omy TTef [aPqy peumreGoYY “ICT Aq paysissy yeqerelpy paalew-ly pqy uesseH “1g Aras.ng JO 82}0N 81ny0T ZEW dqGAN — iteall 5 lee — del I) Als aida — Ui Adal gL 0096265356219 : Si ~ 009626 5343052 :isla p29 cols Aaa 2017 7 Alkhatatbah, Hassan Abd Almajecd Petra Emtiaz Lecture Notes of Surgery! Hassan Abd Almajeed Alkistatbah ‘Asnman, Dar Jalees Al Zaman for Publisking of Distribution, 2017, Description : Surgery/! Medicine ISBN a poses apie Oe Sig yp Le a as (GS tea GJ Bae AA olga Blood and blood products. 2 Frostbite and burn... 7 Skin Cancer. (7 Trauma...& frond Of GaloleS Conkenmes H P: 1-8 he 4 Pianeta G/w eee Teer jent should fast 6-8 hours pre operation wo oo Fee oor nary ae ae = — Um Capant Male 1 Peal i volume). : Comma Lecobon im SubserbSu Im TuFcim, corel COPD, imeunle Fee AY Netting ent Also surgical stress increase the catecholamines(increase 02 demand of the heart). ve XL 2 paar aa Post op MI is usually silent and has high mortality rate(60- _? esteopesis 4 ctede hea | 70%) usually occurs at 3" day post op. F Gat Gmpuarioa cf Cry. tine Ss Qneumo Merun. Post op MI is due to rupture of atherosclerotic plaque(mostly appear as not serious on angiogram) so it doesn’t correlate with the degree of stenosis or its location. Congestive heart faiture is the most important risk factor for cardiac complication post op. Patient risk factors for cardiac complications THD CHF CVA DM_ renal failure high risk procedure ‘American college of cardiology physician (ACCP) classify the post op cardiac’ complication risk intolow risk(zero risk factor) moderate risk(1-2 risk factors) high risk(>=3) 1“yay yop. Asepdorue uojjeq sye syom [RSAC Jeye WedT “SWE Joye yuow | yseay 12 padejap aq plnoys ArZns earoo[a Og “aj 303 ponumnuoo st oumndse pue paddoys st jorBopidoj poued sim sayy “stsoquionp, quays qussaid 01 gaa aye seed [27° SIN JOYE yUOU 1 20} WoAts si(jexSoprdoyot oumndse)Ip I ampaooud am ax0Joq SOM Q9-YE DAIS aq pmoys sixepAydorg ‘sompaooid upyscyA1orestdsas “wap axojoq uo quoned Ysu YsIy soy poworpuL sf spxesopua aayaaguy 203 sexeycydoad snorqnery “Ad waaaud 029415 QAT pasur pue (ueday (yOOT/SUr | AI ares oupuRosd)aopHoe aaiS pue 1 doys uoyy'mooo uuedsy wor; Sumpoayq JT -uuedoy onnaderoip 9418 pouiad oanjesado ysod uz m900 LACT £40006 Uyedaq so(asop 1948) HANT 21s 7IS1 UTH eM 000S UTedoY 30 O°g BUOY HAT 2418 ASH arEIAPOHAL (uorssardwos oneumoud yuaymaayun)stavAqdord oruvypoum 3p woHDNquTe Aye quaped ys M07 ALA J0 stxephqdoad sanrsdoreg -sjuoned pazsqenidsoy ur weap ayqzyussaad Jo ssne9 vowuos ysour sy SILA) utstoqua AreuourNg (sexephydoad qya)steuXydosd wsyoquisoqui0ayy, fasBingSurgery 3-intubation done at deep anaesthesia level to prevent bronchospasm during anaesthesia. Routine Pre op O2 therapy decrease the wound infection but doesn’t decrease the pulmonary complications. EEP is indicated to decrease bleeding tendency If the patient has severe ascitis pre op transjugular intrahepatic porto systemic shunt (TIPS)decrease portal pressure ,decrease the ascitis &esophageal varesis. Long acting insulin &oral hypoglycemic agents(sulfonylurea) should be stopped the day before the surgery (risk of hhypoglycemia),fthe patient started on short acting IV crystalline insulin(sliding scale). Metformin (doesn’t cause hypoglycemia) and can be continued. Good blood sugar control decrease the wound infection risk. But tight glycemic control(80-110) increase the risk of hypoglycemia and increase the mortality. So the best glucose level in hospitalized patients is (100-180) in ward patients. (140-180) for ICU patients. Patient on antihypertensive medications should continue to take his medication.also at the morning of surgery(with sips of water)m.c.c of HTN in post op patients is pain. Cortisone decrease the wound healing and increase the wound infection, Vitamin A mask the effect of cortisone on wound healing Patient on cortison shouldn't stop his cortison suddenly (risk of adrenal insufficiency). Surgery is stressful condition that increase the cortisone need.so stress dose of cortisone should be given to meet the increased demand of cortisone. Note:Stress dose is additional dose(the patient should continue on his ‘usual dose of cortisone also) Sign and symptom of adrenal insufficiency(AI) are the same as sepsis symptoms but important to know that AI crease K+ level and decrease the Na level(sepsis doesn’t affect K level)‘00001 -000$ yonoo yoqa1e1d amp sosvazour yuN Yud"UOISTYSHEN 1319} Suypa9jq snooumyuods Jo ys st 19]a0eI¢ OO00T> 0000s St Aes op 0} Noo yofaqe[d wNUTTUTE sy], 0000S¢-0000ST st HuMo9 rojow}d JeaLON, wruadorAo0quiosq], (Ga remo yng sump Surpo9|a-y JLLd poseozout) sae] wom, wep sepper st *Atenbo sopemapy soreurs0ag38*psostp Suypoo|q ogous uourmioa our oup St (({y)IMEUNLLOP [PUIOSOHNE St LALA, ‘aseasyp SUMS pore st osye e wxGdouDHY “(KT sO12% paswaxo9p) MYouay (TIA 1010 porwa.9p) “TyRdOMEY LOMO ‘OLN downy “ows Bepo9|q pu Lg TeEUON Inq LL pOsEOUDSAR| p rege Apsour “sassonar poyUrTX eYNOLO “FE BION, GMA 219498 m1 aHNdI9axdOKK IANA az2nas 203 pasn you'(radhy ay Bu1p291q Jo Gowsiey JOURN UA GALA PH JoF Ws9q om SAAVACL (pq Aqrensn)| ad& st QA Jo 9d&i tourttod ISO (AMA seasIp puTsqgiyAs woA -apeudioardo.sia 30 (jseq)§ gorse yuRMquiosar a8 gqeyydouogy Ses SERSESSESE=SSSEEssssnsnsnsntnsasnanans ____ iatang | ' I | _—— OL cemydourog Jo quommpan wT pasn OU OF B IOIIUF UE Sf>Ad] MOL Sey LAT WP HON, roe ojoadeoourme+ dA WOC-P (wopensturumpe JAVaG mye paimsoo suorduids ND 0 aunzios J ermraseuod.ty yoodsns)ermaneuodAy st Jay apis ceyrydomy aranas Ut past ou inq‘ernrydomay pr 30s 1S2q EAVAC-E -suonoagut yanpoad pooyg jo ys St eyEdisardok g 20}9% juemqmo9ar ou sy azamp J¥ exydouroy ar9aas uy pasn)aeydioodocis-z (aonoayuy Jo 3st ou st oxom se'eyrydowoy o1Aas ut ys2q otp)g soIONJ IeUIqUIODDI-| {g.40}0%y asKax9US 0} MOK ROOT 01 8 10}OUy asvaxsuy Stpa9|q aAno8 I] WOS-0E J (QAq)uoNowsIHOd sepNOEUOA amyUIOL -do sod vrunpqare wounn09 ysour ap st woHRTTBQY, wy -do ysod Kop nf 2p UEMI90 Aensn THY do sod suoprayduos serpstO-f ‘sous08149p PunoM 19] 0}>Ry YSL JOU st eIaNOUE JEM ONT “eysampsoeue eeu spun punom ayy Jo Suumsojsor st quouneary, sword pauopynnufear uy azour “uoJsiou auNiprUE UE AIOE -uumsopp poq or anp do ysod skep 9-1 1990 Tey idusoa snowas st yp (punom 104s 21H Jo Furuodo s1) aomoostyap punos-E stsopion o1foqujaut ‘ uorsnjsuen pooja’ srausinodsy 1 BuypooyayAtpedoynsee do sod ponboo jo sosneo ower, sycaged pazporpsaeue w uotsysues;poo}g yo Wons¥es HNAjoWY aunoe Jo ufls jesse oops Aaaresadoenu Sopooig. powmelésoun, =H0N “s[osson poora arp sapoxe yeu ORDA st sour do qsod step Q[-, sinoo0 Smpaayq A1puossg ——— tasting i I | I ol ammo paddiys 40 uoneiado ai Suump sisejsouray s00d sf oro uopesado amNY! sMOY HZ yl AP UE sinos0 Suypoo|q AxeuoN>eIy uoperado aug Bounp Jpssoa pasnfiy 0} onp aayesdoenur sinovo Surpasyg Axes ‘opnyour Supaayg jo sad Burpoayq-¢ -roagy doysod jo asnea ueuodurt ame worstysues) poojq'sSnup'wstoqusoquionp'snrqaydoquiostp‘euownaug “hep gl amp saye xray dowsod w paysadsns st ssoosqy -doysod sep 1-pye yuosoud Atjensn wosayus puna, (aarg proas)yeu uonoaya 2 esearou, -syotpee sj Jo SurBueyp