Scanned with CamScannerClassification . 1 Distributive Shock... a Dynamic fluid response... <2 3 Occult hypotension Resuscitation. Ischaemlo-reperfusion injury HAEMORRHAGE... ossification . ‘Monogement.. TRANSFUSION.. Blood transfusion Safe blood transfusion Mismatched blood transfusion . Complications of blood transfusion ‘Massive blood transfusion. Wounds, Healing & Tissue repair.. Ueer 6 Compartment syndrome. Pressure 507€ moe Degioving (Crush syndrome. Sear. Surgical infection Erysipelos/Lymphangitis. Ccellulit Abscess. Cold abscess:.. Boil (Furuncle). Gangrene. Synergistic spreading Gangrene (Necrotizing Fascitis /Flesh-eating Carbuncle Tetanus Surgical site infection (SS). Systemic inflammatory resporse syndrome (SIRS). Prophylactic antibiotic. s Hospital acquired infection/Nosocoma) Infection cay “he pisian Intake-output chart... Artificial Nutrition supply Burn. Stoma .. Disinfection and Sterilization.. Operative surgery. Postoperative complications wurnrm32 ond 4 tne a3 Minimal access surgery. Anaesthesia General ancesthesia (GA). Local anaesthesia. Regional anaesthesia Preanesthetic assessment Investigations Biopsy. FNAC.. Frozen section specimen/Biops) ‘Metabolic response to injury. Vascular Scanned with CamScanner; Basel cel carcinoma, , | Marjolin’s ulcer (RU-July't8) Incision .. | Electrolytes imbalance . ‘Hypokaiemia, ‘Hypercalcemia (RU-Nov. 22). 49 Abdomen... The Esophagus Achalosia cardia ‘Stomach and Duodenum. Peptic ulcer disease (PUD).. Bleeding peptic ulce Perforated peptic ulcer. Gastric outlet obstruction (GOO) 600 due to pyloric stenosis. Carcinoma stomach .. Gastrointestinal stromal tumours (GSTS) Intestinal obstruction... Colon... | Po! | ye. serene Familicl adenomatous polyposis (F Colon cancer. “APES Rectum and Anal canal, Haemorrhoids... Anal fissur Fistula-in-ano . investigations. y Benign breast disorders. Mastalgia (Breast pain). Phyllodes tumour.. Nipple inversion... Nipple retraction... Golactocele Golactorrhoea.. Periductal mastitis Mondor's disease. Breast lump.. Gynecomastia. Thyroid. Thyroid investigations. Geoitre Discrete Thyroid Nodule.. Hyperthyroldism/Thyrotoxicosts Thyrotoxic crisis (Thyroid storm). Hypothyroidis OES sa Scanned with CamScannerAdrenal glad .. Incidentaloma Chest Trauma... Tension pneumothorax. Haemothorax. Deadly dozen’ chest injury. Cardiovascular ... Tongue . . 102 Inguinoscrotal swelling ..... 103 Hepatobiliary. 107-119 Gall bladder. 107 Cholecystitis 107 Laparoscopic cholecystectomy... 109 ‘Asymptomatic gallstones... 110 WHITE BILE 111 Choledocholithiasis.... 112 ERCP. 14 Acute pancreatitis. 115 Pancreatic pseudocyst. 115 Liver. Liver abscess. Spleen. Urology. Investigations. Hydronephresis Haematuria .... Bladder outflow obstruction (BOO).121 Lower urinary tract symptoms (LUTS)/Prostatism.. oo Benign prostatic hyperplasia (BPH) 122 Urinary Retention . Renal stone.. 117 119 120-130 120 120 120 Ureteric stone Bladder stone (Vesical calculus)... 125 ‘Rupture urethra: Urethral stricture Bladder tumour Testicular tumour .. Renal Neoplasm. Renal cell carcinoma. Acute scrotum. Priapism Phimosis and paraphimosis.. Paediatric Surgery.......131-139 Circumcision .. 131 Hypospadias 132 Infantile hypertrophic pyloric stenosis (HPS) . 1322 Intussusception. Hirschsprung’s disease.. Undescended testes (UDT) Acute scotum.. TORSION OF THE TESTIS. 137 Abdominal pain 138 Will’ tumour (Nephroblastoma). Neurosurgery. 140-145 Head injury. Glasgow Coma Scale score Raised intracranial pressure (ICP). 141 Extradural haematoma (EDH) és $42 Lucid interval.. Hydrocephalus... Brain tumour. Bibliography: Scanned with CamScanner ov a a in}a at Any shock i's assumed ad Ayovelumn? shack nn provn etarurs Be EE Hyprvolunvc shat Ms ae homes end prona ettrowsse- General Surgery Shock [2] 21 sof at = Haemorrhagic Secs ‘+ Define shock, (RU: Nov. 23) (RU- Nov.'19) + Non-haemorrhagle << Gla tes (RU-July/17) (RU-July’16) (RU- Nov'22) Y Intestinal obstruction’ ™ £P*%n4, ‘+ Classify shock according to severty. ¥ Perforation of GCHY (RU- Nov. '21) (RU- Nov.'22) Y Poor fii intake #Glassify shock on the basis f inttiating (dehydration), mechanism. (RU-suly'17) (RU-luh/16) v it ‘+ Write down the clinical features of : hhypovolemie shock. (RU- May '21) (RU- Y Excessive sweating July’47) (RU-July’t6) Y Urinary loss (e.g, disbetes ‘Principles of treatment of hypovolaemic insipidus) shock. (RU-duly/47) (RUJuly'26) Y ‘Third-spacing **snock sa systemic state of low tssue perfusion thats inadequate for normal cellular respiration, (80 atta) ification of initiating mechanism ¥ Hypovolaemte shock ¥ Cardiogenic shock ¥ Obstructive shock ¥ Distributive shack Endocrine shock \y"4" (Tatra space e143 space a flutd we 4 reabsorption 847, SO SACs Ca FIM CPIcwar ‘ara ascitic luld (peritoneal space) err er wow oer Third space fluld shifts the “Saeribatory space vec, gastrotnteetina| “Beetany fatal | spaces) meaning it erate a to the circulatory system. 