Shock & blood transfusion

∙ Shock is a systemic state of low tissue perfusion which is inadequate for normal cellular
respiration
∙ accumulation of lactic acid produces metabolic acidosis and increased resp rate
produces minute ventilation to prod a compensatory resp alkalosis
∙ Hypovolemic shock may be hemorrhagic or non hemorrhagic due to reduced circulatory
volume
∙ cardiogenic shock due to primary failure of heart to pump blood to tissues
∙ In obstructive shock there is a reduction in preload due to mechanical obstruction of
cardiac filling.
∙ Distributive shock: Septic shock, anaphylaxis and spinal cord injury
Vascular dilatation + hypotension + low systemic vascular resistance, inadequate
afterload and abnormally high cardiac output
∙ Endocrine shock: combo of hypovolemic + cardiogenic + distributive shock
Causes- hypo-hyperthyroidism, adrenal insufficiency. Low cardiac output
∙ Pts who are on Beta-blockers or who have implanted pacemakers are unable to mount a
tachycardia
∙ In all cases of shock, first line therapy is IV access and administration of IV fluids. Access
should be thru short, wide bore catheters that allow rapid infusion of fluids
∙ Hypotonic sol (dextrose) are poor volume expanders and should not be used in the tx of
shock unless deficit is free water loss. Crystalloid sol (normal saline, hartmann, ringer
lactate) or colloids (albumin) are give for resuscitation
∙ In cardiogenic shock, inotropic therapy may be required to increase cardiac output +
oxygen delivery. Dobutamine is agent of choice.
∙ The best measures of organ perfusion and the best monitor of the adequacy of shock
therapy remains the urine output
∙ clinical indicator for Gi perfusion is lactic acidosis and mixed venous oxygen saturation
∙ On going bleeding w/ fluid and red blood cell resuscitation leads to a dilution of
coagulation factors which worsens the coagulopathy
∙ Reactionary hemorrhage is delayed hemorrhage (within 24 hours) and is usu due to
dislodgement of clot by resuscitation, normalization of BP and vasodilation
∙ Secondary hemorrhage is due to sloughing of the wall of a vessel. Occurs 7-14 days after
injury
∙ Packed red cells are strored in SAG-M solution (saline-adenine-glucose-mannitol) to inc
shelf life to 5 weeks at 2-6 degree C
∙ FFP is stored at -40 to-50 degree w/ 2 yr shelf life
∙ Cryoprecipitate is rich in factor 8 and fibrinogen, stored at -30 w/ 2 yr shelf life
∙ Platelets stored at 20-24 degree and shelf life of 5 days

Wounds, tissue repair and scars

∙ Normal wound healing: 1. Inflammatory phase: 2-3 days. Bleeding-> vasoconstriction

->thrombus formation -> platelets release ADP -> bleeding stops -> PDGF, cytokines,
 TGF-beta -> attract PMN + macrophages
2. proliferative phase: 3rd day to 3rd week, migration and proliferation of fibroblasts,
epithelial cells and endothelial cells, angiogenesis, granulation tissue -> type 3 collagen
3. remodelling phase(maturing phase)-> lasts for months, collagen replaced by type 1
collagen
∙ In nerves, wallerian degeneration occurs distal to the wound, traumatic degeneration
proximally
∙ Healing by tertiary intention aka delayed primary healing is when wound initially left
open and edges later opposed when healing conditions favorable
∙ Open degloving: ring avulsion injury with loss of finger skin
∙ Closed degloving: rollover injury
∙ In compartment synd pressures are constantly greater than 30 mmHG + clinical signs ->
fasciotomy
∙ High pressure injection injuries are common in finger or forearm. Tx is surgical with wide
exposure
∙ Pressure sore frequency: ischium, greater trochanter, sacrum, heel, malleolus,occiput
∙ Bed bound patient should be turned at least 2 hours
∙ Wheelchair pt shud lift themselves for 10 secs every 10 mins
∙ Dishwater pus (greyish drainage) is sign of necrotizing infection
∙ The variant of necrotizing fasciitis with toxic shock syndrome results from strep
pyogenes and is called 'flesh eating bug'
∙ An atrophic scar is pale, flat and stretched in appearance, often appearing on the back
and areas of tension
∙ In keloids, there is more type 3 collagen
∙ Contracture: where scars cross joints or flexion creases, a tight web may form, restricting
the range of movement at the joint, can cause hyperextension or hyperflexion deformity.
Tx is multiple Z-plasty

Paeds surgery

∙ Neuroblastoma most common solid tumor in childhood, mc in adrenals, c/f include

opsomyoclonus syndrome.
∙ Wilms tumor is mc primary malignant renal tumor of childhood + mc intra abdominal in
<10 yrs. Ass w/ denys-drash synd, WAGR, Beckwith-Wiedmann synd. Flank mass, does
not cross midline.

Surgical Infection

∙ Abscesses need drainage and curettage.