aupnor 30 seppeig Jo Nore UNOS OST “@ proav)poumsysas perzayo0q Jo ¥sLE 9q) osvarour juoyed posiajouyeo J0F stxeL vodsuen pur stsomucs soy Apeynyr2cemur posa ABsou91SOyy ‘sonssy [e 10} saunos ABrou9 wLPU amp Sf ASIN) -Rep/re=IONS SPAR SOHO Ajgep wosrad Sy o2 mt os Amp yneoy Of St ayer olfoqriour Teseq TeULON ‘sa)0N, —— stn ss -9 (woreayduroo ota om st wed) va8ormt pmnby wm Aderotpodto-¢ orstoxa Jaye SYM Z gL 9 UT 389g UOISTOXa JOYE UONEIPEEy MOneIpeE WALA WoIstOxS aunties 03 3oeq souomaoar YI “(@mso[9 aay] wor TEM oMssH Yos sqyssod yseal am sAouTAI)UOTSIOXD -f ‘woissoudutoo pur Sulssaxp Su0dys-Z squuep at owt perpen prosaysoorzoo JeuOISoTENUL S} OUy IT ‘posn aq uma sonyepous 2u0 eT SION, uauyeaay, stingsSurgery Gilycogenolysis(breakdown of glycogene stores in the liver and skeletal muscles with release of glucose to be used as energy source for all tissues. Glycogenolysis last only for 24 hours as glycogen store finished. At2™ day body start using fat for energy (lipolysis). Triglyceride which is the main fat metabolized is converted into glycerol and free fatty acids.ttee fatty acids is the major source of energy after the 1% day& used by most tissues.(except brain jnerves and RBC as free fatty acids don’t cross the brain barrier) Glycerol is converted into glucose by liver which is used by brain jerves&RBC. After 2-3 days of starvati bodies(acetoacetate,B hydroxybutarate).ketone bodies are used liver start to produce ketone as energy source for brain and RBC. Other tissues continue to use free fatty acids as its energy source. In late starvation when fat mass is depleted(need week or more) muscle breakdown(proteolysis) start to release amino acids that are used fo produce glucose as energy source .so lean body mass(muscles) start to decrease late in starvation. 32 1 Surgery Negative nitrogene balance means more nitrogen is exereted in urine and it is sign of protein breakdowm(occur late in starvation). ‘Muscular persons have less fat thus start using protein earlier in starvation Notes, 4a starvation ft is the main energy souree(90%) for most tissues ‘rom protein. Brain and RBC continue to use glucose as there energy source(also use ‘ketone bodies less than glucose) Stress could be surgery, trauma, sepsis, or bum Response to stress is catabolic ‘Major bum is the most stressful condition to the body. In stress increase the metabolic rate and increase the energy needs(hypermetabolic) Surgery increase BMR by 1.2, trauma and sepsis by 1.5, bum increase BMR twice. Energy source in stress 50%fat 25%protein 25%4glucose (mixed although fat is the main source) Protein breakdown start carly in stress unlike starvation(late) 33“suost09 9a Ty se pasouelp F189) om op uoIp suoseMoMEXED eAt8 1 payoadsns st oustoqgnsor Teuaipe fos ( 11 AYE j,UoP suosepauENa mq Ise] eR JANE ‘uospyos)sa1 HoRINUINS FLIOY s({¥) Kouarrgaser waaspe Jo swsousesp Aouotouynsur jeunape ovp 3semun eo ssans aaAos (quawo|duoo ygofioxdeymLey yuXs uysoxd oseyd aynoe aip aswarnay [IM ssons mae “ssons OF g°9.7Nq UORRAMS Ut ("9 st yHeRON Goyndsoy “uoRBAIES 1 poonpoud serpoq suo1ey azour inq ssans ut peonpod aie soxpoq auoR=y soffeydorsmun Aq paonposd Aue [RIND ‘osnajar euousoy Aaeynyid so soremumns UIeUE at St TIE CAN Depeaioue aonpoud ssans oy asuodsas oyoquiayy “we opwuios arp acearom {nq “ev MYO paypmG Joy aseaioap [>A2] splow OULD wruEs ssaNs UL (wonotoxe waBonu soy pasn oururesn/? | Aq posn vow, suse) umopryearq jos wor posvojau(e) spine om meu atp am MuREIAT pus auIEELY "bap ast wa sjanoy say f eaudyse, eipmokyse) Johay etxasoue ose uED (suSaYSED p2|f9 Osf2)NI, Auvtang we 9v9po2 ANIL Jo SuaE|MMERS wre yp axe sUPRCIOPU, ‘jsdas -uread yo woyge aquransts o1p aonposd yorp ourjoyso ureU omp St INL sao -sourys04 UASUY 69 an SSans UF aseaIOUL ‘Kew yng euoumog ssams 30u pure anonION afOKEUR Sf MINSK FEM ION, “souesisod UHfMsU oxp aseaLOUT OS UITNSU Ne OTe souounoy sans spy “SOUOULIOY arjoqeIE axe soOMLOY ssoNg ounsvjord asvazout -9 -(eurmedop'gN ‘di])ssuTuEjoysates asealouy -¢ ‘auofeony3 aseasoUt -y uondiosqe s9yUss pure BN auOIaISOPTE ~¢ uondiosqe OTH HAV ~@ ‘uosryioo Ul aseoroUT tre S9sMB> FLOW -L SomouLLoy Ssaays 94} UI aswIADUT S89.98 UY DORAN aTAPEN squysisay Uynsur ase=s2UT cwordumsuos sou aseat9Uy sy Apoq aseazap pur'sseur £poq tej 95e0100¢T 971 VM ANT asea1ou stsaueBoanoon asea.0u] oso ICV FLOW 2sea200, sisfjouaBooKi8 aseaxouy sadinego yeuomoT wire SOTEPTT Sea oF aT, AnamLean body mass is the active metabolizing mass in the body. And consists of water and proteins in the muscles organ &bone. Lean body mass=body weight-body fat Lean body mass is more in males than females .also more in muscular. Nitrogen balance=nitrogen taken-nitrogen lost in urine Most nitrogen lost in urine are in the form of urea. Positive balance means more nitrogen(protein)taken (anabolic state)while negative balance means more protein lost. in urine(catabolicsthypermetabolic state) In normal conditions the person should be zero or positive nitrogen balance to preserve his lean body mass. Respiratory quotient(RQ) =CO2 produced/O2 consumed In sugar metabolism RQ=1 fat RQ=0.7 protein RQ-0.8 Fat is the largest energy reserve in the body(400000 kilo joule) Surgery, ——————________. See Giycogen stores depleted only after 24 hours of starvation (8000kj) 11gm fat give 9kcal(the most efficient energy source) gm sugar(carbohydrates)give 3.4 keal. 1 gm protein gives 4 Keal Normally glucose is the main source of energy.but in starvation or stress fat is the main source, Energy need increase in stress(in major bum energy need double) While in starvation decrease in the energy needs Good nutritional support is important in stress or starvation to prevent the adverse effects of metabolic response, 1 gnitrogen=6.25 g protein Signs of malnutrition 1-involuntary weight loss >O%weight loss in 6 months >S%weight loss in 1 month Body mass index<18 2-protein depletion Albumin, 3g/dl(half life of albumin is 3 weeks so it is the best for chronic malnutrition but not acute malnutrition). 37oF ‘Surpoay 281 Moy snonumuoo st 189q Os' ayer vaya sayy sey Supaay snjog. (onowso uou)yoses asea1our —(%QS)aIeIpAyoqIED osearoap (4405) Iw) seRIOU] suogeor dros vay.Lrerp asvaz39p OJ, WaBaK FORT wa swojqoad axonseta, SHOTS pe (X2W'r0a) uy aseaxop pum uynsur | eps yeydson aseaioap Krafis sofeU esvaxsin) — surospuds —Buypoayay | soye Sinpaay aanesodo ysod Ape -BAOOaT op SE cwoneiopod' wonesaoqn suoysor9 | pue Ayjeuour seep sqeanued rdaioo _voniesuy | now alanos mt Suxpoos reseyue Aw ‘GaN ON tg SK NAL oF parades snomenoarma wu axow) wonsaput | suomeoydinos ondas _asvox09qt (wore uIOS Sea eens. snowas souijtonendse pue xnijoy{| 0} asuodsax aoqeraur yp aseax99qq “woneoojsimg jeHoIoa9, x anp (uopraydues sujesuumc. | pue Aydone wsoonut JO YOAatd | Hrarpaay teaayae yo ewonean darcy juypooy TeINVWD fo STEIEAPY “uoneooisuen 1D Ppa}eg asearoop os'Aydoxpe esoonun 4p swuanasd yf asme90q ‘ajqussod J: pomjour Supaag ponayard oxy st Smpaqy yerovusy -suimqoadygs TEST syespAyoqreay,g/)sureuoS — uoNJos —_Surpaa,y uorssazdwogop pue Suypaay mojje 0} taumy a{gnop axe s9qm TTY “VL aIMIEP yoeUO}s arp asneoaq