General Surgery

Lec.1 Introduction to clinical surgery and general principle

of patient assessment
General surgery means a surgical specialty that associated with wide
range of surgical procedures that performed on soft tissues.

Anything from small lesion in the skin to the large cyst and
colectomy, also it is associated with all content of the abdomen
starting from the esophagus, stomach, small & large intestine, liver,
spleen, bile duct and thyroid gland.

The general surgeons have an important role to play in emergency

cases, so in rural and remote areas, general surgeons are in demand
for their wide range of skills; also they are performed surgery
following accident.

Category of Surgery
Classification of Surgical Diseases:
1- Trauma: it can be mechanical such as any machinery or
instrument trauma, thermal due to the over heat, chemicals,
some chemicals and chemical products, electrical and war.
2- Infection: abscess, sinus…
3- Neoplasia: benign or malignant.
4- Anatomical abnormalities: congenital or acquired, like
acromegaly.

1
 5- Metabolic and hormonal disorder: like diabetes mellitus,
goiter, hyper or hypo thyroidism, hyper or hypo
parathyroidism.
6- Infarction & ischemia: This is usually effectively on heart like
coronary artery disease.
7- Others: obstruction, parasite diseases, vein varicose.

Classification of surgical specialties

According to characteristics, Operation methods, age,
specialty.
1) Characteristics:
a) Neoplastic surgery: surgery associated with any neoplasia
like tumors either malignant or benign.
b) Emergency surgery: surgery associated with the urgent
cases
c) Trauma surgery: it’s any surgery associated with the
traumatic injury like chemical, mechanical or electrical
trauma.
d) Burn surgery: this surgery associated with burn injury.

2) Operation:
a) Plastic surgery: the surgery that treats any deformity
associated with the body.
b) Microsurgery: the surgery that uses microscope like
repair of the fine blood vessels.

2
 c) Transplantation: it is the surgery that associated with
transplants of any tissue or organ of the body from donor
to recipient.
d) Minimally invasive surgery: any surgical procedure that
uses a minimal or least aggressive way to treat any lesion.

3) Age:
a) Pediatric surgery: surgery treats the patient less than 12
years old.
b) Adult surgery: the surgery that associated with treatment
of any patient aged more than 12 years old.

4) Specialty:
a) General surgery: as we previously mentioned the surgery
that associated with any tissue or organ present in the
abdomen like esophagus, spleen, liver, intestine and
others.
b) Orthopedic: surgery that associated with bones and their
lesions.
c) Neurosurgery: surgery treats any neurological
deformities or deficient.
d) Gynecological: surgery that associated with any
gynecological disease in the women.
e) Otolaryngology (ENT): surgery that associated with any
lesion present in ear, nose or throat.
f) Ophthalmology: surgery treats any lesion in the eye or
ophthalmic.

3
 g) Maxillofacial: surgery or specialty that associated with
any lesion in the head and neck, especially the face and two
jaws (upper and lower).
h) Plastic: treats any deformities in the body.
i) Cardiovascular: surgery associated with heart and the
vascular lesions.

Case History -Case Sheet-

Case sheet: is defined as the document that recording the
medical status of patient.
The case sheet has many advantages:
1- It provides information about the general medical status of the
patient.
2- Allow for communication of different doctors from the different
specialties.
3- It provides the database or record for the condition of the patient.

Personal information:
( name, age, sex, occupation, residency, religion, date of
admission, date of examination).

Personal information: means information of patient that includes

the name, age, sex, and others.

Name, is important to provide communication between the

doctor and the patient.

4
 Age, some disease associated with pediatry or adult.
Sex, some disease associated with men rather than women.
Occupation, some disorders occur in some occupation like
poisoning is more occur in the workers in laboratory rather than
other.

Residency, where the patient lives either in the rural or in urban

area.
Date of admission, important to know the time that the patient
remain in the hospital and to know the disease progress if it is
worse or better.

History
History includes the following characters:

1- chief complain.
2- history of the present illness.
3- past medical history.
4- past surgical history.
5- drug allergy & sensitivity.
6- family history.
7- social history.

5
1- Chief complain: means what complains that the patient suffers
from, or what is the problem of the patient. It is usually depend
only on the patient’s words i.e. depend only on what patient
say to us.