∙ Cellulitis is non suppurative invasive infection of tissues
∙ Lymphangitis- painful red streaks in affected lymphatics.
 ∙ C.Perfringens produce alpha toxin(RBC WBCs), phi-toxin(myocardium) and kappa
toxin(conn.tissue+blood vessels)
∙ Fournier's gangrene-necrotzing fasciitis in perineal area.
∙ Meleney's synergistic gangrene-" in abdominal wall
∙ Smokers should be encourages to stop smoking 30 days before surgery
∙ Hair is best removed by clipping immediately before surgery
∙ Prophylactic antibiotics should be given IV within 30 mins before incision

Arterial disorders

∙ Leriche's syndrome- Buttock claudication in association with sexual impotence from

arterial insufficiency (aortoiliac)
∙ Dependent rubor/ sunset foot sign: Elevation of limb produces palor that changes to
red/purple when the limb is allowed to hang down
∙ Continuous machinery murmur over an artery usually indicates an AV fistula.
∙ Rest pain is dec by hanging the foot out of bed or sleeping in a chair.
∙ Ix techniques -> Handheld doppler ultrasound probe, Ankle-brachial pressure index
(normal:1, Necrosis: 0.3), Duplex scanning(accurate as angio except in aortoiliac),
Angiography-> percutaneous catheter method (seldinger technique), digital subtraction
angiography and CT/ MR angiography (intrathoracic or aortoiliac)
∙ B-blockers may exacerbate claudication.
∙ PTA used for dilating iliac and femoropopliteal segments, long occlusions may be treated
by subintimal angioplasty.
∙ Aortoiliac occlusion: Aortofemoral bypass using Dacron graft
unfit patients: Axillofemoral bypass
Single iliac occl : iliofemoral/ femorofemoral crossover graft
superficial femoral artery disease: Femoropopliteal bypass/ autogenous saphenous vein/
PTFE/ miller cuff
Isolated common femoral artery/ profunda disease: endarterectomy and patch/ short
bypass in the groin
Tibial : femorodistal bypass
∙ Subclavian steal syndrome - arm exercise -> syncope -> reversed flow in vertebral artery
-> cerebral ischemia (discrepency in BP of both arms of > 15 mmhg)
∙ Dry gangrene: gradual slowing of bloodstream
wet gangrene: superadded infection and putrefaction
∙ Diabetic gangrene: 1) Ischemia (atheroma)
2) Peripheral neuropathy
3) Immunosuppresion (excess sugar in tissues)
∙ Bed sores: 1) pressure 2) injury 3) anemia 4) malnutrition 5) moisture
∙ Arterial thrombosis has collateral circulation buid up whereas embolus does not.
∙ Ischemia beyond 6 hours is irreversible-> limb loss, to prevent this -> 5000 U of heparin
IV before embolectomy
 ∙ Embolectomy: done by fogarty balloon catheter
∙ Air embolism: Air injected into venous circulation or sucked in during head n neck
surgery, cut throat, fallopian tube insufflation or illegal abortion. Tx by placing pt in
Trendelenberg position or pt placed on left side to prevent rt heart failure if air reaches
pulmonary artery or by air aspiration thru needle below lft costal margin
∙ Dead limb: Severe rest pain, contracture/paralysis OR major unrecoverable traumatic
damage
∙ If femoral pulse is absent, amputation should be above the knee.
∙ Flaps used for below the knee amputations are: long posterior flap (popular) and skewer
flap
∙ Above knee amputation: Equal curved anterior and posterior flaps
∙ Early complications of amputation: haemorrhage, haematoma, infection, abscess, gas
gangrene, wound dehiscence, DVT, pulmonary embolism
Late " : pain (sinus, osteitis, sequestrum), bone spur, scar, amputation neuroma,
phantom limb or phantom pain
∙ Morphology of aneurysm is assessed by CT scan. Majority are true fusiform
atherosclerotic below left renal vessels. Tx by open or endovascular repair.
∙ Ruptured abdominal aneurysm: 1) Abdominal/back pain 2) hypotension and 3)Pulsatile
abdominal mass. First, Ct scan -> oxygen, fluid, cental line, catheter, permissive
hypotension, cross match 6 units of blood,rapid OT transfer
∙ " postop complications: MI, atelectasis, lower lobe consolidation, colonic ischemia,
sexual dysfunction, spinal cord ischemia, aortoduodenal fistula (haematemesis or
melena)
post EVAR complications: endoleak, graft migration, strut fracture graft limb occlusion
∙ Asymptom popliteal aneurysm: elective repair if >25 mm

Venous disorders

∙ Ambulatory venous HTN is a consequence of valve failure (reflux) or obstruction in the

venous system and may lead to lipodermatosclerosis (inflammation of the layer of fat
under the epidermis) and ulceration.
∙ Klippel Trenaunay synd: are congenital vascular disorder in which a limb may be affected
by port wine stains (red-purple birthmarks involving blood vessels), varicose veins,
and/or too much bone and soft tissue growth. The limb may be larger, longer, and/or
warmer than normal.
∙ Posterolateral calf varicosities are suggestive of short saphenus incompetence whereas
anterolateral thigh and calf varicosities may indicate isolated incompetence of the
proximal anterolateral long saphenous tributary
∙ Signs of varicose veins: Telangectasia( <1mm), Reticular veins (1-3 mm), Saphena varix
(large groin varicosity), atrophie blanche (localized white atrophic skin on ankle), corona
phlebectasia (fan shaped patterns of small veins on ankle), pigmentation (brown),
eczema, dependant pitting edema, lipodermatosclerosis, ulceration
∙ Duplex ultrasound imaging: mainstay of inv of varicose veins
 ∙ Management of varicose veins -> compression hosiery, US guided foam sclerotherapy
(sodium tetradecyl sulphate) , endovenous laser ablation (for primary + recurrent VV),
radiofrequency ablation, surgery-> saphenofemoral ligation and long saphenous
stripping, saphenopopliteal junction ligation and lesser saphenous stripping, perforator
ligation, phlebectomies.
∙ Causes of recurrent VV: neo-revascularisation, reflux in residual axial vein, inadequate
initial surgery and new junctional reflux
∙ Pelvic congestion syndrome: Premenopausal, multiparous women aged 20-45 who
present w dull, aching pelvic pain. Tenderness over the uterus/ovaries, vulval varicosities
and haemorrhoids. Dx-> initial> abd, pelvic, transvaginal duplex, superior-> MR
venography or diagnostic venography
∙ Virchow triad-> endothelial damage, venous stasis, coagulability
∙ Phlegmasia alba dolens -> white cellulitic leg, Phlegmasia cerulia dolens-> cyanosed leg
(seen in dvt)
∙ Homan's sign: resistance of the calf muscles to forcible dorsiflexion
∙ A venous ulcer has a gently sloping edge and granulation tissue
∙ Ulcers mc on the medial side of calf but if ass w/ lesser saphenous incompetence
develop on lateral side
∙ Ulcers initially tx by compression bandaging. 1) Charing cross four-layer bandage/ rigid
multilayed system (steripaste three layer bandage) 2) low compression regimen 3) Bland
absorbent leak proof dressing beneath graduated elastic compression bandaging
∙ Marjolin's ulcer -> squamous cell or basal cell carcinoma can develop in chronic long
standing venous ulcer
∙ Size and extent of hemangioma are best visualized by nuclear magnetic resonance with
short tau inversion recovery (STIR) sequence or Ct w contrast