1 botwe! obstriietion or pancreatitis » pf. cardi Myocardial infarction Cardiac dysrhythmias Valvular heart disease » condhorapeity : e 4g Real pocurdio€ Aapy Seat tot ft meade Bit Cardiac tamponade Tension pneumothorax Massive pulmonary embolus Mild (blood pressure maintained, mild reduction of urine output) mount Y Moderate (olood pressure startsto O| class $< 18% fell trina output reciices below clss 18-30 0.5 mi/kg/hour) Dice Oe EUs. Y Severe (patient is hypotensive, Urine @\CSSs > KO w output falls to zero) eure Blew! tar "apc ceed ol by boty {Normal urine output in a healthy adult is at least 0.5 ml/kg body weight/hour. = lal\i« eg, Ina 60 kg welght patient it must be at least 20 ml per hour (0.5%60=30 mi) A out pub > 2 MCL ey/hy eden or aut! pw. Navmat rier tort Pickering No Adetnatina cant say pre Scanned with CamScannerGeneral Surgery Distributive shock © Write short note on ~ Distributive shock (RU-Nov.’22) Distributive shock is characterized by vascular diatation with hypotension, low systemic vascular resistance, Inadequate afterload and abnormally high ediyliac output. Anaphylaxis (due to histamine release) Spinal cord injury (due to failure of => sympathetic outflow ~ neurogenic shock). ¥ Septic shock (due torelease of bacterial endotoxin) Y Correction of fluid and electrolyte by Intravenous fluid, blood transfusion, @& or inhalation @ Ventilatory support may needed ¥ Dobutamine/dopamine/noraérenaline tomaintain blood pressure ‘scavenous antiviotc Treat the cause or focus of infections nical feat lemic sh (RU- May ‘21) (RU-July’17) (RU-July’16) ‘Tachycardia (Rapid thready pulse) cold periphery Sweating Hypotension Restlessness ‘air Hunger Tachypnoea Otiguria proynsiot pst toa BARS R468 ec +++ monitoring for patients in shock Minimum * ECG * Pulse oximetry © Blood pressure © Urine output modalities Central venous pressure Invasive blood pressure Cardiac output Base deficit and serum, lactate + How will you monitor a shocked patient minimally? (RU- May ‘21) (RU- Nov’19) © What are the additionai/invasive modalities of its monitoring? (RU- May ‘21) (RU- Nov.'19) Dynamic fluid response © Whatdo you mean by dynamic fluid response, (RU- Nov./21) (RU- Nov22} Dynamically determination of shock status by the cardiovascular response to the rapid administration of a fluid bolus. In total, 250-500 mL. of fluid is rapidly given over 5-10 minutes and the cardiovascular responses (heart rate, blood pressure and central venous pressure) are observed. Patients can be divided into Responders have an improvement in their cardiovascular status that is sustained, © Transient responders have an improvement, but this then reverts to the previous state over the next 10-20 minutes. + Non-responders have no improvement. Scanned with CamScannerGeneral Surgery Management of Shock/Hypovolemic sh¢ «Immediate resuscitation: ¥ Wide bore canuia opening Y- Intravenous fluid e-¢9Hartmann’s solution wail CSr.0n 6 conkaindzactd $V! ec ery a lalten tot + Specific According to causes e.g. Y If hypovolemic shock due to inte obstruction/perforation of @CHV- Laparotomy ¥ Ifitis due to haemorrhage ~ - Haemorrhage control - Blood transfusion Occult hypotension Occult hypotension is a state of metabolic acidosis despite normal cardiovascular status. Explanation: + Inshocked state, cardiovascular status/vitas (pulse, blood pressure, urine output) are maintained until last stage of shock ~ But this are only maintained by reducing blood flow to skin, muscie, gut (which causes metabolic acidosis) and divert the blood to essential organs brain, lungs, kidney. ~ This state of normal cardiovascular status but continuous under perfusion (which ‘causes metabolic acidosis) is called occult hypotension. ¢ Importance: Patient with