aqn1 Auorsounfot eq) aqm AwoIsoRse# 0 ani aq ue uonnjos smoedsy keting Be axour (aqny Ausoysounfafjumunfof 0 (aqny Auoysonses)qoewOIS ©} powasur aq = pynoo.saqny— gayua-snoauemnozeg, -shep gg.Bunpaay mea Buoy 303 pasn saqna Lio ius snocuvynosed anya sep O¢>Surpaay wy} WOYS IOJ pos ‘sf oLIgqUD0seU Os saqn} UBUD snosuE|Oed ueIp 5sH uoYEHTASE zaySiy sey Ing aes UONOAFUE ssof YaISea st oqmy oINsEOSeN Guoned pavonmynujent ut aseasour Aeut)poay putea T-1 PHEpURIS YIM Avp/S¥/[WOE St UOAIS Spex Suypaay yer9yUg-T (Nd 1)uon|N Ay 20 (eqn snoauenoid 0 aqm ouiseZoseu q)Supaay yexo}e9 apnyouy woman jo sod, JAusaqo piqiom gp=< oseqo aronos 6g-<¢ Asoqo aysapout p¢-o¢ qyBlomuano 67-SZ HIOAUDpUN gI>J ST-RI SEINE [EUUON, Zl nHI9 CANE :9pUEssemE KPO (Guanpeos upps ou) axBtoue-g eyuadeyKsoyduiy -p LOH pte Hf aseass9p-¢ 966 L>xapUL yBIOY ‘uyuyeax g9T>Joraisajoys unas aoupyeq wala Sarre ON, (wonunnuyeur aynoe 209 107891 qsaq_ aly st os skep 7 st ayy sTey)p/SugT>urungearg (sep 6-8 ay seyIpAwozz-waaysMeTL taotungSurgery —————————-— To decrease reflux and aspiration risk: Head elevation 30 degree during feeding and 30 minutes post feeding. Continuous feeding alse has lower risk of aspiration than bolus feeding. Avoid over night feeding Jejunostomy feeding has lower aspiration risk than gastric feeding(so jejunostomy is the preferred method in unconscious or if has high risk of aspiration) Refeeding syndrome Sudden high carbohydrate solution rease insulin release insulin shifis the electrolyte to intracellular level causing decrease in PO4-2,K+,mgt2 2-Total parenteral nutrition (TPN) Js feeding through the central major veins(central line) subelavian .internal jugular or femoral vein) Feeding solution contains fluid, fatprotein (a.a) dedextrose sugar. ‘Also some vilamins minerals and clectrolytes.insulin can be added to prevent hyperglycemia. 40 Surgery, solution through peripheral veins becaust zuse thrombophlebitis of the veins. Indications for TPN 1-NPO>7 days. 2- contraindication to enteral feeding(fistulashort bowel syndrome) 3- when the enteral feeding calories don’t meet the encrgy need of the patient( as more energy can be given by TPN). Notes TPN solution energy source are 70% fat carbohydrate 20% protein 10- 20%. Protein used in TPN are in the form of amino acids to prevent muscle breakdown, Dextrose solution range from0-70%(more dextrose concentration are used when we need to give more energy ,or When we need to restrict fluid 9s in heatt failure, 1100 kcal) while 20% give 2 keal/ml(1 liter gives 2000kcal). Protein given at g/kp/day as amino acid(more protein in stress or 41{enqwa Out ss9] Soy 1wj YoquiaMI)"405 0} Wy asvaIOU! pu %OS 01 asoon{F aseavep urojgoxd smmp aseansap 01° YINOUIP uoHe|BUDA Jo Suress aySUI TED SILL ({=asoony8 uy Oy soquiautar wonenuscn0s asoonfs Y8Iy 0} oNp)uONUMar 700-9 uoneoo|suen yeuD}92q 30 YH pur Aydone esooNUH TD- ue VORIESHL 1W-T NaiLJ0 suonvayamey “fexOOOL=2400S s9x88 oR 1B240SS=1°1400§ S98 vos SSiou2)uU OSC=HDT/OSe00S MEDD ORXAPHAOS JO 2900: w “Teoyope-eoyy'€sBooT = esomxp HL 1 ABsouo os)as0omf# 3 9OL-O01/0140001 SuHPIHO® esoRxePHOL APH “Aydone esoont Jp pur suopeoy|duuos onas ax0w sey NAL ost BUEpOSY wsaus oxgqun)ssans 0} asuodsas stfoqerot amp aseas00 3,0890P Nd. do cud shup 1 parsipa st Na. PoUORIANTESE fvsnos sj yroqed op JF amg “(GuopeN|ZiNO> woHsapUT amp s9=¥e=0p 14 Auopoyeday 30) vdaoxajyouag ou Jo St Nall eanesadonsd oupnoy qeour ayy aseausap 1,usoOP 7g" eIMSAE Jo ayer amsoa 943 25692001 aqua Jo quemon WI posn St NAL aco Jo omnos 8200895 (PDR SR EP HONS) PEA yamog [rews Jo aoinos Afioue ofp st (2) SUIEIENMI -soluayp Uys pure sogses trys st Kouapstp prov Anep yeuassa Jo vats yuonodu ISO 4g 5 Souattjp pioe Any waoud uo perp yusazed ej Sane aqy NAL 994 22f Joye Shop NF-L Simone Aovaroyep PLO® ARH 85 tao Zodky punogas quanaid ‘oy wor njos soup %OT 2AI8 AD fos nox Jt s0}9yex amp asvoI0ap Appagersdostd os quoyed yeogiins wi wrureosifiedky osne9 w> NIL (wmoagiodey punoqas Jo yst1) Awappus NAL dons 1.00, snoN sou ‘uz! soddoot wunruronyo‘suramepeqooouckst ourxoplscE'pI9e 1 useyoqs numa oy sqemoIUER smUBYA Jo uopeueumddns fxtngSagey ————_—___—— 7- feeling of bunger(TPN gives the energy need but don’t abort the feel of hunger) 8-increase the risk of adder (GB) stone and cholecystitis(as _cholecy: which cause GB contraction and emptying is released in response to enteral feeding not TPN.so in TPN no cholecystokinin so GB stasis and stone) - infections and thrombosis of the central line is the mc complication of short term TPN.m.c bacteria that infect the central line is coagulase negative staphylococcus epidermidis(subclavian vein has the lowest rate of infection and thrombosis while femoral line has the highest rate) Note that cardiac arrhythmia is the most common cause of death in refeeding syndrome To decrease the risk of refeeding syndrome start TPN at Iow rat, ‘condition TPN used Renal failure | Use Essential aa(decrease BUN) ‘Also hypartonic dextrose (decrease K+) Don’t use or decrease non essential a.a(as it increase BUN) Tiopatcatiare | Decrease catbabyiraieVA) incense iched chain aa while decreasing ease the mortality and hepatic encephalopathy) Decrease glucose(S0¥2) mnorease Fa( 50%) Metabolic acidosis | increase the acetate Surgery Signs and symptoms of some mineral deficiency Mineral deficiency Sign and symptoms rine | Mw important akin rach and Ws Changes aio with diarrhea, poor wound healin; : “Metabolic | Increase the chloride(CL-) allcalosis _ 44 Essential fatty acid defeciency | Skinchanges &rash, poor wound healing ‘thiamine | Beriberi & Wernicke encephal n r ike encephalopathy teins | Cutiomyopaty encephalopathy ‘manganase, _| !fease insulin resistance causing hyperglycemia ‘cooper ‘Mieroaytic hypochromic anemia zal 45ly “Av /99 OST -001 Aq sso] s2ye asvaxour aanyexoduray ut aseazoUE 9 | Aroag “oywsuaduroa 01 papaow PMI a10 os sso] sores osearDUE We voudyoeTunaams! Bunmoa’ vayserp’ — ssays “soAgy—_“uustjoqujounodsyy = o0r-008 ( 3 008-001 Sp 99 009-008 UPS oo 2 onst Cousn Soup, —(oameracon)eiquaasuy “sso] raqeat AEP Pron om enbs onerur soem Afrep ye}. suOMTPUOD jeUUOU UT one seInyjaseNUT roleUr mM St Z-4Od uote e]n|JoseNX JOFEUE 9HP $1 7D uoneo xeynyjpoemur sofeur amp st +3 Moyes zefnyjasen xo sof a1p SE HEN Gaeqnypoeme %os amynyjaserMNesos)iureM Apoq 94 JO ST aIMASHOD wor (p/e)epnsieut 10 zejnoseaRnxXa (eurseyd st Hq PHY seen Jo y/T)eMoseAeU apnfour Yor rUBteM Xpoq omp Jo ZO (c/t)mIMIpaoENXe-c PeReeE Se EE Ce Pee eee cece eee PPP Ege ob sia] 3Z—1Stam Apog ampjo y' (€/ZEINTPORAULL pnyouy oye KPO, “wu SEOLeS'O AEA J FOMITH=OL49°O =AAELL wostod 84 OL UT soem Spoq wea} sso] strvous saynm ssaf‘ssear Apog wea] 910UT SUBD IOTEH 0}, (403° ouopuay‘ su0q)snoanbe wow 30 (suedso‘josnus‘emse|d)snoanbe aq pines seat Apogt “ata Apog amp JO 3°O=SHEFUT pue sopuoou ur st s3y2K Apoq om Jo uorrodosd ysoustHT -suosiod ryynasmat Lay sayWA YOU! os IPA Jo yuNOU ee] wIEIHOD apOsNL 3YBt9Mm Apoq ayy Jo ¢O=TaveM Apog Je101 aseaxoep sopeutay 20 2$9G0 UF O$ JOPEAL BIH] WIEIUOD yey, “Ufo Spoq 91p JO 9'Om(ANGLL)s1eM POG THIOL Sa}0N,Surgery — ‘Minimum urine output =0.5 mi/ke/hr=30ml/day in adults. In kg/h. intake also 350-400 cc children minimum urine out Fluid intake mainly from external or from intemal metabolic water production. ‘Normal blood osmolarity is 275-290 mosmil. ity varies from 50-1200 mosm/l. depending on the hydration status. Dehydration increase the ADH level which increase the H20 absorption,reducing the urine output but concentrated(high osmolality) But if more water intake ADH level will decrease and urine osmolality will increase. In dchydration, the minimum urine output that below it BUN start to rise is S00ce/day. Regulation of intravascular status Blood osmolality 2*Na+ glucose/18 + urea/2.8 ‘osmolality which inerease the thirst ‘Also increased osmolality isthe strongest stimulsior of ADH. release . ‘water and H20 absorption in distal tubule.also RAS increase angiotensin 2 which will cause vasoconstriction. 