Lymphatic Disorders

∙ Axillary web syndrome (AWS) is a side effect of breast cancer surgery. It can develop
after the removal of the lymph nodes from the armpits. The condition involves the
development of scarring or connected tissue under the arm. AWS, or cording, can be
painful and limit the range of motion in the affected arm.
∙ Milroy disease: AD, familial lymphedema, both legs, genitalia, arms and face, hydrocele,
upslanting toenails, papillomatosis and cellulitis. Develops from birth or before puberty
∙ Meige's disease: lymphedema of legs + arms, develops b/w puberty and middle age
∙ lymphedema congenita: <2 yrs (males, whole leg)
lymphedema praecox: 2-35 yrs (females. unilateral till knee)
lymphedema tarda: >35 yrs (obesity)
∙ Lymphedema ass. w/ malignancy commences proximally in thigh rather than distally
∙ Podoconiosis- non-filarial, non infective blockage of limb lymphatics by silica particles
∙ Class 3 compression stockings (40-50 mmhg) are used for control of swelling along w/
bed rest, elevation, manual lymphatic drainage, multi layer lymphedema bandaginng
and drugs (benzpyrones eg flavonoids)
 ∙ Surgery: Sistrunk operation (thigh), Homan's operation (calf), Thompson's op OR Charle's
op (poor cosmesis)

Anesthesia

∙ General anesthesia: narcosis, analgesia, muscle relaxation

∙ propofol: most widely used induction agent, continuous infusion
∙ Thiopentone: neurosurgical pts
∙ Etomidate: adrenocortical depression
∙ Ketamine: field anesthesia
∙ Inhalational induction w/ sevoflurane useful in children, needle phobic adults and
difficult airway
∙ Total IV anesthesia: neurosurgery, airway laser surgery, cardiopulmonary bypass and day
case anesthesia
∙ Rapid sequence induction used where there is risk of regurgitation or delayed emptying
of stomach
∙ The gold standard for intubation in difficult situations is use of fibreoptic intubating
bronchocope
∙ For short procedures, the mc used muscle relaxant/ depolarizing agent used is
suxamethonium
∙ EMLA (eutectic mixture of local anesthetics) is a mixture of lignocaine and prilocaine->
venepuncture in children
∙ Bier's block is usd for short surgery of upper limb
∙ Neurolytic techniques for cancer pain:
subcostal phenol inj for rib metastasis
celiac plexus block w alcohol for pain of pancreatic, gastric or hepatic cancer.
Intrathecal inj of hyperbaric phenol
percutaneous anterolateral cordotomy to divide spinothalamic tract

Surgery in the tropics

∙ Amoebic trophozoites in colon form flask shaped ulcers in the submucosa

∙ Amoebic liver abscess contains chocolate colored odorless anchovy sauce like fluid.
∙ Amoeboma mc affects the caecum
∙ Larva of ascaris causes loeffler's syndrome: cough, chest pain, dyspnea, fever
∙ adult worm of ascaris causes GI, biliary or pancreatic symptoms
∙ Hydatid cysts which are asymptomatic and inactive are left alone, monitored by US.
Most accurate test is indirect hemagglutination test. CT shows space occupying lesion w/
smooth outline septa. Active cysts treated by full dose of albendazole + praziquantel.
Surgery is TOC. Laprotomy then PAIR.(puncture, aspiration, injection, reaspiration).
Calcified cyst gives egg-shell appearance
Daughter + granddaughter cyst give rosette appearance
 ∙ Mycetoma (fungi: eumycetoma)(bacteria: actinomycetoma) presents w/ a triad of
painless subcutaneous swelling, multiple sinuses and seropurulent discharge. Foot is
most common site.
∙ Plain x-ray of mycetoma shows sun-ray appearance and codman's triangle due to
periosteal reaction. MRI shows 'dot in circle' sign which indicates presence of grains.
Biopsy can show 3 types of tissue reactions. FNAC is confirmatory.
∙ Eumycetoma is treated with ketoconazole, intraconalzole and voriconazole.
Actinomycetoma tx w/ amikacin and co-trimoxazole
Surgery: wide local excision, de-bulking excision and amputation. Local anesthesia
contraindicated
∙ Tuberculosis of small intestine is of ulcerative type (virulence greater than host defence,
ulcer is transverse w/ undermined edges) and hyperplastic type (vice versa). Former is
caused by swallowing infected sputum and latter is caused by drinking infected milk.
∙ Cassava ingestion can cause dilatation of pancreas w intraductal stones causing tropical
chronic pancreatitis.
∙ Asiatic/oriental cholangiohepatitis is caused by clonorchis sinensis (liver fluke) . Stool
examination for eggs and adult worms + duodenal aspirate is diagnostic. ERCP also
confirms. Praziquantel/albendazole is DOC. Surgery: cholecystectomy, exploration of
CBD
∙ Filariasis caused by W. bancofti, 2nd mcc of long term disability after leprosy. immature
worms seen in a nocturnal peripheral blood smear. Tx w/ diethylcarbamazine.