occult hypotensiot { More than 12 hours have a significant high > mortality rate, infection and incidence of multiple organ failure. — Resuscitation ‘+ Define resuscitation. (RU- Jan.’17) ‘© Write down the principles of fluid resuscitation in a shock state. (RU- Yan/17) ‘* What are the end points of resu (RU- Jan.'17) © How will you resuscitate a patient with hypovolemic shock? (RU- Nov.'2) tion? Resuscitation is a process of restoring stable physiological condition tha critically ill patient. (RU-Jan.’17) End points of resuscitation (RU-Jan.’17) ‘These are some parameters when these are achieved, we stop resuscitating shocked patient. Traditionally shocked patient has been resuscitated until normal urine output, pulse and blood pressure. (Traditional end point of resuscitation) But now shocked patient is resuscitated until correction of global perfusion end point (base it, serum lactate, mixed venous oxygen pre RZ @D A[raditional end point of resuscitation- 0 ‘, resuscitation @AToccult hypotension FAAchance | GME OR global perfusion end point WASeorrection _) Scanned with CamScannerGeneral Surgery Principles of fluid resuscitation in. shock state (RU- Jan.'17) intravenous fluids. 2) + Administration of inotropic or chronotropic agents to an empty heart is * Firstline therapy, is intravenous access (wide bore canula) and administration of ‘ot indicated as first-line therapy in hypovoiaemia. {scminstravion of these agents nthe absence of an seqete pried rani leads to deceased eranoy pefnion and depletion of myocardal apgen rere) ‘zy * Mfbloodis being ost, the repiacement ‘D Aid is whole blood BD + \nmoststuis of shock resuscitation ‘there is no overt difference in outcome between crystalloid solutions (normal saline, Hartmann’s solution) and collolds (albumin or commercially available products). Furthermore, colloids are more expensive se side effect profiles Gpotonic solutions e.g. dextrose in agua a 7 (OA) lore poor volume expanders] should and have xt _/-tict be used in the treatment of shock Z TF unless the deficit is free water loss (eg. Aiabetes insipidus) or patients are sodium / ~ overloaded (e.g cirrhosis), ARAL A 1" tient with shack (RU-Nov.’22) Management of shock cice eve gs ee specific cb bi areraa1 1 ude specific x ‘wm. Then I resuscitate according to causes Sra) ‘nical consequences of shock ¥ Unresuscitatable shock Y Ischaemia-reperfusion injury Y Systemic inflammatory response syndrome (SIRS) ~ Muliple organ failure Shook 2 rahe >A tye of heck A reorbily A pudue {TIS 66G be Goilune {schaemia-reperfusion injury Ischemic effects to the tissue due to shock causes injury to distant organs (such as the lungs and the kidneys) when blood flow is restored (reperfusion). Mechanism shock + Systemic hypoperfusion Ischemic effect to tissue + Activation of the inflammation leukocytes and complements Formation of toxic products + Restoration of blood flow (Reperfusion) ‘ Toxic products are flushed back into the circulation Injurytto distant organs such as the lunes and the kidneys Q. 30 years old man following RTA ect dosed fracture of right femur and came to you with rapid and thready pulse and fow blood pressure. (RU-July'28) a)" What type of shock developed here? 'b) How will you resuscitate the patient? Mention the non-invasive and invasive ‘modalities to monitor shock patient. “Answer: Hypovolemic Shock Resuscitation Y Wide bore canula opening ¥ Intravenous fluid ‘eg, Hartman's solution Y Blood is sent for screening and ross matching Y Blood transfusion (See Mx of Shock portion for coordination and understanding) Scanned with CamScanner @*#General Surgery HAEMORRHAGE [2] ‘* Define hemorrhage. (RU- May'22) (RU- Nov'20) (RU- Jan.’17) ‘© Classify haemorrhage, (RU- May'22) (RU- Nov.’0) (RU- Jan.’19) (RU- Jan.'17) Mention three condition where of concealed haemorrhage occurs. (RU-May'22) What is the basis of treatment of haemorrhage? (RU- Jan't6) extravasation of blood is called haemorthage. Classification os Revealed (SBA) Ff piri vie + Concealed (CMA): "eg, Y Ruptured spleen © Another classitication:. ‘= Surgical hemorrhage © Non-surgical haemorrhage eg. ITP, DIC Wor-surakatheemortace is the generat ooze from ll ene snfoce ti to coagulopathy and canna be topped by juga! means (exept pockingh) @humnshry ta snahinont Se Niesiak caged blood fe frie Veane — enp' tinny Aveterr Menace thaamosthass__ ‘#6 + owning, Identify haemorrhage: Either concealed or revealed. © Immediate resuscitation: ¥ Wide bore canula opening Y Intravenous fluid Hartmann’s solution /Ronye rs foctets ¥ Bloods sent for screening and ‘cross matching ¥ Blood transfusion guid tne Identify the site of haemorrhage Ruptured ectopie Haemorrhage control: By pregnancy Y Pressure a Y Femur fracture ¥ Packing (mete re Y Pelvis fracture ¥ Elevation ® According toduration:/Aere ol 9° v4e0er free! ¥ Tourniquet 1. Primary haemorrhage Y Ugature Hoemorrhage that occurs ot the time of injury Y Diathermy or surgery. 