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176 Cards in this Set
- Front
- Back
What are the three surgical approaches to the thorax?
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Lateral thoracotomy
Median sternotomy Transthoracic |
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If you are working on the thoracic duct theu the right 8th ICS, what is your patient?
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A dog.
A cats thoracic duct is on left 8th |
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You have to do a thoracotomy on some dog cause he ate bones and now one is stuck in his esophagus at the base of his heart. Where is your incision?
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Right 4th
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There are a lot of things going on at the 4th ICS. What are they on the right vs the left?
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Right = esophageal foreign body at the base of the heart
Cardiopulmonary bypass Left = PS, PDA, PRAA, pericardium |
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How would you access the cranial lung lobe?
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5th ICS (on each side)
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How would you access the caudal lung lobe?
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7th ICS (on each side)
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How would you access the intermediate lung lobe?
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Right 6th ICS
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How do you access the cranial, intermediatw, or caudal lung lobes?
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R/L 5th for cr
R 6th for intermediate R/L 7th for caudal |
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So why would you perform a right lateral thoracotomy at ICS 4, 5, 6, 7, 8?
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Rt 4th = esophageal fb @ base of heart, cardiopulmonary bypass
Rt 5th = cranial lung lobe Rt 6th = intermediate lung lobe Rt 7th = caudal lung lobe Rt 8th = thoracic duct in dog |
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And why would you perform a left thoracotomy at ICS 3, 4, 5, 7, 8, 9?
(we dont use the sixth ics on the left) |
Left 3rd = cranial thpracic duct
Left 4th = PS, PDA, PRAA, pericardium Left 5th = cranial lung lobe Left 7th = caudal lung lovebe Left 8th = feline thoracic duct Left 9th = caudal esophagus |
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How do you make a thoracotomy incision?
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Make it curve, so its parallel to the ribs
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Initially, which muscles are transected in your thoracotomy incision?
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Cutaneous muscles and latissimus dorsi
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Thoracotomy requires _______ breathing.
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Captured
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Whats the dofference between assisted vs controlled breathing?
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Assisted = patient starts each inspiration then the machine takes over
Controlled = machine starts AND ends each breath (we have 100% control) |
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What kind of retractors do we use for thoracotomy?
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Rib spreaders like Finochetti and Haight
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Which species has a well-developed scalenus muscle?!
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Cheetah...
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What do you watch for when performing a left thoracotomy at the 4th ICS?
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Phrenic nerve
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If you sever one (or both) of a dog or cats phrenic nerves, what is the result?
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Shwll still be able to breathe--the main muscles of respiration in these guys are the intercostal muscles, not the diaphragm
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True or false. Count the ribs underneath the latissimus dorsi.
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True
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After incising the latissimus dorsi for your laterall thoracotomy, what other muscle layers do you go thru?
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Cutaneous trunci
Latissimus dorsi Serratus ventralis Scalenus Intercostals |
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What must you place before closing your thoracotomy incision?
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A thoracostomy tube
(remember the surgery were doing has no s in it, its the tube that has the s in its name) |
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Before cutting thru your intercostal muscles, what must you ask your anesthetist?
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To stop bagging
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What will you hear when ypu enter the thoracic cavity?
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A hiss! You just created a pneumothorax
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Where do you place a thoracostomy tube?
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@ 8th/9th rib
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True or false. When tying the ribs back together, you should overlap them at least 10%.
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False! No overlapping the ribs, ypu are simply apposing them.
(if you overlapped the ribs, the resulting fusion between them would cause restricted motion of the thorax.) |
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True or false. When you appose the ribs, you are not creating an airtight closure.
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True
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Why is it peobably ok if you accidentally puncture one of the intercostal vessels?
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Cause they have a dual supply--dorsally and from the internal thoracic artery so the anastamosis makes it ok
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Where are the intercostal vessels and shit located in relation to the ribs?
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Caudal surface of the rib
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Before beginning closure of your thoracotomy, what should you ask the anesthetist to do?
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Partially re-expand the lungs by giving them a "sigh" (inflating to 30-40 cmH2O) while rubbing your wet finger over the lung surface to work out any atelectic spots.
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True or false. Do not suture the pleura or intercostal muscles.
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True
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During thoracotomy closure, should the T-tube be opened or closed?
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It should remain open until the thoracic incision is closed (to avoid trapping more air in the pleural cavity)
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True or false. When closing your thoracotomy incision, you should stagger your suture line.
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True. This prevents any dorect communication between the thorax and the environment aka air
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When do you remove a T-tube?