48 Surgery, Intravascular status ean be assessed by L-central venous pressure (CVP).The earlies indicator of decrease in the intravascular volume is decreased CVP.(The best) but invasive technique. 2rurine output (the best non invasive technique) 3-blood pressure(BP). Hypotention occurs late in hypovolemia ‘when >30% of plasma volume are 4-tachycardia is the 1% clini dehydration. ign of hypovolemia & S-urine specific gravity if >1 12 indicates concentrated urine and non adequate hydration. Signs of dehydration Decrease skin turgor ,sunken eyes,tachycardia, hypothermia, oligutia,hypotention .hemoconcentration(increased hemotacrit) Itis important to differentiate between low urine output caused by dehydration or acute tubular necrosis(ATN). 491s Avp/Ayyoo Oz 9a13 suresso[ry S94 THOT Aeppoqos—Aep4P2 0S 34 OL pat “Sep/909001=Aep/5/20001 34 OT wl peou pin souvuTEHUMeUT amp aTBIN9IEO OF MOF cpaou ping Ajrep yeutiou amp st aouenayurEAL “saunqunisip aseq pioe asnea 3,uop Ty 3nq jonoue an] of woAid 3p siopioe ajoqsionn de woqce wom asns9 wEaR(6'9 HTS Suonons ogni QN.40 unWOK was REDE TE SSOLEAE suoquiem armaroroodsy armoyyody wean of 39) ap St eeE IMS (errs someynoose Sy OMSL pny wus Us som|deL oF pM Is aq TE “Ta pi ese ox pry Apon asotsoyo op py eunSH (ybompg £OOH bows ooupyreN)suremed pry mos emg (xe0qs uz 2d pang 80g a oOuS 4 ssoptae anoey yoat09 uRozPIBAH M FOOH CF PAHRALOD SETA ME AIEIET ‘yoru an 01 pas sf (ex ou harem axonxapryeruasevosy anewoydusks won 0} pasn(eny yg) ames amouedyy (waspngo ames asomap soyeabrysynpe ‘Astro seuyes sggesonxap seq) souruayareus sof 109 amp S ‘amg go 4ep 1 28 UF pasn 20% promo, cwojsavdxa sejnaseaesnus prdea ur 3899 axe SpLOO AaxBang 0s “amg, so yooys"eunen ty rsogt a1 sf 08 wuuse|d 0} yasoyo om st arRaEL ASOT S00 [CaN Rie RIT _upeoa)ourres asonxoC7 (qoms)psehoe EIS ESN) oeveou | Aapedoynn0ot ‘aonavar Sond oman bomgz so2y2 opts cooH ERE] ‘PIED baw £69, sanssp osearsoc, yor F15h ‘uorsundx2 baw 601 1D sejroseaenut yjbou OT BN iden remo zneu| —— avevet soma) ant ous poe HOU sods pim[y = OG | oper ooNeSONDAT - a ‘mmpos Krenn, Seaeeaoce “aaeomso Gnoein, Wem wNaT ALY fasting,Surgery Best maintenance fluid in adults is DS half saline. In children's DS quarter saline. Example calculate the daily maintenance fluid for 70 kg patient. 1* 10 kg=10*100=1000. 2 10=10*50=500. Rest=50*20=1000 Total =1000 +500+1000=2500ce/dayDS half saline. ‘Note: study the electrolyte disturbances from the medicine book. ion(tissue hypoxia) A ‘Tissue hypoxia result in anaerobic metabolism and increase in lactic acid produetion. inadequate tissue perfusion&oxygs Shock types | Hypedynamic shock ce [Decrease cardiac outpit(COywith alee #5 | increase in systemic vascular face resistance(SVR) due to vasoconstriction Tncrease capillary refill time(decrease capillary refilling and skin is cok’). Doeceace pulse pressure Beamples GpHtypovolemicshock(decreasein | é S a 5) Anaplastic shock ©) Adrenal insuticiency shock g @| Hepatic insufficiency ‘CVP scentral venous pressure PCWP=paimonary capillary wedge pressure CVP&PCWP are called filling pressures ‘Compensatory response in shock include increase a sathetic activation with RAS activation. Increase in aldosteroné > _(Na8&H20 absorption), angioteSBe I. Also increase in ADH,ACTH Qeortison. Also increase in gluconeogenesisé& (=> ‘proteolysis. Err rEeEeeeECreE 33ss (poo so xmnoureofiey ssoj 01 aoeds ou se) OHS ojtuayonodAy, snes 3,909 SupEs|y GHEISEAUT nq’ YPOYS ommajoaodAy, osnes uueo Bupaaiq jeueyxa so* yn stapod’ ysoqp “ uowopge omp UL Bumpooig, sno @ Seer eee eee gece _PuNBrTo payreu pur worsajodKy paw | %Ob<)p ams e 0002-00510 S01 260% Gndyno suyA aseaz9ap)eLin is 0e) ¢ 98mg | ___S” dino saan estou Ferree ‘_[enuon 99, ‘Supus wo gy sseaep)uoSUspOaNT @o00ST-0SL, cpiieoipio” —amsxaid_ovjnd oneatoap yyar| 30 80] 08 ‘Arequdes oseansp uns pfos vandkuon wupweacyory,| siz 3%mg “ay 7 (© 0si-00 Gi] sso1po014 tious AITO ( TRE TIN| KSI) ams ‘poys atmapoaodiy Jo saSuig “SOE TO TRE AS We TOT aT MOTSTSTOTA 0s {95a sso} poor Thun amssaid poojq FEY maaaud ssuodsax yeorSojorskyg “SpSSABipO 0) PAMAMIT ALVA SH OF Moy. POO TA Peseos0U sanelar us ynsax yr si Sea. KeU0100 1290] 0} anp) SBS TretiOHs wy yse3y noLysuos0seA, add Austins +s ‘TexgguangsopstU PS 6Sninflg, wine output >0.Smakgfhr CVP 8-12 if these findings not met then transfuse blood until hemotacrit >30% Nofe thatMean arterial pressure =1/3 systolic pressure #2/3 diastolic pressure Important definitions Systemic iaflamanafory | Is presence of or more of te fllowings response syndrome(SIRS) Note that SIRS is not specifi(caused by _______| infectious and non infeotious cause) sepsis ‘SIRS +documented infection ‘Severe sepsis Sepsis that is complicated by organ damage ‘Septic shock Persistent hypotention despite IV fluid L _ management ,or lactate level4 ‘baacterimia Presence of bacteria in blood TReart ate Reaping rate6 open doo xesorpoiunoud von og wonNaA Te Jo 38H OMFG omp suy (qFai@)UONE|UAA amssoud Kaovendxe pus eanisog “soy Arex pus 20eds soar ox gna _s04p wom UN R[NoAR pr donde YisOOIIOF ME3F oYsSODOp sypeau 1 sumamman(p1s yesmeues oy of ETON aye Peseofom Sun; om on nue aw aseainep s2¥S wssoqoUIAN UO|SIA, (xapine rUaASoyaGns)Swo;orpENTOd Awins 20 aonendse Aousfioms fq st epeuodum jo wounvaxy, uesfoxpzecoyso Ay 3599 st apsuodure) Jo stsouFeicy aac pesearour‘osind prdar yeom* wouuosodAy)pen 39oq S| svg apeuodurey, (SSIDROTIETERASLASUOS eeNYSTATEAAS w woos osye)>pHibaey wy woos ‘sy(uoORdSHT WOR BAGDT SAA SiowsAs ur asvassep) snxopesed snsing ‘toduueqp je uy amssaud jo uonezyecbe 1yia somssaxd Sumy ur oseaiour sosmeo apeucdurey avspse:) S10 lwstjoquia Sreuownd! eworeway jeusespaut uoRE] UDA sunssaud aanisod® xexoioumaud wonuay apeuodume, Aq poses (somssod- Bunty gAr WAS) asvarour'Q aseazsep)(aananaysqo)yooys — aatssaadusos-z “dma HULOD HIM AD 25H aocepuL e(TOTUDA TYING, TIRERD sTaa ‘moss Jt pasn st gN 10 ourumedop 1ng ‘gcd H10ISAS 31 2010] Jo Sup op st Gmenqop) yusIE SdoHow ‘ping :ywomyEasL, dod dAo'dAT asramurapmesipar woumodi ss a 0R< aes semnayea‘aujedorn “AT op asuodsax ou Jt past) poys aquoSomou Ut e104 al op Si(shiOFe Eade amd) saL|as|AGGT — ssossardosea GQuounvan wreur oqT)pING AL puoMEOLY, (ax@emderp Jo uopearoun sruaryd ‘Jo Sso] 