1. Reactionary haemorrhage ‘Techniques of haemostasis Hoemorrhage that occurs within 24 hours after ‘0 iajury. eecauses: Y ‘Slippage of a ligature Y Dislodgement of clot Y Normalization of blood flow. © S**examples: After tonsillectomy Aer thyroidectomy 30 % After haemorrhoidectomy a After prostatectomy ot I ll, Secondary hemorrhage Peale - Haemorshage thot occurs 7-14 days after an injury. Causes: Sloughing of the wall of a vessel due to infection, pressure necrosis (such as from ‘a drain) or malignancy. WALR Write down the techniques of arresting haemorrhage in surgical practice. (RU- Nov.’20) (RU- Jan.’19) (RU-Jan17) Pressure Packing Elevation(rasticon) Tourniquet Ligature Diathermy eendieof Ole! vent % Rep of load gabe Embdivatdon « aS8 Scanned with CamScannerGeneral Surgery wr i rhage hvsblogialexhaustion &death Trauma Haemorrhage Hypovolemic shock Decrease blood supply to tissue v , 7 Aewetraunatc Hypothermia lacie coxuopatiy actors (Endogenous cooquiogatty) Trauma induced coagulopathy 1 Physiological exhaustion 1 Death 4 Write down the pathophysiology of haemmorhage leading to physiological exhaustion & death. (RU-Jan’16) + How a patient of concealed haemorrhage may present to you? (RU- May’22) “nswer: > History of treuma > Features of hypovolemic shock eg. Tachycardia Sweating Cold periohery Hypotension Restlessness 9 Ale hunger Tachypnoea Oliguria SSA S494K45 TRANSFUSION [2] [3] © What do you mean by the term ‘infusion & transfusion’? (RU-July'16) Intravenous administration of blood and blood products is called transfusion, {Intravenous administration of flu other than blood is called infusion. Injection forceful parental administration drug {usually less than 50 ral}) Blood transfusion ‘* Name four blood products commonly used for blood transfusion with their indications. (RU- May ‘19) ‘¢ Write down the Incications of blood transfusion. (RU-July’17) lood and bi Whole blood Packed red cell Fresh-frozen plasma Cryoprecipitate Platelets Prothrombin complex vyyvvvy concentrates - wiv} tee Scanned with CamScannerGeneral Surgery oducts wi Indications (RU- May “19) + Whole blood—Acute blood los: €.9, blood loss in RTA or surgery + Packed red cell—Chronic Anaemia ‘* Fresh-frozen plasma—Dic + Cryoprecipitate—Haemophitia A, Low fibrinogen status + Platelets-- Patients on clopidogrel undergoing major surgery may require almost continuous infusion of platelets. ie Prothrombin complex concentrates ‘emergency reversal of anticoagulant (warfarin) therapy in uncontrolled haemorrhage. Fresh-frozen plasma: Plasma separated from {fresh blood and stored (frozen)in -40 to -50°C. Itistich in coagulation factors. Uses: DIC Grvoprecipitate: Supernatant precipitate of FFP ITisrich in factor ViMend fibrinogen. >) Uses: Haemophilia A, Low fibrinogen status. Safe blood transfusion What do you mean by safe blood transfusion? (RU- May 19) Formulate a comprehensive chack list to bbe followed before transfusion to avoid mismatching (RU-July'17) Transfusion of blood ater proper blood srouring > aah aaied " mnaClese es dl {Migktions for blood transfusion (RU-July’17) + Acute blood loss eg, blood loss in RTA ‘* Perioperative anaemia (Pre-operative + per-operative +post- operative period of surgery) ‘© Symptomatic chronic anaemia eg., Hemolytic anemia, aplastic anemia a % antov vw v vou ne for s fusion ~ screening ‘ond cross matching ‘Shelf life Shelf life refers to the maximum time from collection of the blood product until the product must be discarded, tion of bloo Blood is safely preserved in 4*Ctemperature in refrigerator. Fras vs blood Fresh blocd contains ali components of blood. In case of stored blood some components will be lost. Comprehensive check list to be followed before transfusion to