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Until the pleural space is free of air and fluid
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What are your three methpds of analgesia post-thoracotomy?
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Intercostal nerve blocks cr and caudal to the incision
Narcotics Intrapleural bupivicaine (put it thru the T-tube and lay the animal on his incision so the bupivicaine coats that surface) |
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True or false. Median sternotomy is a good approach for routine thoracic surgeries because it is not as painful as the other approaches.
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False--the median sternotomy is very painful and is associated with higher morbidity than the other approaches. It also takes longer and is more difficult than the others.
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What are the advantages to median sternotomy?
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You have access to the entire lung field so its great for an exploratory surgery.
Subtotal pericardectomy Aortic valve replacement |
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Why would you perform a subtotal pericardectomy and thru which approach?
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For treatment of chylothorax; via a median sternotomy.
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True or false. You can access the thymus and thyroid thru a median sternotomy?
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True?
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You are cutting thru the sternebrae on ypur way to doing a subtotal pericardectomy when all of a sudden the bones start oozing. Eeeeek what do you do?!
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Relax its normal, just put some bone wax (aka beeswax) on the oozing and itll stop.
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What do we have to do before closing our median sternotomy incision?
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Place a T-tube.
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How is the sternum closed?
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TIGHTLY--using orthopedic wire in a figure-8
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Why do you have to close the sternum tightly after a median sternotomy?
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To prevent movement/sliding of the sternebrae
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To place a T-tube after median sternotomy, make a stab incision over the _______ ICS then tunnel cranially _________ spaces to enter the __________ cavity.
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8thish ICS, tunnel cranially 1-2 spaces to enter the pleural cavity.
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Whats the point of thoracosotomy tubes?
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To remove air from the pleural space to re-establish negative pressure
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How are you going to induce anesthesia in a patient in reapiratory distress?
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Get the ET tube in asap and dont use any masks or induction chambers
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Hats the pathophys of pneumothorax?
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Air gets in the pleural cavity, so the negative pressure is lost, and the lungs undergo elastic recoil and therefore collapse
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What does the heart look like on lateral rad when theres a pneumothorax, and why?
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The hearts floating.
The lungs collapsed, so now instead of the heart contacting the dorsal sternum, its sitting on a collapsed lungs. (see pic on pg2) |
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What are the two sources of air that cause a closed pneumothorax?
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Resp tract or a foreign body piercing thru the esophagus
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What causes an open pneumothorax?
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Some kind of penetrating injury tp the thoracic wall (from bite, bullet, stab, impalement, or inadeuate thoracotomy closure!)
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If you dont stagger your suture line when closing your thoracotomy incision, what can result?
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Open pneumothorax.
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What is spontaneous pneumothorax?
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Occurs in the lungs when blebs or bullae burst, releasing air
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How do you treat mild vs moderate vs severe closed pneumothorax?
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Cage rest and observe with auscultation every hour or two
Thoracocentesis +/- T-tube T-tube w/ suction drainage or a Heimlich valve |
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How does an animal present with mild vs moderate vs severe closed pneumothorax?
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Mild hyperventilation vs respiratory distress vs progressive, marked respiratory distress with hypoxemia, hyperventilation, and resp acidosis
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What are the normal lung sounds called?
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Veaicular murmur
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If a dog has a T-tube placed and three days later hes still got air coming out and isnt doing any better what are you going to do?
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Exploratory thoracotomy
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What causes flail chest?
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2 consecutive broken ribs in 2 places
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What type of breathing does a dog with flail chest have? Describe it.
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Paradoxical respiration--when he inhales, his chest compresses instead of expanding
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What type of wire do we use to repair a broken rib?
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Kirschner wire
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Why isnt a diaphragmatic rupture considered a true hernia?
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It has no serosal covering
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When serous fluid accumulates in the lungs, we call that
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Hydrothorax
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What are your two surgical options for treatment of chylothorax?
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Thoracic duct ligation or subtotal pericardectomy
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Chylothorax....chyle has more triglycerides in it than serum does. True or false.
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True
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Whe do you incise for PDA in a cat vs a dog?
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Left 4th in dog vs left 5th in cat?
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Where do you hear a machinery murmur?
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Left side at the base of the heart
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What two surgeries could you perform to fix a PDA?
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You can occlude the ductus via ligationwith braided silk suture or performing a coilocclusionwhatever that means
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What kind of suture do you use for aurgical ligationof a PDA?
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Braided suture (it wont loosen)
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What side do you ligate firat when repairing a PDA?
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The aortic side!!