2- History of the present illness: how long the patient suffers

from this problem.

3- Past medical history: if the patient has any medical problems

like hypertension or heart diseases which maybe affect on our
treatment, because his treatment maybe impact with his
illness.

4- Past surgical history: any surgery that the patient has been
done. This point is very important in order to provide
information about any complication in anesthesia or
complication in healing in past operatively or about any
treatment given to him.

5- Drug allergy & sensitivity: if that patient has any allergy from a
specific drug in order in prevent the anaphylactic shock and
that maybe lead to failure result.

6- Family history: if the patient’s parents have any disease or

maybe heredity disease that can be affect on our treatment.

7- Social history: if the patient smokes, have drugs, drinks or

others habits which affect on treatment or surgery.

6
 Case examination
After checking the general personal information and also taking the
history of the patient. Now we should examine the case:

Firstly, we should know the 4 important principles that relate to the

case examination :

1- Inspection: mean feed by eye.

2- Palpation: use the hand to palpate or touch the lesion.
3- Percussion: knocking on the lesion or on the tissue.
4- Auscultation: done by stethoscope usually that means the
listening to the organ or any region.

First describe age (child, young, middle age, old age) then describe
sex male or female, then condition status conscious or not,
comfortable or not, built of patient either thin or fat or normal.

Second general examination:

 ( the patient either lying or sitting on bed ).
 Vital signs (pulse rate, blood pressure, respiratory rate,
temperature).
 Color changes:any change in the color of the patient either in
skin, tongue or sclera like: jaundice, anemia, cyanosis
(definded in page.10).
 Shape changes: Leg edema, clubbing of fingers.
 Obesity.
 Dehydration.
 Lymphadenopathy: any pathology in the lymph node that
maybe associated with some disorders like the autoimmune
diseases. Or maybe tumor or any inflammatory reaction in the
body.

7
Vital signs:
1- Pulse rate: arterial pulse. radial in forearm (simple, superficial,
bone under it), brachial , carotid, femoral , popliteal, dorsalis
peadis, posterior tibial arteries.
Normally 60-100 bpm if < 100 tachycardia , and if > 60 bradycardia
Rhythm either regular or irregular.
Pulse rate means the pulse in the artery of the body. there are many
point in the body that can be use to detect the rate, but the most
common one that usually used is the radial artery.
 The radial pulse is felt on the wrist just under the thumb. And
it’s most commonly used because it is easy, simple, superficial
and there is a bone under to it , so we can ‘t miss it.
 The other points that can be used to take the pulse rate are
brachial artery that present in the arm.
 Carotid artery in the neck.
 Femoral artery in the pocket area.
 Popliteal artery just behind the knee.
 Dorsalis pedis present in front of the ankle in feet.
 Posterior tibial artery which present in the posterior part of the
ankle or heel.
The normal of pulse rate ranged from (60-100 bpm),
If more than 100 bpm it’s called tachycardia, while less than 60
bpm called bradycardia.
The pulse rate is very important to know status of the patient if
the patient has any problem in the heart or in the blood volume or
dehydration or not.

8
2- blood pressure: can be examine by the use of
sphygmomanometer and stethoscope.

Stethoscope has many advantages:

a) Amplify or focusing the sound.

b) Transfers this sound from the body to the ear.
c) Usually prevent any noise from external sources.

the patient should be relaxed quite, not eating, not smoking, not
with tight clothes, put the cuff at the level of the heart above the
cubital fossa 1 inch inflate cuff till brachial pulse disappear add 30
degree (nearly to 200mmHg) then hear by stethoscope & deflate, the
first sound is systolic, when the sound disappear it means diastolic,
normally 120\80 mmHg.

9
Systolic: systolic sound result when the heart contracts in order to
pump oxygen in the blood to the body.

Diastolic: relaxing of the heart.

Less than normal blood pressure → hypotension

More than normal blood pressure → hypertension

3- Respiratory rate: normally 14-20 breath/ min. type ( acidotic

air-hunger, cheyne-stokes) mode normally female with thoracic
breathing & male with abdominal breathing.