avoid mismatching v => First, we check the particulars of patient (Age, Sex, Res. No., etc.)is same or not on the admission paper among with supplied paper from Blood bank and Blood bag. Check the receiver and donors blood group Cross matching is ok or not. Check the lab ID No. is same or not on. supplied paper from Blood bank and Blood bag. Another health care provider must recheck the above things before starting transfusion. (Ref Practica experience) Scanned with CamScanneree ee General Surgery Mismatched blood transfusion Complications of blood transfusion A. Complications from asingletrarseson incompatibility haemolytic transfusion Transfusion of incompatible groups of blood during. transfusion . reaction; eas Clinical features «febrile transfusion reaction; a allergic reaction; 4 ererand er vee ot eporanin Y bacterial infection (usual 4 Chest pain and chest tightness fouky storoeh iol ¥ Oliguria hepatitis: ’ ¥ toinpain YH, In anaesthetized patient - persistent 4 malaria; me hypotension and unexplained oozing from a alrembotismy the wound thrombophlebitis; 2 ‘+ transfusion-related acute lung injury (usually from FFP). Prevention — By proper cross matching. 8. Complications from massive tronsfusion 1 v = conn, Y Immediately stop blood transfusion ie Injection hydrocortisone 1 5 byeslabenis ¥ Injection Pheniramine (Avil) ‘= * hypothermia ¥ Intravenous fuld ( 5 eee hon iret transfusion * Iron overload. (e.g. patients with thalassaemia) hypocalcaemia; hyperkalaemia; ¥ Infusion mannitol 7 ¥ Injection frusemide O-f-... Y Blood sample of recipient and transfusing blood is sent immediately for two laboratories for rechecking. ¥ Patient should be treated in ICU Massive blood transfusion + transfusion of blood in a patient he davlpedoaleabea Ranubisth ven © Write in short, a standard guideline for with loin pain and respiratory distrass- the management of coagulopathy in iismearzai anticipation during massive transfusion. a) What could be the most likely (BENS) aalend, © Name 5 complications from massive b) How.will you manage the case? transfusion. (RU- Jan‘16) ©). Make a checklist to be followed S1v0d ve 2eby before transfusion to avoid such Pent in | by type of incidence Transfusion of blood equivalent to patient's “Answer: Mismaiched Blood transfusion own blood volume within < 24 hours duration. So, in case of adults it is S~6 L) Complications Write from complications of blood transfusion portion, Scanned with CamScannerGeneral Surgery janagement of coagulopathy Correction of coagulopathy is not necessary if there is no anticipated (eeiPrerexpected) active bleeding or haemorrhage {no impending (@PR) surgery) 7 However, management of coagulopathy is rust if massive transfusion Is anticipated Delivering balanced transfusion regimes of red blood cells, plasma and platelets in a 4:1: ratio, Transfusion of FFP, Cryoprecipitate, Platelets is needed according to laboratory test results, ¥ Injection Tranexamic acid Wounds, Healing & Tissue repair [1] * Define and ciassify wound healing. (RU- Jan.’17) * Define and classify wound. (RU-July’26) ‘Wound — Break in the continuity of body tissue (due to viclence, accident, or surgery) xratlfing Sin ove eallulay reenter changes sate Tapes) Tien De Rene SS Bie, 7, CoN rere spat Y untiey FORE Tay Untidy Tncised (Crushed OF aVuIsed, paras ec ean Contamnineted Healthy tissues Devitalised Hecues Seldom tissue loss | Often tissue loss Surgical classficatlon(tecgrdiny fy Rok O{ ‘fection |. Cleanwounde.g, hernictomy, , herniorrhaphy, excision of lipoma -Huyeoi Au eter» woydies {elective surgery +o breech of olmenton,senitourlnany or ‘respiratory trae] (we “inka in ) i. Clean contaminated e.g, bowel surgery, hepatobiliary surgery {elective suger ¢ breech of alinntary,gerttourinaryor “respiratory tract] Mm. Contaminated e.g. perforation of GCHV, gangrenous appendicitis [Breech of elmentary, ceniteurinary or respeatony toc + provence of spt tsv] Galore IV. Dirty e.g. abscess drainage, empyema gallbladder, Faecal peritonitis, sor so0 present} @¢ Tyxugredic. wound fw! tyvob cleans ‘(Pus present) ~~ **N.B. only name & example is enough to pass ‘exam. Text within the bracket Is for understanding. © A25 years female underwent appendicectomy for gangrenous appendix. (RU-Nov.’22) a) What type of surgical wound It is? [Answer - Contominated wound) Scanned