You have to tie off the high pressure side before you tie off the low pressure side |
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True or false. To ligate a PDA, first ligate at the aortic side then the pulmonary side
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True
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What is the Branham reflex?
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A reflex bradycardia that occurs after you ligate the aortic side of the PDA
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How might you be able to avoid the Branham reflex bradycardia during a PDA ligation?
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Tie the first ligature sloooooowllyyyy
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Whats the most common vascular ring anomaly in the dog?
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PRAA
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what should you do with the dilated esophagus when youre repeairing a PDA?
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Nothing, itll fix itself or it wont,but dont do anything surgically to it
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What important structure must you avoid during a PRAA surgery?
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The vagus nerve
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Post-op PRAA protocol =
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Treating any pneumonia he may have and feeding in an elevated position
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40% of dogs with PRAA also have...
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A persistent LEFT cranial vena cava --- dont ligate it!!
They may also have a hemiazygous vein |
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What is en bloc resection of the thoracic wall and when would you perform it?
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Removing everyyyything...pleura, ribs, intercostal mm, fascia, skin
Cancer, trauma, infection, multiple fistulae |
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What are the common neoplasms of the thoracic wall?
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Osteosarc and chondrosarc
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Why is polypropylene mesh helpful in closing a large resection?
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Its non-reactive, resistant to infection, has great tensile strength, is porous, and wont fragment
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Whats a diaphragmatic advance?
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Converting a thoracic defect into an abdominal defect?
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Why would you perform a diaphragmatic advancement?
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Its simple, doesnt require prosthesis, wont be rejected, has good functional and cosmetic results
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How are small defects of the thoracic wall closed?
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Centripetal closure of the muscle layers...beginning at the 4 corners
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How are big defects of the thoracic wall closed?
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Using myocutaneous flaps +/- omental pedicles
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How big should a T-tube be?
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About 1/2 to 1/3 thr width of an ICS aka about the diameter of the mainstem bronchus
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How many holes should a T-tube have, and how big should they be?
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3 holes that are less than a quarter the diameter od the tube
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How is an Argyle catheter placed for a thoracostomy?
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Give it a thump with a hit
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T/F. Forceps should extend just beyond the end of the thoracostomy tube during placment.
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True--the rubber tube isnt going to penetrate theu anything, its the end of the forceps that needs to lead the way
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What will you have ready to attach to the end of the T-tube after placing it in a 13 kg dog?
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3-way stopcock
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If youre going to have to place a T-tube in a 34 kg dog, what are you going to grab to put at the end of it once its in?
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Heimlich valve
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What is PRE?
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Pulmonary re-expansion edema
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How can PRE be reduced?
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Insufflate the lungs slowly, roll the patient around ha, and do something called cupping?
Somebody immediately explain to me what i just wrote down |
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T/F. You should never leave semi-collapsed lung lobes behind.
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False--theyre better than PRE
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When do you know its time to remove a chest tube?
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Les than 50 cm3 has come out in the past 24 hours and the xray is normal.
Drainage is less than 2ml/kg/day (the volume is consistwnt with the one produced by the tube itself) |
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Subtotal pericardectomy...what are the two possible surgical apporaches and which one is better?
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*median sternotomy* vs left lateral thoracotomy at the 4th/5th ICS
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Whats worse, granulomatous or idiopathic pericarditis?
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Granulomatous has a fair px, idiopathic a good prognosis
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How is an Argyle catheter placed for a thoracostomy?
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Give it a thump with a hit
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T/F. Forceps should extend just beyond the end of the thoracostomy tube during placment.
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True--the rubber tube isnt going to penetrate theu anything, its the end of the forceps that needs to lead the way
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What will you have ready to attach to the end of the T-tube after placing it in a 13 kg dog?
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3-way stopcock
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If youre going to have to place a T-tube in a 34 kg dog, what are you going to grab to put at the end of it once its in?
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Heimlich valve
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What is PRE?
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Pulmonary re-expansion edema
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How can PRE be reduced?
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Insufflate the lungs slowly, roll the patient around ha, and do something called cupping?
Somebody immediately explain to me what i just wrote down |
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T/F. You should never leave semi-collapsed lung lobes behind.
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False--theyre better than PRE
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When do you know its time to remove a chest tube?
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Les than 50 cm3 has come out in the past 24 hours and the xray is normal.
Drainage is less than 2ml/kg/day (the volume is consistwnt with the one produced by the tube itself) |
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Subtotal pericardectomy...what are the two possible surgical apporaches and which one is better?
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*median sternotomy* vs left lateral thoracotomy at the 4th/5th ICS
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Whats worse, granulomatous or idiopathic pericarditis?