Female respired with the thoracic breathing that means they use
thoracic muscle for breathing. while the man use abdominal muscle.

this difference associated with physiological difference.

as the female usually be pregnant, the use thoracic breathim is more

appropriate in this Condition rather than abdominal because
abdominal breathing during pregnancy can usually affected on the
uterus and press on the abdominal muscle.

* acidotic air- hunger mode: occur when there is acidic condition of

the body like there is a heart failure or if there is Ketone bodies. in
the body So decrease O2, increase Co2 so the body become very
hunger to air which cause Increase in respiration and cause deep
abnormal respiration.

*cheyne-Stoke: is also associated with some of diseases in which

there is a cycle of breathing.

*Hyper Ventilation/rapid breathing: that is usually fast, rapid,

shallow, then become gradually decrease until it is stop, this cycle

10
takes 30 Sec to 2 min. and then repeated again. usually associated
with the metabolic toxicity or encephalopathy can't breathe or
Poisoning or Coma, this is Called apnea.

4- temperature :- examined by using thermometer 35-42 c°, it

should be Kept in disinfectant solution such as Dettol then shaken
well till return to zero then use orally (under the tongue) or
auxillary or rectaly for about one min. normally 36-6-37.4 c° if
below 35c° hypothermia, more than 37 Pyrexia and if more than
40c hyperpyrexia.
Why this range (36.6-37.4 C°)?
Because of many Causes including:
1) The Seasonal differences, so in the winter is difference about
Summer.
2) Physiological status of the body, if the patient doing exercise or
not.
3) The area from which the temperature was taken, because the
oral temp.is different from the axillary or rectal area.

Color changes

1- Jaundice: yellowish color of skin and sclera (ask the patient to

look downward). usually associated with the liver problems.
2- Anemia: Pale color of the skin and tongue and sclera (ask the
Patient to look upward) usually associated with the decrease in
red blood cells which is associated with many problems in the
spleen or bone marrow or body Volume.

11
 3- Cyanosis: bluish discoloration of skin and mucous membrane of
tongue due to deoxygenated blood, it has two types:
- central, if the tongue and hand and lip are bluish in color
with warm hands.
- Peripheral, if tongue isn’t bluish and hand bluish and cold.

Q / What the difference between central and peripheral cyanosis?

A/

 Central: which is usually associated with the heart problems

like ischemic heart diseases or any heart failure usually can be
affect on the hand and lips are bluish in color with warm hand,
and it associated with series of problems.
 Peripheral: not associated with series of problems but
associated with peripheral deficiencies in the oxygenated blood
usually occur when there is a tongue not and hand bluish and
cold.

Case examination of Cardiovascular system

1- Inspection: apex beat, epigastric pulsation.
See by eye, start with apex beat and epigastric pulsation, these two
conditions is very important because associated with cardiac or
vascular problems.

Secondly, it’s mean beat that can be felt on the point called the point
maximum impulse point, which is usually located as the most lateral
and most inferior part of the heart and this can be seen clinically on
the patient by point most lateral and most inferior to the sternum, so

12
apex beat usually associated with some pathogenic conditions like
enlargement of the heart called cardiomegaly or maybe pulmonary
diseases or maybe deformities of the chest or the thoracic vertebrae,
while the other condition epigastric pulsation :

The abdomen is divided into many regions include:

1- Right hypochondriac and left hypochondriac region with

epigastric region.
2- Right and left lumber region with umbilical region.
3- Supra pubic region with right and left iliac region.

So the pulse felt at epigastric region called epigastric pulsation,

this pulsation usually occur due to the blood flow as the
abdominal part of the aorta when the blood pass through it.

This pulsation can be seen in normal people when they are very
thin do excessive exercise but also can be occur in disease like
when there is aneurism carcinoma in the stomach.

13
 2- Palpation: apex beat position, thrill palpable murmur.
It is touch of the region or the body examinant this include
apex beat position and thrill palpation.

Q / what’s the meaning of the murmur?

A / It’s the sound that produced by the blood when it’s pass from the
heart to the vessels, the presence of the murmur maybe normal or
maybe also associated with some pathologies in the heart or in the
vessels.

3- Percussion: in the examination of the heart is of limited value

and not used commonly.
4- Auscultation: heart sound, murmur, apex beat, is very use and
very common in order to hear the heart sound and the
murmur.