Nutrition

∙ Fasting for 12 hrs or less uses energy from the last meal, glucose levels rise from
breakdown of glycogen from liver
Muscle glycogen broken down-> lactate -> liver -> glucose
>24 hrs: denovo glucose production from non-carb precursors (gluconeogenesis)
∙ Hepatic production of ketones from fatty acids is facilitated by low insulin levels and
after 48-72 hours of fasting, the CNS may adapt to using ketone bodies as their primary
fuel source
∙ Starving also causes dec conversion of T4 to active T3
∙ Unintentional weight loss of more than 10 % of a patient's weight in the preceeding 6
months is a good prognostic indicator of poor outcome
∙ Pts w/ albumin levels below 3 g/dl show an independently ass. inc risk of developing
serious complications within 30 days of surgery.
∙ Pre-albumin has half life of 3 days (unlike albumin 20 days) so is a more useful indicator
of acute changes.
∙ Retinol binding protein <4.1 mg/dl represent malnutrition
∙ Simple method to asses nutritional status is weight loss
∙ Measurement of skin fold thickness and mid arm circumference is for estimation of body
fat
∙ Bioelectrical impedence analysis is to estimate intra + extra cellular fluid volumes
∙ Fluid loss occurs by 4 routes: Lungs (400 ml/day), skin (600-1000 ml/day), feces (60-150
ml/day) and urine (normal output: 1500 ml/day)
∙ Basal energy expenditure requirment for most stressed patients is around 25-35
kcal/kg/day
∙ 1.5 gm of protein per kg body weight should be provided daily
∙ Ileum is the only site of absorption of vitamin B-12 and bile salts, if resected, steatorrhea
and increased stool loss
∙ Short bowel syndrome means pts who have had more than 200 cm of small bowel
resected together w/ colectomy. These pts will have jejunostomy. Divided into net
absorbers and net secretors.
∙ Absorbers have more than 100 cm of residual jejunum and absorb more water and
sodium from the diet than passes thru the stoma. These pts can be managed without
supplemental parenteral fluids
∙ Secretors usu have less than 100 cm of residual jejunum and lose more water and
sodium from their stoma than they take by mouth. These pts require supplements,
∙ It is inappropriate to encourage pts w/ high output jejunostomies (secretors) to drink
large amounts of hypotonic solutions bcuz sodium fluxes across jeju mucosa. Should be
drinking glucose or saline sol.
∙ Complications of short bowel syndrome: peptic ulcer, cholelithiasis and hyperoxaluria
slurred speech, ataxia and altered affect due to fermentation of carbs to D-lactate
∙ Enteral nutrition if given <4 wks: nasogastric, nasoduodenal, nasojejunal, if >4wks:
gastrostomy, jejunostomy
∙ Bolus feedings are reserved for pts w nasogastric or gastrostomy tubes. 50-100 ml every
4 hrs.
∙ Continuous infusion is req for nasojejunal, nasoduodenal or jejunostomy. 20 ml/hr
∙ Complications of enteral feeding include, tube complications, hypernatremia,
hyponatremia, hyperkalemia, hypokalemia, hyperglycemia, aspiration pneumonia,
nausea, vomiting and diarrhea
∙ If feeding is maintained for more than a week or so, a fine bore feeding tube is
preferable and is likely to cause fewer gastric and esophageal erosions
∙ If pt requires enteral nutrition for 4-6 weeks, PEG is preferable. Two methods of PEG
tube insertion are, 'direct-stab' and transoral or push through
∙ Jejunostomies may be used in pts w/ severe pancreatitis, in pts in whom a degree of
gastric outlet obstruction may be present
∙ Peripheral parenteral nutrition is indicated for patients with compromised gut function
and who require short term (<10-14 days) nutrition. Limited by development of
thrombophlebitis.
∙ 1 gm glucose yields 3.4 kcal. Glucose req is 2 g/kg/day. 4 mg/kg/day is oxidized i.e 1500
kcal/day in a 70 kg person with non-oxidized glucose converted to fat
∙ In non oliguric renal failure ( serum Cr >20 mg/dl) pts should be given D20W 500 ml,
ESSENTIAL amino acids 500 ml and limited amounts of Na, K, Mg and phosphate
∙ Liver failure pts should be given D20W 500 ml, branched chain amino acids 500 ml and
Na content limited to 40 mEq/L.
 ∙ Total parenteral nutrition is req in pts w compromised gut function AND who req long
term (>10-14 days) nutrition.
∙ Refeeding syndrome is characterized by severe fluid and electrolyte shifts in
malnourished pts undergoing refeeding. Hypophosphatemia, hypocalcaemia and
hypomagnesaemia.

