins the ventilation cycle at an elevated airway pressure and intermittently releases the pressure (i.e., deflates the lungs) to create tidal ventilation and allow removal of carbon dioxide.

APRV has been described as continuous positive airway pressure with brief releases of pressure. While teleologically similar, APRV differs from CPAP in that it allows for both ventilation (i.e., CO2 removal) and oxygenation.

APRV is now used commonly in acute lung injury to ventilate using maximum lung protection strategies.

Some advantages of its use include the reduction of patient sedation, the ability to breath spontaneously throughout the cycle, lower airway pressures, minimal effects on the cardiovascular system (e.g., mimimal effects on venous return), and elimination of neuromuscular blockade.

Dorsalis Pedis (DP) Artery

This small artery runs on top of the foot. The ability to palpate a pulse in this vessel is very important (along with the posterior tibial artery) in clinical exams to determine blood flow to the foot.

It forms as a continuation of the anterior tibial artery after it passes through the inferior extensor retinaculum. The DP runs on top of the foot slightly medially (toward the toe) to the first interosseus space (space between the big toe and second toe). As it passes through the first dorsal interosseus muscle, it becomes the deep plantar artery.

In the ICU the DP is a site where an arterial line can easily be placed for second-to-second blood pressure monitoring.

This small sesamoid bone is found buried in gastrocnemius close to the proximal attachment behind the knee at the level of the mid-patella and posterior to the distal femur. It has no bony attachments.

Fabella is the Latin word for bean. It occurs in 3 to 5% of the population and is readily appreciable on lateral radiograph (X-ray) of the knee. It is sometimes mistaken for a bone chip off the femur in the inexperienced.

Z-plasty For Treatment of Chronic, Refractory Pilonidal Disease

Pilonidal disease is inflammation with abscess formation and very often chronic drainage from the natal cleft at the tip of the coccyx. First line techniques such as drainage, excision, fibrin glue, and marsupialization are often unsatisfactory and do not provide definitive repair. One technique used by plastic surgeons and some general surgeons as a second line treatment when earlier attempts at treatment have failed is the Z-plasty.

Z-plasty is a surgical technique that is used widely in plastic surgery to close large wounds and to release contractures. In pilonidal disease, it has the advantage of eliminating the deep natal cleft and replacing the tissue defect with healthy, sinus free tissue from the lateral lower back.

Typically the pilonidal sinus is excised down to the presacral fascia (i.e., close to the sacral bone). Then two parallel incisions are made at the superior and inferion edges of the wound. The subcutaneous tissue (i.e., the fat layer beneath the skin) is raised to form skin flaps and the hook retractors are used to transpose the edges of the initial resection from the horizontal to the vertical.

The skin is then closed using nylon mattress sutures after a drain is placed. Generally, the patients tolerate the procedure well and have a fairly rapid recovery.


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Biologic Prosthetic Materials for Hernia Repair: Human

Human tissue prosthetics have found a use in the setting of a contaminated or infected abdominal wall. Although they are approved by the FDA for use in inguinal hernia repair they are rarely used, except in contaminated fields, do to their lack of strength of the repair. Use of a sterilized human tissue prosthetic carries the risk of human disease transmission, although no reports of this exist. Human tissue prosthestics are listed below:

AlloDerm – manufactured by LifeCell, widely used hand harvested human dermis, processed by complete removal of all cellular tissue and freeze drying of the dermis without end gas sterilization to avoid structural degradation. The product is refrigerated and needs to be rehydrated prior to use.

FlexHD – manufactured by Musculoskeletal Tissue Foundation, human dermis with the cells removed, has long storage time, no preparation required before it is placed in the patient.

Bard AlloMax Surgical Graft – Davol, Inc., Sterilized using low dose gamma radiation, proprietary process used to remove cells and pathogens.


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Biologic Prosthetic Materials for Hernia Repair: Non-Human

Biological prosthetics are useful when the surgeon is faced with a infected or contaminated wound but must cover a fascial defect. Their goal is to create a scaffold that will allow cells to attach but will not serve as a continuing source of infection. The disadvantage of these prosthetics is their lack of strength in effecting a long-term repair. Because of this, they are not routinely used in elective abdominal hernia repair and many surgeons have abandoned them and have opted for placing a Wittman patch with staged closure.

Surgisis – Cook, made from the submucosal of pig intestine, decellularization reduces risk of immune-mediated rejection, scar tissue encapsulation does not occur because of lack of collagen cross-linking.

Permacol – Tissue Science Laboratories, made from collagen harvested from pig dermis, can be used in infected site, cross-linked to improve durability and strength.

Bard CollaMend – Davol, Inc., made from acellular collagen from pig dermis, cross-linked fibers require rehydration before use, retains good elasticity.

FortaGen – Organogenesis, Inc, made from pig intestines, non-cross linked, not widely used.

Veritas Collagen Matrix – Synovis Surgical, Inc., made from cow pericardium (sac surrounding the heart), more commonly used to reinforce anastomotic staple lines (Peri strips) than hernia repair

SurgiMend – TEI Bioscience, made from fetal cow dermis, not cross-linked, requires rehydration, has extended shelf-life.

Tutumesh – Tutogen Medical, Inc., made from cow pericardium, susceptible to shrinkage, relatively non-inflammatory.


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Prosthetic Materials for Hernia Repair: PTFE (polytetraflouroethylene)

These meshes are widely used in ventral hernia repair. They are usually solid but are available in woven models. They have a lesser degree of inflammation than polypropylene meshes. The mesh can interact with surrounding tissue to form a persistent seroma. PTFE generally should not be placed in a wound with a risk of infection and must be completely removed if a sterile wound subsequently becomes infected. Some types of PTFE with associated characteristics are listed below:

DualMesh, DualMesh Plus – W.L. Gore, the Plus material differs from the plain DualMesh because it is impregnated with antimicrobial silver carbonate and chlorhexidine diacetate to inhibit bacterial colonization.

Bard Dulex Mesh – Davol, two-sided mesh with a smooth side to be placed next to the bowel and a microporous side to be placed against the abdominal wall to promote tissue ingrowth.

MotifMESH – Proxy, has high porosity that facilitates tissue ingrowth, has low tissue inflammation.

Composix – Bard, combination PTFE and polypropylene with the PTFE side placed against the bowel wall, widely used

Composix Kugel Patch – Bard, combination PTFE and Polypropylene, some sizes recalled by the FDA.


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