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Granulomatous has a fair px, idiopathic a good prognosis
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Whats the "puddle effect?"
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When, because of gravity, the contrast pools in the most deoendent part of the patient's esophagus (depends what recumbency hes in)
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Whats the treatment for pulmonary bullae or blebs?
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Partial lobectomy or pneumonectomy.
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Dog was hit by car, broke a couple ribs, and now has open pneumothorax. How do you figure out where the defect thats letting air in the thorax is?
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Fill the thorax with warm saline, have the anesthetist inflate the lungs, and look for bubbles.
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T/F. Normal respiration is thoracoabdominal.
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True
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T/F. For hydrothorax, place thE drain ventrally.
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True
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T/F. A left-to-right shunt from PDA cant be treated =(
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False. It can be treated, right to left is the shunt you cant treat (luckily it accounts for only1% of all PDAs)
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What nerve do you have to be careful of during PDA surgery?
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Recurrent laryngeal nerve
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Before a PDA surgery, the dog should be treated with diuretics or digitalis---whatever it needs to control the pulmponary edema, atrial fibrillation, or CHF thats going on. T/F
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True
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Whats better for surgical correction of a PDA?
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Ligation (not coil occlusion)
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Following PRAA surgery, will the esophagus go back to normal if its currently 2.5x bigger than it ahould be?
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Prob not, it really only reverses back to normal when the diameter is less than 2x the normal diameter.
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True or false. Turkel catheters which remind me of Steve Erkel, can be used for thoracocentesis.
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True
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Whixh is the preferred approach for subtotal pericardectomy?
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Median sternotomy (vs lateral thoracotomy)
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Where should the incision for subtotal pericardectomy be in relation to the phrenic nerves?
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Ventral to the phrenic nerves.
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If an animal had idiopathic pericarditis with recurrence effusion, how might you have to correct?
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Pleuroperitoneal shunts
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What is the purpose of bronchial vessels? Pulmonary vessels?
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Bronchial vessels nourish the lung tissue.
Pulmonary vessels oxygenate blood and go between the lungs and the heart. |
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Where would you enter the thorax to work on the lung hilus?
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4th ICS
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If an animal has a tumor at the hilus, what procedure would you perform?
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Complete lobectomy
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If a dog has an abscess on the distal left cranial lung lobe, what procedure would you perform?
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Partial lobectomy
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What are the special instruments you use for lobectomies?
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Angled forceps
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WHERE do you ligate vessels and bronchus?
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At the hilus!
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Which vessel is ligated firat when performing a lobectomy?
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Pulmonary artery
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The pulmonary artery is usually ligated before the vein. What is the MAJOR exception to this rule, and when else might you ligate the vein first?
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If neoplasia or abscess, ligate the vein first, you dont want it to spread into circulation.
In small dogs and cats you will ligate the vein first too, because ligating the artery in these little guys will cause the little vein to collapse, making it difficult to ligate |
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T/F. The distal ligature is transfixing.
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False
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Where do you excise the vessels?
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Between distal and middle ligatures.
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T/F. Cut between the cartilage, not thru it, when transecting the bronchus.
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True (same with tracheal surgeries)
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T/F. In small dogs and cats, ligation of the pulmonary artery causes collapse of the pulmonary vein.
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True, thats why we ligate the vein first in these guys.
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T/F. Pulmonary artery and vein are transected differently than bronchus.
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True. The pulm vessels are transected between two ligatures.
The bronchus is dissected between two crushing clamps. |
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After transection of a bronchus, which row of sutures are placed more distal:
Horizontal mattress or simple continuous |
Simple continuous--they close the cut end of the bronchus
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What should you do to ensure th bronchus is completely closed, and why?
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Bubble test.
If bronchus has any air leaks = closed pneumothorax. |
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What kind of stapler may be used for a complete lobectomy?
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TA stapler....staple the entire pedicle!
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What are your three steps for complete lobectomy using a TA stapler?
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1. Isolate the hilus of the lung
2. Staple the entire pedicle 3. Excise the lobe distal to the staples. |
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For a partial lobectomy, which do you do first:
Horizontal mattress suture or place clamps |
Place crushing clamps across the lobe, proximal to the lesion (beyond the safety margin youre going to leave)
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You have placed your crushing clamps for a partial lobectomy and want to place your horizontal mattress. What suture are you going to ask your tech for?
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3-0 to 4-0 absorbable on a small taper needle
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How do you perform a bubble test to examine the bronchus for air leaks?
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Drip sterile saline across the suture line while the anesthetisi inflates the lung.