with CamScannerSite of the wound skin tension Hypoxia and ischaemia Vascular insuificiency Lymphoedema Contamination Infection Presence of foreign bodies Radiotherapy Systemic factors ‘Advancing age Obesity Malnutrition ‘Smoking Diseases (e.g. diabetes mellitus, connective tissue diseases) ¥ Immunocompromised (e.g. acquired immunodeficiency syndrome) ¥ Medications (e.g. steroids, Immunosuppressants, chemotherapy) ANS ssases RSARN ‘assfcation of wound closure/healing/Sutures Primary intention/closure/suture Y Wound edges opposed ¥ Normal healing Minimal scar ‘Secondary intention /closure/suture ¥ Wound left open Heals by granulation, contraction and epitheliclisation Poor scar Tertiary intention (also called delayed primary intention) /closure/suture Wound intially left open Edges ¥ Later opposed when healing conditions favourable. General Surgery [Primary closure CHES BCA CHUA Cafe Wound edges opposed ISIXICA opposed WTR FETC ATH CHM, TCA ATTA I Tertiony closure [also called delayed primary closure] q ‘SICH wound open HINT SH, FAA infecion ey ITA TAASITS infection contro! (favouratie conditions) BUT CATS BUA CHA HI delay UH CTR CHT RH AR delayed pinay closure 707 | Secondary intention /closure ¢ (CHATS CHAR AAT Wound open ARH granulation tissue formation ™C% wound dow xy am] Principle of wound management + Name the steps of management of ate wound. (RU: Jan.’17) "| ¥ Antibiotic prophylaxis ¥ Tetanus prophylaxis Preparation | adequate analgesia/anaesthesia ¥ Wound irrigation Early debridement and 1 inrigation Exploration Repair structures Haemostasis Squamous cell carcinoma (Mxjplii = Basal cell carcinoma = Malignant melanoma Seen) = ents bw investigations - Complete blood count - Blood sugar Scanned with CamScannerGeneral Surgery Wedge biopsy wae we *ica to differentiate between benign ulcer and malignant ulcer and'also to find out cause. wedge biopsy triangular shape ¥a five ai triangle «i apex ulcerated lesion #4 fic# ‘ai normal skin 4% se ‘actaxt ulcerated lesion S/o Re GAT REI eA.© BT part —normal tissue, margin ad of ulcer, ulcerated tissue. Causes of ulcer/Aetiology of ulcer Vascular (venous, arterial, mixed) Trauma (bites, self-inflicted, burns) ¥ Infection (bacterial, fungal, mycobacterial, syphilis) Metabolic disorders (diabetes mellitus, gout, calciphylaxis) Y Autoimmune disorders (vasculitis, systemic sclerosis, rheumatoid arthritis) Y Neoplastic (squamous cell carcinoma, basal cell carcinoma) SN ‘Treatment/Management of ulcer ‘A. Treatment of causes eg. + Control of diabetes in case of diabetic ulcer = Anti-tubercular drugs in case of tubercular ulcer 8. Nutritional Improvement: By > Correction of anemia = Correction of protein deficiency _ Infection and pain cont - Antibiotic = Analgesic ©. Care of ulcer: By > Debridement ~ Regular dressing Skin grafting may need Management of a non-healing leg.ulcey ‘A. Wedge biopsy has to be done to find ou, the exact cause. nal improvement: By - Correction of anemia - Correction of protein deficiency Infection and pain control: By = Antibiotic = Analgesic D. Care of ulcer: By = Debridement-r4! Aan po = Regular dressing 7 - Skin grafting may need = ASS years old debilitate patient presented with non-healing ulcer on right side of his neck. Examination revealed ., undermined edge and pale granulation in ' ) the floor of the ulcer (RU-Nov.'20) a) What is your probable diagnosis? b) How will you confirm your diagnosis? cl Give the treatment plan, Diagnosis - Tubercular ulcer ‘+ Confirmation by wedge biopsy. «© Treatment ‘A. Antl-TB drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol end streptomycin) 8. Nutritional improvement: By = Correction of anemia ~ Correction of protein deficiency . Pain control: By - + Analgesic [ewer sate wx Antibiotic Fre waa i anti-TB drugs 88 D. Care of ulcer: By ~ Debridement ~ Regular dressing + Skin grafting may need Scanned with CamScanner Fen pres teaa pas 7 the ther min ey=i = 30 Compartment syndrome is raised prGatrein ‘an osseofascial compartment toa level that compromises tissue perfusion. Clinical features Compartment syndrome is a clinical diagnosis characterised by ~ ~ Pain out of proportion Pain on passive stratch au (% Paralysis [6p's) O'S Paraesthesia hoe 7% Pallor (DY \¢ pulselessness (late sign) ‘Treatment - Fasciotomy ae Pressure sore/Trophic ulcer Tissue necrosis with