0} onp)JsA5T ED aAoge Amnfiy yr mng00 1SSHE ATOHATSY WHIM WEE st UBS “Gjoogs omtafomon st eipres kpeIq TEAK ypoys ATuo orp)erprescpesq WLM ({LAS eS¥OI99p) HOREFETLPOSEA UL yInsax woneANoe snayeduiAs Jo sso :KBojosdqdomegSerg¢¢9 — $$ Surgery PEE is matty usd in treatment of acute respiratory distress syndrome to ‘Shosk type] CO [SVR | Filing ae TR [Caper ee pressures(CVP,PCWP) y refill Hypovoiemie [>] + Y= wold [poor ; , ss pram shock = A Ae Early septic |+ [>| Normal orlow ‘wana [+ normal a oe shock Caused by sever allergy to drugs(penicillins) ,fo0d or contrast Tate septic |= |__| Nomalariow eid |= [poor ae ae shock allergy. ‘Nearogenic | /- | Normal oriow wan | > Paommal Ha shock vD IgE mediated(type 1 hypersensitivity) rapid release of histamine Amaphyacte[*-| Normalorfow warn | | aonmal Byala spu tom masLeslls cause mnssivevasodietaon.can be associated Cardiogents [2 |¥ | Hat moma POWF a [oold TE por with broach shock sight ventricular wospasin infurction) Treatment epinephrine is the drug of choice in anaphylactic Tele Notes LV ftuidcontspo, anthistanin, aminophylline, itbatin Gf Gl circulation decrease in all ype of shock &this can result in GI mucosa IV fluid,cortison, antihista disruption and bacterial translocation so early enteral feeding is important sever bronchospasm) ial 6 ‘Increased lactic acid>3 is bad prognostic sign of shock ‘Due to adrenal insufficiency ' ‘ye Hyasopressor used then intraarteral line should be inseited to monitor BP ti closely Labs: decrease Na decrease CL- increase = Jy Nach tek me ¥ PCWP measure left heart filing pressure while CVP measure right heast Usually unresponsive to IV Suid management cea TNE jin septic shock is mainly produced by macrophage ot Note thai[ Gexametiasond is the first drug given in suspected adronal (eupprer ells) shock before the ACTH stimulation tesi(as it doesn’t affect the test) Jn shock aromatic amino acids increase while branched chain eee eo mee 7 Butonce diagnosed cortisone is used atfct the test so used after the test) amiaoacdsIcicinejaoleuine valine erase 60 a9 (conereysposea sosnes paw RWHDEMUCD JeIpI sear) ATW O om asTaxDUf AONE [I] ase.z9ysaxpoydsoyd st euOULATTA-L "aN 20 aururedop 01 8upuodsar owysoys ohdas Arovoeggar Uy Pas) S| ‘uonomnstiooosea Suisneo sioidsoary A uo ye -uyssaxdose,-9 Spous aun sydeu ao1oyp Jo Snap ou, v v v ysuoe qay eydje — auuqdamdg-s “Aymmoenuoo7y YH aseex0U ose'(auuredop wey azow)uonoiAsuOs0SeA St yAYD URW, Ve aceudienage (aN) sureqdontds o20N-4 RE cae: 2 —= apreo peg oper st 1AyD opIS SOT SndSs we. 30 ypoys oyve¥lomou uy pasn st 31 USFISPAEUOSOSEA, SosME GstuoSe eydye asd) supaydyduayd-¢ (O8 Vwrtionophsin. Wich is sated in he emt of ied ; vossels) | 3002s | i Factor VIt has the s | ~ | Use te teat neutropenia post Factor XIII (cross link of fibrin) If deficient can cause bleeding but bey chemotherspyeael sed | | seperate an nowadays as drugs ike @- | \ ithout increasing PT or PTT. (CSF or GM-CSF are used in Se this case) Factor XII deficiency usually doesn’t cause bleeding(atthough it increases the PTT). Factor XIL is the least important in hemostasis, ‘aucsFeprsclogye monocyte coloy stimulating tor 64 65Ls posmoidaooomanml or Inq “ywoyed pouuou ur “wojgosd snowias asnea jou []Jai 1} Se posers AfauTMoY 100 STAID IL ‘pO0|q SToWSp [IP WE pouDSISs Afsuinos axe AQH © AGH * AIH -uorstysuen pooja wioy uonayu uounnoo sour amp SfAWO_] “(ADAH AGES AIH pnToM Honsayuy “Dey paysed UeGy oes WORDT sso] SPY Poor FOUN -wurseydhy roja2[d tye azo } onpaurs {woo syqy wanasd oy waned jusioy7ep VB] wo poojg asn quored wopsyap VAL UT os -juared quoroyop V8] Ut WoUNEMOD IOWA “TEHEA woypees s1819]Ie- (reves you)stssjouroy aynry“yorwar ss0r9 £q paro>I9p ON woRiysuen, ysod shop { mm009. “Auypiqeyeduoour. dnox3 poojq suru so Kiiqeredumoout yy 01 np mooostskjouroy seMOsCABNXD $1 IL stshyomay posejop- sTapaoge POUT au suasoid yoamed pamowssere ul uoysror onéjouey ojo ‘woyova okay [aa] wigo|Sordey asearsop-y vomuLgo[sowoy-¢ WES, Gi 20m sseasour-z (Gaqyiso quios sanssod -jstsouseIg se fainIIqoysouIDY o1 anp)saEN ‘SPS (sisdjouroy zemnaseaenU speq “urd lope AUTHSP ITA * spi way ororur ayy St 1659 PEOUSTO. _ishfouuDY xejnoseACNU ST -Aiqqereduoou Sav 01 amp mooQ —-pawan you Jt uorwoydusos yer uonsear asyouay 4289-7 ‘uonvorjduioo sip sosesso9pQUS!99p DAAM)POO|A paryty “osm uTEUL o~P ST JEM Jo vouasard, (qe T)aonseas afaqay-1 orsnysuesy poorg Jo suoneaydmto Faiood BO Weed TTA om sores Fomo( wopuodep yf uO astngSargery Swe gery, $a patient(like organ transplant patient) CMV can cause serious J1-dilutional thrombocytopenia (the most _—_ common problems and should be screened complication after massive blood transfusion) fy CMV usually mild but severe in immunacompromised 12-clotting factor deficiency(m.c factor deficiency patient.so in immunocompromised or post ransplant patient use transfision is decrease in factors V&VET) CMV negative blood, : 13-bleeding from thrombocytopenia & clotting factors 3. HCV is the most corimon infectious hepatitis(HCV>HBV) deficiency. 6-volume overload & acute heart failure. \4-metabolic acidosis (stored blood has increased level of H+& ‘iron overload: each unit packed RBC contain 250 mg iron. K+,decreased level in 2,3 DPG& decreased PH) 15-hypothermia. S-graft versus host reaction Occur due to donor lymphocyte which attack recipient organ. ‘More in immiunocompromised patient . ~Theparia ‘warfarin MOA ‘Activate antithrombin | Tahibits vitamin K Irradiated blood (lymphocyte depleted) decrease this dependent clting complication, Half iife | Ominates.5 hous) 15 da Monitored | PTTGawinsic pathway) Pilexensie pathway) eae , by 9-transfusion related lung injury(TRALD Factors | DO. XIGaaialy Vite X and protein C 5 : : affected | factor X) 88 Mostly occur with FFP. can cause respiratory failure and Reticaloendothelial sytem (uot | Meubolicd by Tver j fm | *daey) | Adjust the dose(desrease pulmonary edema. metabolism | <3 ro need to adjust the dose |i) im hepatic fare ; in hepatic or renal failure 10-hyperkalemia(fiom hemolysed RBC in stored blood). Frotmine sle(V) Vitamin K or FFP : artes : FFP is rapid and used in Sélypocalcemia(from citrate which is Ca* chelating that is | naaote Lee eee evar used as anticoagulant in stored blood) seed met st Safely in| Safe oesi't cross the Tnsafe(eross the Pregnancy __| placenta) —___| placenta) 68 0-uyeday ‘WEP S59] MQ HAINT WA Inso0 we osye aatoxpucs LTH -pusoxpuds IIH Jo voneoydaros sofew om st (Surpesyq 10u)stsoquiomyy, (yea csnouea)sisoqurony 3p emadovooquomy OF ynsax YSTIA, “(aquOIOas‘{qV)ssO}EIpeMT opoquiom ap aseajor pue sjopred om Aonsap yy eBe sorpoqnue way ‘ soR}INS yajarE]d om] BO soqe] shop €-¢ paddoys upedoy pue pappe st uaEprEM wor ‘uurejsea azoyaq Aqfensn poymis st uredoy wraiqord sxq plone Ol, “equ JBAMOT 7p'YoonnG ‘ ysvaIg OAT SvarE ANE St SISOIOIL UNAS JOF IS ovu))s{SoID9U MEAS asnED [TAA TEMP AES a}CEINTeooIadAY, UW YNSOF GOAN RTA St01ey uF aseaxsap ay azojq ‘asvaso0p [PAa{ $299 Wajoud! pasn st TUEPTEN uayAs os(sIC}Ey @umop IP ap veMP ap] eG JoBOYS tp snremBeoonTE OL Sys0rs oy ow 298uo] pou y Se yf MIURA OU ang -2yedrooudoszo _wypavo wy