Post-op care

∙ Air embolism may occur when >15 ml of air is accidently introduced during or after
insertion of venous catheter. Causing dec BP, rise in pulse rate and distention of JVP
∙ Cannulae should be changed at 42 hrs.
∙ Cannulation of the radial artery may disrupt the blood supply to the hand causing
ischemic necrosis of fingers.
∙ Oliguria is most commonly caused by reduced anal perfusion resulting from
perioperative hypotention or inadequate fluid replacement
∙ Return of function of bowel occurs in the following sequence: small bowel, large bowel,
stomach
∙ Abdominal surgery complications: anastomotic leakage, bleeding, localized infection,
paralytic ileus
∙ Post op fever day 0-2: atelectasis, 3-5: wound infection, 5: UTI, >5 days: wound inf,
anastomotic leakage, DVT/PE
∙ Wound dehiscence occurs from 5th to 8th post op day, usually presents with
serosanguinous discharge
∙ Drains should be stopped if drainage becomes <25 ml/day
∙ Skin sutures or clips should be removed b/w 6 - 10 days.

Emergency and elective neurosurgery

∙ Best way to prevent secondary brain injury is to prevent hypoxia and hypotension
∙ First step in primary survey is airway control with cervical spine protection. (ABCDE)
∙ The gold standard for evaluation of acute head injury is a non-contrast CT scan that
spans from base of the occiput to the top of the vertex
∙ The motor response (M) is the best predictor of neurologic outcome
∙ Region of trigeminal nerve distribution (supraorbital ridge), is the preferred site of pain
stimuli to look for eye opening.
∙ Partial CN 3 dysfunction implies uncal herniation as a result of a mass on the ipsilateral
side.
∙ Extradural hematoma mcc is tearing of meningeal artery. MC site is the pterion. Lucid
interval +
CT scan; lentiform (biconvex lesion)
∙ Acute subdural hematoma: CT scan showing concave hyperdense, crescent shaped
hematoma. Shearing of cortical vessels.
∙ cerebral contusions mature and expand for 48-72 hours following injury so repeat
scanning is done within 24 hrs of initial scan
∙ Spinal trauma: hypovolemic shock: hypotension,tachycardia, cold clammy peripheries
neurogenic shock: hypotension, bradycardia and warm peripheries
spinal shock: paralysis, hypotonia, areflexia
∙ Resolution from spinal shock is indicated by the return of bulbocavernosus reflex
∙ Central cord syndrome: greater loss of motor strength in upper limbs as compared to
lower limb. Hyperextension injury with cervical canal stenosis. Forward fall
∙ Anterior cord syndrome: flexion compression fractures of vertebral bodies. Damage to
bilat corticospinal tract + spinothalamic tracts
∙ posterior cord synd: hyperextension injuries. Damage to posterior columns, loss of
propioception - ataxia
∙ Brown sequard synd: damage to corticospinal, posterior column (ipsi) , spinothalami
tracts(contra) + loss of all sesnsation + ipsi flaccid paralysis (at the level of lesion)
∙ Power's ratio measures the degree of subluxation of the occiput on the axis
∙ Jefferson fracture, burst fracture of C1, tx: halo jacket for 3 months
∙ Hangmans fracture: spondylolisthesis of C2 on C3
∙ Chance fracture of thoracolumbar junction, ass w/ lap belts
∙ Cytotoxic edema occurs as a result of cellular engogement where as vasogenic edema
due to breakdown of BBB
∙ Subfalcine herniation causes compression of anterior cerebral artery
∙ Uncal herniation causes 3rd CN compression, post cerebral artery and ipsilateral cerebral
peduncle compression
∙ Lumbar puncture is contraindicated in obstructive hydrocephalus
∙ Triad of normal pressure hydrocephalus - ataxia, cognitive decline, urinary incontinence
∙ Complications of ventriculoperitoneal shunt are: shunt blockage, shunt infection(staph
epidermidis,e.coli) , seizures, csf leak, stroke, intracerebral hemorrhage
∙ Signs of incomplete cord injury: preservation of perianal sensation, voluntary anal
sphincter contraction, any sensation or voluntary movement in lower limbs, voluntary
toe flexion
∙ A diffusion weighted MRI is used to differenciate cerebral abscess from tumor. CT shows
ring enhancing tumor.
∙ Glioblastoma is a butterfly glioma because it has a tendency to cross the midline
∙ Cerebral metastasis most commonly arise from lung
∙ Aneurysmal subarachnoid hemorrhage may show cushing's response i.e hypertension
and bradycardia may be seen in patients with altered consciousness secondary to raised
ICP
∙ Lumbar puncture is performed 12 hours after CT for SAH. Biirubin peak is diagnostic of
SAH.
∙ Chiari 1 malformation is associated with >5 mm of tonsillar descent through foramen
magnum, young adults, presents w/headaches
∙ Chiari 2 malform ass w/ descent of tonsils and cerebellar vermis, presents in infancy w/
signs of brainstem compression such as poor feeding, stridor and apneic spells
Burns