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How much of the trachea is collapsed in Grade II disease?
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50%
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What is tracheal collapse a disease of?
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Tracheal cartilage
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What is th cartilage on the dorsal surface of the trachea called?
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Dorsal tracheal membrane
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What is the first line of treatment for a mild to moderate tracheal collapse?
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Medical management--weight loss, no collars, no heat, no exercie, might need cough suppressants
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What surgery can you perform on a mild to moderate case of tracheal collapse (grade I or II)
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Dorsal membrane plication
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What kind of blood supply does the trachea hav?
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Segmental
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T/F. Loss to th tracheal blood supply can also damage the recurrwnt laryngeal nerve.
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True? Someone had this in their notes?
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What muscles do you hve to bluntly dissect thru to access the trachea?
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Strap muscles aka sternohyoideus and sternothyroideus
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Where is th recurrent laryngeal in relation to the trachea?
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Dorsolateral to the trachea
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A tracheal spiral splint can be placed where?
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Between the trachea and the neurovascular structures
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What can result if longitudinal blood vessels of the trachea are compressed?
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Tracheal necrosis
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T/F. As you twist a tracheal spiral splint onto the trachea, you have to be sure to avoid the recurrent laryngeal nerve.
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True
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How do you secure a tracheal spiral splint onto the trachea?
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5-0 monofilament NON-absorbable suture
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What is a major post-op disadvantage of an externa
Tracheal splint? |
Other segments of the trachea may collapse now
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What is a major advantage of the internal tracheal stent?
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Doesnt require surgery
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What is a major disadvantage of an internal tracheal stent?
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Once its in, it cant be removed,
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What do you have to have to do before inserting an internal tracheal stent?
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Put a catheter into the esophagus to measure how long ypure going to make the stent.
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An imaging modality is required to insert an internal tracheal stent. What are your choices?
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Fluoroscopy or endoscopy
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How do you insert an internal tracheal stent?
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Thru an ET tube
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T/F. The trachea is not user friendly because it has a poor blood supply.
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True
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True or false. Resection of 8-9 tracheal rings easily done.
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False. 3-5 rings can be resected without undue tension on the trachea, anything more than that its going to get tricky
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True or false. A smaller percentage of the trachea can be resected in small Pups than in an adult dog.
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True. 25-50% can be removed in the adult dog, but only 20-25% in puppies.
This is what they say, but Dr Bruhl-Day doesnt believe you should ever remove that much. |
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What kind of suture technique must be used when tracheal resection is performed.
Where do they go? |
Tension sutures, 2-3 rings cr and ca to the anastamosis.
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What can be placed over the suture line of a tracjeal anastamosis to bring better blood supply to the incision site?
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Pleural patch
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Whats the purpose of the sutures closing a tracheal resection?
Whats the purpose of the tension sutures? |
The sutures in the center are for apposition and healing of the trachea.
The tension sutures prevent the trachea from pulling apart. |
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With which instrument should you handle the trachea?
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Umbilical tape or stay sutures--not thumb forceps
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True or false. The tracheal ends should be brought together before the sutures are placed.
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False. Pre-place the sutures then bring the ends together.
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What sode of the trachea should be sutured first?
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The back wall aka dorsal wall
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What are the three steps in anastomosis of the trachea?
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1. Pre-place sutures
2. Bring edges together 3. Insert ET tube |
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How do you check for leaks prior to closing your incision?
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Bubble test
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How long can your tracheal incision be for placement of a tracheostomy tube?
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Has to be less than forty percent of the tracheal diameter!!
Otherwise the trachea will break in half. |
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If a dog has had a tracheotomy or a tracheostomy performed, what can he never ever do again?
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Go swimming!
He also shouldnt have his head hanging out the car window or hell get lots of bugs in there yuck |
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True or false. When performing incision for tracheostomy tube, cut thru the cartilage
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False never cut thru the cartilage
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Wgere should you make your transverse incision thru your trachea for a tracheostomy tube?
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3-5 rings caudal to the cricoid cartilage.
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What do you have to place after making your transverse incision for tracheostomy tube?
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Stay suture caudal to it for easy handling
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Whats the difference between tracheal and endotracheal tubes?
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Tracheal tube is shorter and has a metal lining which preventa it from kinking.
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Once you remove a tracheostomy tube how are you going to suture the incision in the trachea?
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Youre not
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You are performing a total lobectomy. The pulmonary vessels have been ligated. Now which vessels should we ligate?
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Thbronchial vessels. Ypu can use henoclips if theyre small OR ypu can just ligate them woth the bronchus.
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