ulceration due to prolonged pressure.) it Ares 42 le Less preferable terms are bed sores, pressure ulcers and decubitus ulcers. [for curiosity: Pressure sore froquency in descending order: bschlum Greater trochonter ¥ sacrum Y Heel YY Melleolus (lateral then medial) v Occiput tN sig 7 Yexternal pressure exceeds the copliay occlusive ‘pressure (over 39 mrag), blood flow tothe skin ceases. leading to tss1e anoa, necrosis and ulcereton Pressure sore awareness is vital, and the bed-bound patient should be tuned at least every 2 hours, with the wheelchair bound patient being taughe tolift ‘themselves off thei seat for 10 seconds every 10 Dee ee Rc? Degloving Degioving is the avulsion of skin and. Subcutaneous fat from thgfinderlying fascia, muscle or bone. SS ee ee sal ST gem “ General Surgery , Crush syndrome [3] ™") this is the association between erush injury, rhabdomyolysis and acute kidney injury, ((Crush’ meaning cxrsyeteerayorn Mex ere / Crush injury is one where @ part of the body Is being squeezed/ compressed between two heavy ‘or immobile objects (high force or pressure systems).] ‘Mechanism |. Prolonged crushing of muscle due to crush injury , Ischemic-reperfusion injury when the casualty is rescued. ‘ Release of myoglobin 1itt0 opened | Myoglobinuria Tubular obstruction co aie isch + fe wssd eos Te ay A Renal failure "G thes Ul. Crush injury also causas fluid sequestration in damaged muscle + Reduces the intravascular \ volume(hypovolemia) y ‘ } Renal vasoconstriction 1 Renal ischaemia ’ Renal failure ~ Scanned with CamScannerGeneral Surgely Treatment = Initially aggressive intravenous fluid 1000- 1500mI/nour + Infusion mannitol - Injection sodium bicarbonate ~ de wont bathe! en ~ Early fasciotomy [Mannito!-alkaline diuresis of up to 8 litres perday should be maintained, Keeping the urinary pH greater than 6.5, A late fasciotomy makes things worse not better] Scar A scarlsa mark left on the skin aftera wound orinjury has healed. Umnmoture sar—Type Icollagen ure -Type 1 slog ‘Three types — ¥ Atrophic ¥ Hypertrophic Y Keloid An atrophic scar is pale, flat and stretched in appearance. Abypertrophic scar is defined as excessive Scar tissue that does not extend beyond the boundary of the original incision or wound. Akaloid scar is defined as excessive scar tissue that extends beyond the boundary of the original incision or wound, ‘Treatment of hypertrophic and keloid scars ¥ Pressure ~local moulds or elasticated garments Slicone gel sheeting Intralesional steroid injection (triamcinolone) ** Excision and steroid injection Excision and postoperative radiation Intralesional excision (keloids only) Laser Vitamin E or palm oil massage a8 V0ees Surgical infections sf BI spied, fle, ef Nya By ce A, Exysipelas/tympharigs® #0 Fy, Y Acute rapidly spreading non- «suppurative pflammation of “skin and , subcutaneous tissue. ¥ Causative organism — Streptococcus pyogenes ¥ Clinical features = Rose pink rash Well defined margin Y Treatment 1 wrounral Ail deta = Rest and elevation Tissue debris ~ Bacteria Pyogenic membrane Is composed of - = Inner layer of neutrophil and bacteria + Quter layer of granulation tissue! 2°" “Plamen by ral ante Granulation tissue is composed of = “dapsavh + Fibroblast = New blood vessel Criteria of granulation tissue + Pink, soft, granular appearance + Bleeds on touch \._ Insensitive to pain “Resistance tg infection Hallmark of tissue repair E- When the abscess cavity is left open to drain freely, there is no.need for antibiotic therapy. “Antibiotics should be used if the abscess cavity i=) iosed after drainage -Most abscesses relating to surgical wounds take 7-10 days to form after surgery ~ Abscesses contain hyperosmolar material that draws fluid. This increases the pressure and couses in.) Treatment of abscess ~ Incision and drainage slab blads no || Antibioma Sterile pus containing swelling formed due to use of antibiotic without drainage of abscess. Cold abscess: + What do you mean by cold abscess? (RU- May’22) (RU- Jan.’19) (RU- Jan.’18) ‘© Write down the etiology and common site of cold abscess. (RU- Jan.’19) (RU- Jan.’18) * Write down the pathogenesis of cervical cold abscess. (RU- May’22) © Management of cold abscess. (RU- May/22) (RU- Jan./18) Cold abscess ~ Abscess which has no signs of Inflammation and formed as a sequel of tubercular lymphadenitis, Itis