∙ Burn refers to coagulative necrosis of variable depth

∙ Burns produce inflammatory reactions: complement activation, activation of hageman
factor, mast cell degranulation, neutrophil degranulation
∙ Volume of fluid lost is directly proportional to the area of the burn
∙ When size of burn is 10-15% total body surface area (TBSA)= circulatory shock
∙ When size of burn is >25% TBSA= fluid loss occurs in vessels remote from the burn injury
∙ Abdominal compartment syndrome: It is caused by gut mucosal swelling, gastric stasis
and peritoneal edema. It splints the diaphragm and increases the airway pressures
needed for respiration.
∙ Burn wound should be cooled at 8-25 degree c
∙ Sitting a patient up with burned airway may prove life saving. Elevation of burned limbs
will reduce swelling and discomfort.
∙ Early intubation with endotracheal tube is the TOC in suspected airway burn. Delayed
recognition and intubation= emergency cricothyroidotomy
∙ Fluid resuscitation should be started when >10% TBSA burn in children and >15% TBSA
burn in adult
∙ Three types of fluid can be used
1. Ringers lactate/ Hartman's sol (MC)
2. Human albumin solution/ FFP
3. Hypertonic saline
∙ Parklands formula: Total % of body SA x weight(kg) x 4 = vol (lit)
Half given in first 8 hrs and 2nd half in the next 16 hrs
∙ Plasma proteins should be given after first 12 hours, because before this time, massive
fluid shifts cause proteins to leak out of the cells.
∙ The key to monitoring of resuscitation is urine output. Should be 0.5-1.0 ml/kg/hr
∙ Escharotomy refers to incising the whole length of full-thickness burns in the mid axial
line. Prevents asphyxia (trunk) and compartment synd (limbs)
∙ 4 most common dressings for full thickness and contaminated wounds are: silver
sulphadiazine cream, silver nitrate solution, mafenide acetate cream and silver
sulphadiazine and cerium nitrate
∙ Hydrocolloid dressings for mixed depth burns and biological dressings for superficial
burns
∙ Burns of >15-20 % should receive NG tube and feeding should start within 6 hours of the
injury to reduce gut mucosal damage
∙ Acid causes coagulative necrosis whereas alkali causes liquefactive necrosis

Care in the operating room

∙ WHO surgical safety checklist: Step 1: pre-list briefing, step 2: sign in, step 3: time out,
step 4: sign out, step 5: postlist debriefing
∙ Sign in checklist read prior to anesthesia
 ∙ Antibiotic prophylaxis should be given to patients before clean surgery involving
insertion of prosthesis or implant, clean contaminated surgery or contaminated surgery.
Should not be used for clean, non-prosthetic surgery.
∙ Regional anesthesia (spinal or epidural) carries a lower risk of VTE than general
anesthesia
∙ OT is maintained at positive pressure relative to surroundings
∙ Ideal working temp for surgeons are 19-20 degree. Temp of 20-24 are acceptable w/
humidity of 50-60 %
∙ If radiological imaging is to be used intraoperatively, the patient could be protected with
lead shielding and a radiolucent table used
∙ Total tourniquet time should not exceed 1.5 hours
∙ Time out: before surgical procedure starts
∙ Surgical site infections may be reduced if hair is clipped rather than shaved
∙ Standard scrub solutions: 2 % chlorhexidine, 7.5% povidone iodine + alcohols

Peri-op management of high risk pt

∙ Oxygen demand increases from 110 ml/m2 per minute at rest to 170 ml/m2 per minute
in the postop period
∙ Metabolic equivalent tasks (MET) meausres exercise tolerance related to daily living.
1 MET= eating aand dressing
4 MET= climbing 2 flights of stairs
6 MET= short run
>10 MET= able to participate in strenous sport
pts who can exercise at 4 METs or above have lower risk of perioperative mortality
∙ Peri-op Beta blockade may be considered to reduce risk of MI

Day case surgery

∙ When the pt requires an overnight admission, the term '23 hour stay' should be used
∙ Stand alone units often confine their criteria to ASA 1 and 2 patients while ASA 3
patients are more suitable for hospital integrated units
∙ Patients undergoing procedures upto 2 hours in duration can safely undergo day surgery
with modern anesthetic techniques
∙ Reactionary haemorrhage commonly occurs in the first 4-6 hours after surgery due to
ligature slippage, clot displacement or cessation of vasospasm
∙ Secondary haemorrhage is defined as occuring at least 24 hours after surgery and is due
to infection eroding a vessel
∙ Total IV anesthesia using propofol reduce post op nausea and vomiting
∙ Short acting opiods should be used (fentnyl, alfentanil)
∙ Long acting local anesthetic like bupivacaine should be injected into wounds by surgeon
∙ multimodal analgesia w/ paracetamol and NSAID should be given pre-operatively