suepodum st SLL, Apoquze xz s0,20 Aq pur st pszenos 60 ssod asreaoq 1S9q aup)Na{duo XT JOIPET-T are sopOpHNE ULIEPFEM 405 suON dO ‘ip uawp AiaBis moSsome pood pur wEmpem vo ywoHed 21p JF FEN SION, fra Jpuax ui asop orp ysnipe os Aoupry Aq Apureur payssoxa st HANA “Ayoreos 1X 4onoey saseas09p 71 ng IIT Wiqumosyae Uo JOP 3.US9OP HAT 800 JOUsTY Sey FLAN Ost eurospuds “LIA Jo 38H S89] sey ‘o1oprus ou ‘SunzoyuoUr soy poae ou'(AqLeP 2ouo usars)oyry Fey JOys1y sey wo wos st (HAW DouEedoy BLOM IeNospOU! MOT ‘uy uiseday paeuonoeyun ‘uzedoy pareuonoexqun poe st ose upsedoy, stone Jo msymeysoUl=YOHN ovosojoyp | +f amp aseauour eonp pups “LTH ‘s0s0doors0 iq ‘ssornou | sey 30 eodoye np spay APIS sys ‘sisouodosys0 ‘Grujamias Couwyiuypaaig {saat 2x9 aseasouy ating,Surgeey $$ $$$ Diagnosis 1- ELISA(@PF4 antibody) if negative rule out HIT syndrome. But if positive then need confirmatory test. 2- serotonin release assay(is the best confirmatory test) ‘Treatment stop heparin &LMWH 2- add other anticoagulant like itors(argatroban , lepirudin , bivalirudin,) 3-warfarin is added only when platelet count is >150000 ‘Note that platelet transfusion is contraindicated in HIT syndrome ((norease the thrombosis “Argatroban is metabolized by the liver so the best option in HIT syndrome for renal failure patent, The other mediactions are metabotized by kidney. All the antcoagulans that are used ia teatment of HIT syndrome have short half life so ean be stopped 10-16 hours before the surgery without swithoti therspy.lso these anticoagulants has less bleeding risk thaa warfarine. R Are urokinase , streptokinase ,& tPA MOA is activation of fibrinolytic enzyme (plasmin) which will Gissolve the fibrin and the thrombus. Note that heparin &warfarin don’t dissolve the thrombus but prevent its progression until the natura! fibrinolytic system dissolve it Streptokinase is derived from streptococcus bacterial protein. Body produce antibodies against streptokinase(antigenic) so it decreases the efficacy of streptokinase with repeated uses. Allergy in 10-15%, Urokinase is not antigenic (body doesn’t produce antibody 30 it doesn’t loss its efficacy with the repeated uses. Also no allergy Streptokinase & urokinase half life is<30 minutes. Remember : ‘The natural anticoagulants in the body are L-protein C &S(destroy factors V&VII) 2-antithrombin Hl(inhibit factors IXX.XLXI mainly X) heparin activate it 3-heparine cofactor IT Bst +(Aanfuy uorsnysodos)Sunmremo1 pue Surzsay Moy ose ynsor ues oSvuep onssty, “suopusy 7p souog’ sojosnu SAJOAUE two auaA9s J] “BuUD}STG 7p vUIAPa “uoHESHDs Jo sso] € uonez09qn UPyS ‘S[souEAd * ssoupar : smoydunds ap sting (ennssona Aersadss oympoenes st poroaye Py APoq KOU TEMP HON, “Cempexodwsay Z- 3B)pIny [eEPASTAyNT aqp Jo wonesymsAio UL ynsay Yorys UOrTEPLPOsEA Ka pomoy|oy you pur yeusauad st wonotNsuososeA Qpomyerodim; UNIS ‘usy Ing ‘oSeurep enssy quosad o1 uONBEApOseA JUaRIUDDIUT Aq pamoyjog 1nq woyamsUOdOseA st pjoo ou 04 osuodsax jeRTET Bojorsdydomped “esoury 4a “J0oy “PuRY otp st payoayye alfs UOUILOD 1SOPA, “oraz ummp ssa] st amyesoduioy UPS wey smo00 yamyadma; Buzeay 0} amsodxa ¥L pouad oy] $2 tp aye pasm aq sou pjnoys yore sso19 409 a[dums was WR ‘sunday Jo sun gy a7quoBeuae azyns uuseyoxd yo Busy “dno12 pooyg souop jesroatun omy St Poo} oatTeFOU Sarpooyg osneo uss Kouoronop unum 2p ASWOIOLP 3 HLTA (Gupaayg swooueods 30 U)OOOOT> JX “OOD s siserFOWeY YeNbope 305 yuNeD ZoHET TENT sodas st [Co asnw wowe> W094, sm0N “snquromp oye wEgy 249 DAjossIp urasojd wor (eanse)umused om (eanovmuatiounuaseyd auanuon wR —Spoq ayy UL aurdzua —onsjouniqyy Temyen sofou amp st (Ve 1owanoR usouTUseIE onssst-p ae ee Ere eee eeSangery). Reperfusion injury release 2 free radicals which will cause ‘vasoconstriction , platelet and blood cells aggregation causing thrombosis in the microcirculation also can cause tissue edema and increase the compartment pressure. Treatment 1-Rapid rewarming with warm water(40-42 cc) is the most important step. 2-Warm TY fluid(40 ce) _3- limbs elevation to decrease the edema. 4-analgesia during rewarming as it is painful 5-tetanus prophylaxis Note thataggressive massage is harmfulavoid aggressive massage). No need for prophylactic antibiotics(inerease the bacterial resistance). Early debridement or amputation is contraindicated as it needs months for the frozen tissue to return to the normal appearance(we cantassess the viability ofthe tissue early in frost bite) Complications Infection, tetanus, gangrene, muscle atrophy, compartment syndrome, parasthesia, cold sensitivity, hyperhidrosis, tendone stiffness Aso it increases the risk of squamous cell carcinoma of the skin, 16 Could be due to scald burn(hot water), direct flame bum , chemical bum(acid or alkali) , electrical bum , or inialational burn. Degree of burns Degree of the |1* degree 2 degree bur Epidermis only | Bpidermis and ee dermis ‘Signs and [> Redness and | Pain redness symptoms | ~ pain aeblistering. Heals without |~ Heals with scar ‘minimal scar Calculation of the burn surface area “ae palais Nek &hcad 9 [Neck head fia) ah upper ib, | 95 | Bach upp nb pm “The whole bak Ta |e whois bak BE has and abdomen 19% | Cas ad bomen —— FTE Tosh Tower ab {R95 Bac ower ib Baa) Genitalia 1% | genitalia im | 16L ‘Sapa pouontour oxoge ay us portsosse oN. LuLoaseyps9 105 Ho eoypuy You pure wma rpIAL nao Ajfensn ssaupIed 40 WAP IE. AON sumdp visarpsered o19n2s-s 590) 10 sia8uy amp Jo stsourds -p Suysjas Areydes poxejop-¢ Sqn pg Wl AMO,OAETPDSA 10y suOHEDHPUT HG Word 0} AmooTTSSS pou pue eMMNOySsr ur ynsor ren pug sneiqg osneo ued squny am w wNg TeHUOLEyTURDAI “siiageAT pou Gop Sens sung 2057 TER) Bunyesd arogaq Syl EZ JOF WOM WMG FEHTUDS 99x30p ,.€ ‘amg aadop pk tiie = puvy 20} euop SiON 1) Sunesssy worsioxs AWre SuryRag-¢ SEIEEST| raed watenooad | — ia aa Red sei TOO 5p 3004 RPS soumed ojured | Tymea SuPemEpHINS ZOMNS Hania osns | __qewow opRmaFOH ‘quajed wang 20y ayssoap wy posn 2pojanMe OT. ost 8L Paamaso LHORSSFUL Ht pesn yuo sonorqnu oruaysis ssaeyersay [esyong aM OsvaToUT 11 se BSPDSE Tou s1 onoIgae on>eyAydoud (AI 40 [Bs0}oHINNSKS FUND SION SOMOIgHUE TEI] YIM Buyssaxp-Z Aap a 910 UE posn 9g wea yng ep ,,[ Bt Mi pasn you PIN sPLO|IO> + SOPPM Siou ym sisamip asnzo 1 se waar you osonxeq] & cD mine ened umd UE pIny 1894 STL ARN som 9¢" 1-99 09S/=LZ4OLeb= POpooU PNT L148 14466 Bue D9EETAS TOASTY PUT SOTK oxy puw a Boj por sty 3 » ung qu qwoned ST OL wr paoe pny ap ayinspeo oaut duexsy RTT Wow ap won 8 cee ey soigo xp pu sO YY an uaa [sane STATA, F =pepoou pyres peepee gMoUre stp Jo Je SHASTA 9 nao JO FaW SSefIAe ap uo spuadep pappou ping AL Jo weowre aL oO PIRTPAT pat eI poUe sy edu soy om quowaseuryy, kustangSergey —_— <_— $$ Complications of bura l-infection and sepsis(m.c bacteria in bum patient is pseudomonas. 2-dehydration , hemoconcentration , shock, 3-hyponairemia. 4-scar formation. 