called cold abscess as it has no signs of Jinflammation. (so old obsces not worm). Etiology - Mycobacterium tuberculosis infection, ‘Common site - Neck ‘Natural history/eathoueness of colar-stud abscess Tubercular lymphadenitis 4 ‘Caseation necrosis of the lymph node and cold abscess formation 4 Penetration of pus (cold abscess) thorough deep fascia into superficial space Collar-stud abscess formation Treatment Y Antitubercular drugs ¥Nondependent aspiration or drainage of the cold abscess. (Dependent drainage a sinus formation # ) Scanned with CamScannerGeneral Surgery Boil (Furuncle) Dye we wre Y Acute staphylococcal infection of a hair Teisdueto greduel | Its due to superedaag~ follicle with perifolicultis, loss of blood supply | infection and putrefacton Y tie usually proceeded to suppurationand | ==-srenous tasue | Gangrenus tse central necrosis. becuase, becomes edematous, ¥ Causative organism ~ Staphylococcus shrivelled, putrefied. oureus mummified. | ¥ Boll on the eyelash is called stye. Clear ine of Vague inet ¥ Boll on the external demarcation present | demarcation preset augltnycanalis a ‘Yenipainful due to disease rich cutaneous nerve and skinis firmly adherent to Synergistic spreading Gangrene perichondrium Y ‘Treatment Iriprotieg cies esi tig zen - Resolves spontaneously cule, rapidly spreading, fe Westen pidly spi ing + Antibiotic (flucioxacillin) may needed Gangrene © What is gangrene? (RU-July’17) (RU- July’16) © Classify gangrene with examples, (RU- July’17) (RU-July’16) * Compare and contrast dry end moist ‘gangrene. (RU-July'17) (RU-July’16) Gangrene: Macroscopic death of tissue with putrefaction. Clinical classification Y Drygangrene eg. Buerger’s disease Y Moist gangrene eg. Diabetic foot Aetiological classification Secondary to arterial occlusion e.g, Buerger’s disease, Diabetic foot, Rayncud’s disease Y infective e.g. eas gangrene, carbuncle, necrotizing fescitis Y Traumatic Physical eg. bum, frostbite, chemicals, electricity Y Venous infective gangrene characterized by widespread necrosis of skin and'subcutandios . Seen: ctissue. tis calledmeleney synergistic gangrene when involves abdominal wall end when it iavohes perineum, scrotum or genitalia tis called 90/min, no B-blockers) or fachypnoea (>20/min) White cell count >12 x 109 /litre or <4 10° ftre * Saggggioemereniccumented + al inf 4 Severe sepsis or sepsis syndrome is sepsis with evidence of failure of one or more organs 4 MODS is the effect that SIRS produce systemically 4 Bacteremia is the presence of bacteria in the blood. ‘® Septicemia is the presence and ‘multiplication of bacteria in the blood. Prophylactic antibiotic ‘+ What'do you mean by prophylactic antibiotic? (RU- Nov.'19) * Mention the principle of antibiotic Prophylaxis. (RU- Nov.'19) Prophylactic antibiotic Giving antibiotic before performing surgery to prevent infection, Pcie forthe use tani herp eo dines > fi Y Antibiofe do not replace surgical drainage of infection Y Only spreading infections or signs of systemic infection justify the use of antibiotics Y Whenever possible, the organism and sensitivity should be determined The decisive period ‘Theres up toa 4-hour interval before bacterial growth becomes established enough to cause fan infection after a breach in the tissues, whether caused by trauma or by surgery. This interval is called the ‘decisive period’. It Is therefore logical that prophylactic antibiotics should be given to cover this period and that they could be decisive in preventing an infection, Hospital acquired infection/Nosocomial infection Infection acquired from the environment or the staff following surgery or admission to hospital is termed hospital acquired infection (HAN. There are four main groups Respiratory infections (including ventilator-associated pneumonia) Y” Urinary tract infections (mostiy related to urinary catheters) Y Bacteraemia (mostly related to indwelling vascular catheters) “Surgical site infection (SSIs) Prevention of Ni Staff should always wash their hands between patients Length of patient stay should be kept toa minimum Preoperative shaving should be avoided if possible ¥ Antiseptic skin preparation should be standardised Attention to theatre technique and discipline Y Avoid hypothermia perioperatively and ensure supplemental oxygenation in recovery, Scanned with CamScanner