Investigation and diagnosis

∙ Conventional radiology: lack soft tissue contrast but is cheap, easiy available, easily
reproducible, comparable with prior examinations, low dose ionizing radiation
∙ Administration of contrast with radiography allows soft tissue to be visualized like IV
urography and barium examinations
∙ Modification of conventional x-rays uses flurescent screens to allow real time monitoring
of organs and structures as opposed to snapshot images. Obtaining specific images at
dedicated point of interest only. Like barium thru bowel and vascular intervention.
∙ Medical ultrasound uses frequency in the range of 3-20 MHz. Abdominal US: 3-7 MHz
while higher frequency transducers are used for superficial structures like
musculoskeletal and breast US
∙ Ultrasound is the first line investigation for assessment of the liver, the biliary tree and
renal tract. Also imaging of choice in obtetric and gynae disease, guiding needle
placement in biospsies and drainages.
∙ High frequency tranducers have made US the best imaging techique for evaluation of
thyroid and testicular disorders.
∙ Liagement, tendon and muscle injuries also best imaged by US
∙ Transvaginal scanning, transrectal US of prostate, Endoscopic US for hollow viscus
(gastric wall and pancreas), Doppler US-velocities within major and minor vessels
∙ MRI measures T1 ans T2 nuclei relaxation times. Fat methaemoglobin and mucinous
fluid are bright on T1 weighted images(delineation of anatomy) whereas water and most
pathological processes are bright on T2 weighted images(pathology).
∙ Aneurysm clips, prosthetic heart valves, pacemakers, defibrillators cannot be tested
under MRI however pts w/ joint replacement can be studied safely
∙ IMAGING IN ORTHO SURGERY
All skeletal radiographs should be taken at 2 diff angles usu at right angles to eachother
∙ Synovitis: Radiographs 1st line
DTPA enhanced MRI most sensitive for synovial thickness, US also sens.
∙ Articular surface disease: MRI best, MR arthrography Gold standard
Rotator cuff trauma/degen changes: US/MRI. US higher accuracy
∙ Aggressive/destructive bone disease: Radiograph 1st
local staging: MRI
∙ Mass lesions in muscle and soft tissue: US diagnostic
∙ Infection: US is the most accurate method of assessing joint effusions although not
possible to discriminate b/w joint and pus
Early disease: MRI
∙ Metabolic bone disease (hyperparathyroidism/osteopenia in osteoporosis)=plain
radiographs
Quantitative method: DEXA scan
∙ IMAGING IN MAJOR TRAUMA
In pts who are not intubated, atleast 3 views are performed including AP view, an open
mouth odontoid peg view and a lateral view extending down to the cervicothoracic
junction. May be supplemented with trauma oblique views.
∙ Two perpendicular views are req for adequate skeletal assessment
 ∙ Main current roles of US include assessment of intraperitoneal fluid and
haemopericardium (FAST)
∙ CT is the main imaging modality for Ix of intracranial and intraabdominal injuries and
vertebral fractures. Takes upto 30 mins so should be reserved for stable pts
∙ Value of immediate MRI in trauma is limited and is confined to imaging of spinal injuries
∙ IMAGING IN ABDOMINAL SURGERY
Bowel obstruction: plain abd radiograph
perforation: CXR
∙ Chilaiditi's synd: harmless and asymptommatic interposition of large bowel between
liver and diaphragm
∙ If there is any possibility of leak from GI tract then the use of barium is cotraindicated as
it can induce a serious and potentially fatal peritonitis
∙ Bowel ischemia/ infarction: IV contrast CT
∙ GI hemorrhage: Endoscopy 1st line, radioisotope labelled red blood cells are useful
when bleeding is intermittent, CT mesenteric angiogram
∙ Appendicitis: Plain radiograph for calcified appendicolith, US in children+ childbearing
age females, CT next modality of choice
diverticulitis: US/ CT
IBD: barium follow thru/ enteroclysis, MRI enterography
IBD acute falre up: US
perianal fistulae + abscess: MRI is imaging of choice
Acute pancreatitis: No imaging needed, in mild acute pancreatitis, CT may be normal,
necrosis develops 48-72 hours later and manifests on CT
Renal colic: CT KUB optimal invs, IVU shows level of obstruction or US show
hydronephrosis, hydroureter, calculi
Abd aortic aneurysm: US, CT angiography, MR angiograpgy if iodinated contrast is
contraindicated
∙ ONCOLOGY
Cross sectional imaging techniques (CT, US, MRI) are more accurate in staging advanced
stage T3, T4, than early T1, T2 diseases.
∙ In gut tumors endoscopic ultrasound is more accurate than CT MRI in local staging of
early disease
∙ Nodes are assessed on size criteria of 8-10 mm
∙ Lung met= CT
Liver met=US and CT, MRI may be more accurate
Staging of lymphoma, lung cancer, liver met, colorectal CA mets= PET/CT
∙ Intraoperative US is an additional method of staging

Trauma to chest and abdomen

∙ Hematomas in the lateral zone are usu renal in origin, can be managed non-operatively
∙ Pelvic zone should not be opened, controlled w/ packing and angio-embolisation
 ∙ Best initial test for thoracic ijury is CXR, most acc: spiral CT. US can be used to diff b/w
contusion and presence of blood
∙ Initial management of tension pneumothorax is needle decompression (2nd IC space,
mid-clavicular line), definite management, chest tube insertion(5th IC space mid axil)
∙ massive hemothorax: collapsed neck veins, dull percussion note, absent breath sounds
∙ Beck's triad of pericardial tamponade includes: raised venous pressure + hypotension +
muffled heart sounds
∙ Flail chest: more than 3 adjacent ribs fractured in more than 2 places
∙ Deceleration injury is the mc mechanism of thoracic aortic rupture from RTA or fall
∙ Helical contrast enhanced CTscan is an accurate test for suspected aortic injury,
aortography being gold standard
∙ In presence of competing chest and abdominal injury, treat abdominal injury first
∙ Penetrating injuries to or below 5th IC space should raise the suspicion of diaphragmatic
penetration
∙ Anterolateral thoracotomy is incision of choice in emergency thoracotomy
∙ Esophageal injury caused by penetrating injury presents w/ odyndophagia, emphysema,
pleural effusion, air in retro-esophageal space, unexplained fever
∙ Pulmonary contusion follows blunt trauma usually under a flail segment or fractured
ribs, hypoxemia worst in first 24-48 hours. Hemoptysis or blood in the ET tube.
∙ DPL is used to assess presence of blood in the abdomen in hemodynamically unstable
pt.
∙ FAST is an US imaging used to assess the torso for presence of blood in hemo unstable
pt, either in abdominal cavity, pericardial sac, hepatorenal, splenorenal fosssa or pouch
of douglas/ pelvis. will not detect <100 ml of free blood
∙ CT is IOC in stable pts
∙ Pringle's maneuver involves clamping across hepato-duodenal ligament (i.e free border
of lesser omentum) to control portal triad via foramen of winslow
∙ Warm ischemia of the liver is tolerated for upto 45 mins allowing sufficient time for
hepatic venous occlusion
∙ The most imp factor that determines treatment in pancreatic trauma is whether the
pancreatic duct has been disrupted
∙ A pt w/ peripancreatic pseudocyst and a hx of blunt abdominal trauma should not be
assumed to have a post-trauma pancreatic pseudocyst, possibility of cystic neoplasm
should be considered and excluded