5-jgint contracture ‘Note that : marjoline ulcer is chronic unheated leer that result fro fon cr chronic osteomyelitis it is risk for squamous cel! carcinoma Result from skin contact or ingestion of strong acid or alkali ‘Alkali_is_worse than acid. As alkali cause liquefactive necrosis(cell die and disappear). but acid cause coagulative ‘going into the deeper cells) so alkali goes deeper than acid. ‘Treatment in skin contact 1* to do {Washing with water for a 30-60 minutes: _30-60-minute In ingestion increase fluid intake Wi enoscop? fas soon as possible to grade the severity of injury. ‘Note that: induction of vomiting is contraindicated in chemical bus Mostly affect neryes and muscles more than the skin(deceiving burn) S High voltage burn>1000volt is dangerous that can cause ECG changes and rhabdomyolysis@ OF Rhabdomyolysis release myoglobin that can cause renal failure(aote that myoglobin is aot direetly toxic but its metabolite isthe toxic to the kidney). To prevent goa failure in shabdomyolysis (give WRaia i ‘urine alkalinisation(NaHCO3) , osmotic (mannitol) i Signs of inhaiional bum(naal 1 82 , jnflenS62_ oral eg ere eee shskiaen, altered rental status) CO poisoning is best diagnosed by carboxyhemoglobine levelGi10% asymptomatic. but if-60% fatal) ‘Also PO? and 02 saturation are normal in ‘oximetry don’t detect CO poisoning)8 “Aras: [euoisioxe wey sYMseX oHOWISCO saNaq sey A1oBms SHOW “suy@reur oameZau ajqussod yea, am Yowox am yun WOES SHY Sh OF pus om pue suea MB OH anssp FRUNUIME aye am Yor ut Axons payfoszuoo Affeorydesozoran syoyy (3) your oanedau Ajssox8 wrurg wpim KaxBins yeuoystxo Ci) uaqpia MouneaN papuaummosss aq) sf AioSms — yuoMyear, ssdorg past ssousercy / suosiad gaX3 nq ap sti opHOI “WT any uy ovourg SEE PIo-, — RTTIRE-9 ueyaur rueus eur pue “swouroims [Joo snourenbs “euoMoW |I99 JBseq 10 >HI “YY) umsoqwemiid eumsporx-¢ aunsodxa punodmos owasie-y o ae (oa Ut LOREM SUL omy St suOREIMUT HET EG_)suone nu au—d-— (come eg 5 snot oes snp asso opm stoned soouss owes xxou emyuorssoudensouU-¢ VAN Yep s10u st AN Jo YSH ap Cueuodun sour omy st (GT FEE V62) VETRIPET EAN WSucjonem-poys)roeF YSU yeyOduT ysour ay) st ens ag, Woy aansodxa toner stomenn 1 0 SHOpEE ANA Aasting SOAP Atpensn ame s9Og'° ATTEN =)” “9009, aa ‘amp 0} doop apeaut Ayjeooy wed nq ¢ aziseIseyour WOU 40 Ayame, <[NPO se quasos “OTE TULWOM ALMOTS S13] SGOT Op Sf 200F OUP. WO UOTTBIOT WOUTUIOD ISON + aay ssey om suai pasOdso uns st aus WoUNUIOD WON, LPR st. 99 HUM swoNed 105 SOAR oxy, 1o9uD UPYS LOUTATOD SOU! 3H SI -opnyou pue tupys aup Jo z24e] stuopids axp woxy asi Aypensn sou UNS == Gee eee Sai a: oxo CORT eas wa oN soKoounjeur Jo roquinu aus qj ancy smosiad OH PLU DEI (corsoouejout pre @ “spo subs“ eo sve 0 sa ¢ eon Stawoprci, © (spi “a nq ‘sxoxdaony aarau Ciosuss steoueln® 9tf. SUTIOo fap ayy pue % katang,seee69 gq ‘Topical 5-fluorouracil 5% chemotherapy May be used to treat Js the second most common skin cancer, after basal cell carcinoma. ‘Usually present as ulcerated lesion ‘Mest common site is the face(lower lip is the most common facial site) [Note that BCC usually occur above the line that extend between the angle ‘of the mouth in the ear, but SOC usually occar below it. SCC is rapidly growing and metastasise by lymphatics but not blood. Diagnosis is by biops ee Risk factors: are the same as BCC. Als HPVs risk for SCC. Premalignant lesions that can’ transform into SCC include bowen disease, actinic keratosis. But sebrrohic keratos not : re premalignant. Marjolin ulcer from chronic bum or chronic osteomyelitis is risk factor for SCC of the skin, ‘Treatment the same as BCC Is the 3 most common skin cancer and the most aggressive one, 4 Can metastasize by lymph node and blood. nr Se gh g The most important risk factor is exposure to siulight( UV-B radiation) More in fair skin blonde hairé& blue eyes persons @ ‘Types: The types malignant melanoma are superficial spreading, leatied tignaDesmoplost® melanomas modulat® melanoma &mucosal melatioma, 38+ Mucosal melanoma is arare (m.c site for mucosal melanoma is, the nasal cavity, 2" is the oral cavity) yj Superficial spreading melanoma is the most common melanoma(50%) 2 Lentigo maligna is the least invasive type of melanoma & Nodular melanomas are aggressive _lesions that have only a vertical growth phase, Staging Depth of invasion is the most determinant of prognosis in melons, ~) Proaness 3518. -ovureap pue Tout Aq poqeany aq pmnoyg swayed PIC Ut oY “seyounqres pares are soypa8o paTSSHS sfioq way sapunquey -ynows oq ew SuOTe onoIgnae stisine snDDOGO] AYES a “(paimzoy st snd )opsifioy FRY oy FO WORT IUT IO SHAOHOY ddop v st (Kloq)sojsunany £q pasnes Afuounnos sour ssporqnae St quouneax], “SST SOTOOOTATEAS” st wuojeq wounuos sour - sofSTTOF HET amp Jo wonsayur yerogzadns st spMOMTOA [FSHOGHGE fs woueonadeF ain ur o10u pue SuSE wr x0 ‘shame snagoso|cydeag J0 sausBoKd snooooo\dang £q pasneo' genocides ig is 49 Pi se soquromay semousyoe sqory Jomo] 40 yuna uosy anise azour eae Yoou pu prog om Jo eMONE|L suourjur ye so sound siom oxp ey eaxoueusTsOONP, econ sip st SRAM 1 sARMEMBAT FI KONBLATEUL SOP, x9 yeogsms oye sia Aueur Joye u9so quosoud ued siserseieu dumIsip eWOURaHA Aavding / 98 _ “pom yuk, ounsuy 0 azyseyseyaus ueo quam :960| amp UE VUIOUEL AA, -SARETAT Hoey am puw sopeasy ay AGB axp sp eemouepous sop ays vores 3SOut 94 FMD AION «40SEC wmmounjou yo Adesay asnnfpe se pos 9g Som TEE NUL (qT oaneBou Ajqeoqur 205 Aworsouepegdansy wo0Ny jypunq ou) xPFSAR0d AyeortN 403 auop st AwoyoauaPEUAMK YEH BON - SUIORSTTEPEGATAT SALNS|S FO 2 GN] uonoossip apou ydursy jouus BEM “OTS TeOIBINS ope st wwOUR Jo JouvaN Geund ayy, ywoUpEeAL 9 -SugpsoiG * woTFERH( sigmad* 09 3HeP fa 3 o sro SoprOq RTMAMTEIAGE 20 “SAE FSANGS yery au ysou Sunsrxaaad oy ssSimyp wen Jo wus? por ne Sona 0% UL [Sur x0 134 Bupspaaid woyy osu ED FuDOKTE}ONE Fe SHON, Kadoig hq ys0q stsousercy yi ShosTBMOGHS omp OWL pEards - p [PAT sfiazop refnonad orp ov peaxds - AT PAST oii sfiiiap Tejmonar-syiuiop Maeytded om omy peads - YT 1202] sfoiep Areyided oxy oy peasds - TI 2407 ‘SRTAPITS ap 01 paurpuos - 1 194971 -uoyseaut Jo indop atp uo spuadap WoRRTaT ESE HIFID OS fastingsurgery Exysipelas is @ bacterial skin infection involving the upper dermis thet extends into the superficial cutaneous lymphatics It is a tendét, crytheShatous, indurated plaque with a well demarcated border. streptococcus pyrogen is the most common bacteria itis is nonnecrotizing inflammation of the skin and subotaeous_tissves, prevent with ot well demarated erythema , fever and tendemess.mostly caused by streptococcus and staphylocoStls bacteria treatment TV antibiotics Necrotizing fasci fe threatening necrotic infection of the skin and subcutaneous tissues, usually polymicrobial, usually subcutaneous necrosis is more than the skin necrosis so during, debridement wider area of the subcutaneous tissue should be removed. Necrotizing fasciitis can affect from mnd_ subcutaneous \d fascia. 