Skin and subcutaneous tissue

∙ Terminal hair have 3 phases, anagen (hair grows), catagen (hair shed) and telogen
(remains quiescent for many months)
∙ Specific ulcers: Non specific ulcer> shelving edge
Tuberculosis> Undermined edge
Basal cell CA> rolled edge
 Squamous cell CA> heaped up, everted edge and irregular thickened base
Syphilis> punched out
∙ Sinus refers to blind epithelial tract lined by granulation tissue. free surface into tissu
∙ Fistula refers to abnormal communication b/w two epithelial surfaces lined by
granulation tissue and colonized by bacteria
∙ Hypertrophic scar refers to an elevated scar which is confined within the boundary of
the initial injury or incision
∙ Keloid refers to an elevated scar, but they extend beyond the boundary of the original
injury or incision
∙ Keratocanthoma originates in pilosebaceous glands, mimics SCC
∙ Bowens disease is SCC in situ, involving glans penis is called Erythroplasia of Queyrat
∙ SCC arises from a scar known as marjolin's ulcer
∙ Breslow thickness is the most imp indicator in the absence of lymph node metastasis in
malignant melanoma
∙ Low flow vascular malformations may cause skeletal hypoplasia and high flow causes
skeletal hypertrophy
∙ Port wine stain is ass w/ sturge weber syndrome
∙ Spider nevi fades completely when compressed w/ finger
∙ Glomus tumor arise from subcutaneous AV shunts (Susquet-Hoyer canals), appear
especially in the corium of the nail bed
∙ Kaposi sarcoma is a malignant proliferative tumor of vascular endothelial cells caused by
HHV-8

cleft and lip palate

∙ Peirre Robin sequence is the most common syndrome ass with cleft palate. Comprises of
isolated cleft palate, retrognathia and a posteriorly displaced tongue
∙ Cleft lip and palate predominates in males, genetic factors more imp, can be diagnosed
antenatally by US after 18 wks
∙ Isolated cleft palate predominates in females, environmental factors(maternal epilepsy
and drugs eg steroids, diazepam) more imp, cannot be diagnosed antenatally
∙ Unilateral cleft lip results from disruption of nasolabial and bilabial muscle rings on one
side. Asymmetrical deformity involving external nasal cartilages, nasal septum and
anterior maxilla
∙ Bilateral cleft lip: disruption of both rings on both sides. Produce flaring of nose,
protusive pre maxilla.
∙ Incomplete cleft palate: when nasal septum and vomer remains attached to palatine
processes
∙ Complete cleft palate: when both are separated from palatine processes
∙ Intermittent airway obstruction is managed by nursing the baby prone
∙ Persistent airway obstruction can be managed by retained nasopharyngeal intubation to
maintain the airway
∙ Cleft lip repair is most commonly done b/w 3-6 months of age
 ∙ Cleft palate repair performed b/w 6-18 months of age
∙ cleft palate repair can be done by one or two stage palatoplasty
∙ Children w/ cleft lip/palate are at inc risk of sensorineural hearing deficit
∙ Speech problems may be due to velopharyngeal incompetence or articulation probs
∙ Dental anomalies most commonly occur in the region of cleft alveolus involving the
maxillary lateral incisor tooth

Plastic surgery

∙ Lines of election for surgical excision -analogous to Langer's lines of minimal skin tension
∙ Isograft is b/w genetically identical individuals
∙ Split thickness skin grafts (epidermis + some dermis aka thiersch grafts) are hairless, do
not sweat, thigh is mc donor site, buttock in children
∙ Full thickness grafts (epidermis + all dermis aka wolfe graft) have hair, smaller FTSG used
for contracture release, larger FTSG useful for major secondary burn contracture
∙ Stages of graft take: Adherence, imbibition, inoculatin and completion
∙ Flaps are tissues that are transferred with a blood supply.
∙ Axial flaps have a dominant feeding vessel
∙ V-Y advancement flap is useful on the face and for fingertip reconstruction
∙ Z-plasty is used to lengthen scar contractures, or tissues
∙ Basic rotation flap is useful for scalp defects and sacral pressure sores
∙ Bilobed flaps useful for defects on the nose
∙ Vacuum assited closure aka negative pressure wound therapy appears to hasten
debridement and the formation of granulation tissue in the wound

Early assessment and management of trauma

∙ Primary survery: ABCDE

∙ Secondary survery: History reviewed> AMPLE: Allergy, Medication including tetanus
status, Past medical history, last meal, events of the incident
∙ Nasotracheal intubation in children younger than 9 years should not be performed bcuz
of the possibility of damage to cranial vault and bleeding
∙ If IV access has failed after 2 attempts, consideration should be given to intraosseous
access, esp in children younger than 6 years of age. Proximal tibia or distal femur is the
ideal site
∙ BY the age of 65 years, nearly half of the population has some coronary artery stenosis,
thus, difficult to detect hypovolemic shock
∙ During primary survery, the uterus of the 3rd trimester pregnant patient should be
manually displaced to the left side in order to take pressure off the inferior vena cava
∙ Any pt w a mild head injury over 65 yrs or with a coagulopathy like warfarin use should
be scanned urgently
∙