4» Foumier gangrene is a necrotizing fascitis of the skin of the necrotizing fasciitis of the skin of th scrotum and perineum. is more in diabetic patient. ing fasciitis & Necrotizing fasci % Treatment of nect aggressive surgical debridement(removal of the necrotic tissue) with IV antibiotics. —— debridement is the best treatment to prevent limb loss and amputation [Note that the most common cause of lower limb amputation is peripheral vascular discase especially in Diabetic patients. Other causes(trauma, orthopedic malignancy or soft issue sarcoma of the ) lower limbs, severe soft tissue infection ofthe lowe I Gas gangrene is caused by the gram? anacrobic bacteria cl pfs. Airis prevent a tbe supotanaous Ysa with ty physical examination. Trested by aggresive debridement and IV antibiotics. meets gh The drug of choice for methicillin resistance staphylococcus ‘aureus(MRSA) is vancomycin, 8916 J ini pasa sou ‘woReUTETEXS [reer £q amsoad (ty ayqedjed ~ wouaar aun 20 ‘uoneuE ynougsp * styeout sad Supooiq Gg Aamfuy yeaqyeay © oO eNpaMT Tod) eA umes otsjad ur pant wed30 WoUTUIOD \so/Y Ri esi woe yeaa ct RRTpOTENY my ‘SVR wows Biapaog soye suO Fy ooo) FHS TUS! dosp Git Bexpe9|q Up S370N (@uySeun por uopedpsanin qui)doaans ArensaL-€ (ooqrouraexa oud oitaoy* ‘UORBUTIIEXD [oyoar * AiduEMOYUSS * uSUTOPGE Supnjouy(ssoy sq) “OF Peay oy wOY)uoNUTUNEXs yeorsAyd |[ny)Aoaans Aaepuodas-z_ (GatarpaReSoEce soo 10} 300 07 poq sq asodxa pue waned amp ssexpum)amsodxg-a (opwos Ba09 mooKeTT ay NS ToMOTOMaL Joug amjoam)AungestC-a sting 06 (SiS ra «20700 em (RT ‘eves Goopendisar ogg) SoRINOLA- (woyonysqo: Semme aroyy Jt ro'sseaure op yo Aouaed yostja)sKematy-V a (aqoay)4eains Kreug-T pur sigdes St | Kar ese sp 830 apg | 10H “pT ams som: wourmno syn |_oxap Aso ti | oF np AISON THE (eyeaucdepparet| —souesnog y2-1 | seynur oy spu009s ‘Suoped emma UY ME ‘eumen Jo swno}a woumaH0d 1Sour amp sBTATOZ) -« -Aanfuy ourusopge 7p Aantal ysoyp*canfur an07 £q, ce) e) @ Pomorjoy Mieap Jo asiira uourwo 3sou ap st PamER poo -k CHT@Droppooe open peor sf BUN Jo wslueyoU ysoyy “Tes CFSsyMpe Sunok pee ere eee paw voip wa weap Jo Sane) GowmOD sows om n -* ______— hnsaingSurgery Cone ‘Treatment trial of foleys “insertion (once and gently by iled suprapubic cystostomy with delayed repair. A : : Bladder injury could be intraperitoneal(need surgical repair) 6. cor extrapstitoneal(treated by foleys catheter insertion for 2 weeks,non operative management) Best to diagnose bladder injury i{ CT urography Pelvic hematoma 85% are venous usually associated with pelvie fracture ‘Treatment of pelvic hematoma is (external fixation) of pelvic fracture then angiography and embolizati Don’t do surgical exploration of pelvic hematoma(as bleeding in the pelvis stop by itself ,and hematoma evacuati rebleeding again. is risk for Could. be blunt. abdominal trauma or _— sharp f trauma. (Penctrating)abdominal trauma, 92 Surgery Blunt abdominal trauma Mostly RTA mc organ injured is Diagnosis of blunt abdominal pain (Ber sean is the most accurate imaging in diagnosis of solid yF Ctgan injury(liver , spleen , pancreas , kidneys, retroperitoveal injuries) ¥ Not sensitive for diaphragmatic or small bowel injury # CT used in stable patients(not used in unstable patient) (Brocused abdominal sonography for trauma patient(FAST) ~ Is the best image for unsfabIP abdominal trauma patient(rapid) FAST detect free fluid in the abdominal cavity (hemoperitonium) FAST look 6 places Denic 7 pei Pic peril, subphrenic : peal spelvis(pouch of Douglass)) Sensitive but don’t diff e fe between different types of Mluid(blood , ascitis zurine , bile) so it is sensitiye but not specific. poe ot Fluid appear as anechoio(low echogenicity on US) @ FAST is poor for retroperitonium. 93$6 \ ¥6 word ete ut pny sq ann CTeDavEoe| ar sae IT fe Tw 20 oooye wx asarsapAyamsu95 30 voyed women reuse madly sop pap Anti RT TTTIH HL TAT (onyod ony org nom pe Sao poured fibyswod ing “Amfuy opeaxomed imo ayn 3,us90p [242] a5eH soy powedse poota eq urEusone oy suuewoy syed Jo 960 HF HEF oxi'dmfy 2psaioued syeospuy Ajpessocou 1,usa0p ose poreanou] veomgamgides)p osmotic Jo ose or wit FAG PA IP “(pareposT Fon) sopemlin samp WL poesosse Aqpensn Asn far orate anf yeouowrodonas sst0r Jacl HB 1ON, ox ered jo pau pf Anfyaqerued any ays wars soy SBA Ry 30" SoS {aH TEVA OATS en woos 09 res osye RUTOICART AANWAON * afiq ‘ wuioiong Jo aouasaad * 93 7]0H OOS liver(in stab wound) Note that immediate laparotomy is done if there are si "unstable patientqhypotensive despite TV fh Jn stab wound to the anterior abdominal wal ‘exploration and check if the stab. penetrate pponctration(25% ofthe eases) then the wound is closed and the patie discharged. I penetrate the fascia andthe patient is stable with n0 signs of peritonitis then do FAST or DPL if postive or the pation deteriorate Inter then do laparotomy. Jn back or flank stab wound and the patient is stable then 1 do CT with contrast to rule out kidney or vascular injury. sbot need immediate laparotomy regardless of the patents stle-or aot (no role for DPL. in gunshot). Can result in injury to any chest structures(ribs ; lung , heart diaphragm , stemuin , clavicles , vessels) (#1 Rib fracture is the most common injured structure. 766 “Aderonorsiyd sou ‘udReRUAA ames SATISOd poo Kew puw AAI ZO (cODa‘ Oa * SUSIE TIA op 1oxuompATIOdns } wouneary, [Patists sour 2M SLO 19yp/ yeuuou 9q Kear ap (roudearadiy)ZOoa paseaom ZO paseaxoap)Ogy sisoudercl pxodky asnea wep) (eSoanmp Ainjides wig) Turypiamd San] om wt ping pue pookg yo vonemmunose sp woisnywos Areuomn ® ‘ORERY [oOrsNS Taye] ssansip 2 SRRTER ZO ( TQVSGM SSH IST st omar oD (GuounoAous [eas Soyo 91p. 07 aysoddo)uorTaTdxe hia preAopeq pue ToneNdsar ya premur quwias Sip JO JUSWIDAOWE s} JUSUIAOUE IS9YD eorKopeIeg, LOISTIUOS Bin 10 HOHOUHY xROTTOUMBGT ypu paresoosse 2q pines (uais eyo ysoun)jusindos Sap jo WSWoACTH —— “<7 pSwpeTRM ew pew isoqD oe Jo qwoUES ayqeIsuN UE ANSI styl SHS SIO WO [ wr SH SaTNOOSUOD SzOUL JO F Jo auMOBH sy 36 a -upanpar [eorsans post tat} quTof seMopARPIOURYs amp Jo wondnsip 10 pooepdsip Apoaas st ng * (Bays taepeiso8jeue/s: jwauneasy, [STAB Pp PIU s1 9118 wouNNOD ysOUI aAN]DeAy aPIALLD, -wuoumoud 10j 3st st yp woTaUSAOdAY poonpuy wed quaxud 0} Guepodu, sour amp)siSoBjeNe pue ied st omoesy qu jo yuoumvosy, (ROAM TAT A Fnsas AIST OM vO (Safar FOSSA FO TEUT IO PIG) Aan fy snoyas Jarpo "pin pareosse Aypensn p-eONTey TAY aIDATS ‘SyROIPUT pomNpoRI} JF PUB pamyoey 9q OF YNOGFIP OP Sq! LTP eb SBIOTPOUTDU 10 KETOHOUATY asne9 we (SE, 25Qee/hr blood in the next 4 hours. Note that: most hemothorax blood is from pulmonary circulation which is Jo pressure circulation so chest tube is enough in most cass. 2 Massive tledng esuly comes from sysemie_ Spain oaSehil sytemic_ciculati artery or proximal phontry atery)which usually don’ top and require surgery ia 100 Sorgery & Sternal fracture ‘Most common in upper & middle part ic injury(usually associated with cardiac &major vessel injury) ‘Treatment role out associated cardiac &major vessel injury If no associated injury then stemal fracture is treated conservatively(without operation) @) Cardiac tamponade Blood in pericardium 150ce of blood is the minimum amount that can produce S&S of cardiac tamponade, e @ @ S&S _ beck triad(hypoténtion , increased JVP , muflled or weak hheart sound) ¢ Ithas high mortality rate Diagnosis in stable patient{echocardiography is the best. Pericardial aspiration may be negative in 15 % of cases due to clotted blood. 101