Case examination of Respiratory system

1- Inspection: chest shape barrel (emphysema),
Pigeon (pectus carinatum)(rickets),
Funnel (pectus excavatum)(congenital)
Movement or expansion,
breath rate and character,
back of the chest kyphosis, lordosis, scoliosis.
By it we can detect the following disorders:
Chest shape barrel this must commonly occer in
emphyesem(defined as the air collection in the subcutaneous
area of the body).
Or maybe appear as pigeon shape of the chest which is called
pectus carinatum, this must common, occur in rickets disease
that is associated with the deficiency of the vitamin or maybe it

14
 appears as funnel chest which is also called pectus excavatum
and this most commonly seen in the congenital abnormalities
in which the anterior part of the chest appears as curvature.
Also we should check the movement or expansion and breath
rate and character also we should inspect the back of the chest
(there are many disorders associated with back of the chest or
which spinal cord these disease called either kyphosis, lordosis,
scoliosis.

The kyphosis: is abnormality excessive convex curvature of the

spine which is most commonly occur in the thoracic and sacral
region of the spine.

Lordosis: is the curving of the cervical and lumber regions of

the spine.

Scoliosis: is a medical condition in which the spine usually have

side way curve that usually appears as “s” or “c” shap over the
three dimensions.

2- Palpation: in which we should check the position of the

trachea, apex, beat, expansion, tactile vocal fremitus.

3- Percussion: also can be detect the clavicular and intercostal

space.

4- Auscultation: is very important for listening to the breath

sound as the breath sound can lead us to some of disorders like
bronchi or wheezing crepitation or plural rub (friction), or vocal
resonance
All these sounds can be detected and usually can be lead to
examination of some disorders of the respiratory system.

15
 Case examination of the nervous system
A) Cranial nerves: each of which is responsible for different
part of the body:

1- olfactory 7- facial
2- optic 8- vestibulochoclear
3- occulomotor 9- glossopharyngeal
4- trochlear 10- vagus
5- trigeminal 11- accessory
6- abducent 12- hypoglossal

B) Motor system:
Inspection: we should inspect size and symmetry of muscle,
abnormal movement: fasculation, chorea, athetosis, dyskinesia,
examination of tone, examination of power, examination of
reflexes (biceps jerk, triceps jerk, ankle jerk, knee jerk, jaw jerk,
Babaniski sign, coordination, examine gait, waddling,
hemiplegic, parkinsonial, wide-base).

Fasculation: in which there is involuntary abnormal contraction

and relaxation of the muscle, also called muscle twitching it is
normal 70% of population but sometime associated with some
neurological disorders.

Chorea: it is involuntary movement of muscle but the patient

appear like dancing, it can be temporary or getting worse with
age.

Gait: means the way of walking.

16
 Athitosis: in which it is abnormal movement of the muscle but
the finger of the hands and toes of feet appear like in writing
movement also can affect tongue, leg and other regions.

Waddling: abnormal walking of the patient usually associated

with neurological disorder and also present in normal population
like pregnant women.

Hemiplegic: inability to walk at all.

Parkinsonial: disorder in the muscle in which there is
involuntary irregular movement of the muscle and usually affect
on the way of walking.

Wide-base gait: the person appear like glumby because he is

walk from side to side.

C) Sensory system:

Inspection: 1- movement of abdomen

2- shape of the abdomen
3- shape of the umbilicus
4- visible peristalsis
5- visible vein
6- distribution of hair
7- scar of previous operations
8- cuttary & tattoo

17
 Palpation : liver , spleen, kidney, ovaries, masses.
Percussion : for asitis shifting dullness & transmitted thrill.
Auscultation : bowel sound.

Case examination of the head examination

1- scalp: density of hair if hair loss alopecia.
texture of hair thick silky. distribution & presence of
scales.
2- face: mooning facies Cushing syndrome ( in which there is a
defect in the adrenal gland ).
adenoid facies infection of adenoid.
lion facies in leprosy.
myxedemous face in hypothyroidism (if face appears as
bulshing).
thin face as in hyperthyroidism.
coarse features as in acromegaly.
malar flush as in mitral valve stenosis.
earthy paler face as in renal failure (this occur due to high
concentration ketone acid or acidosis).
catchaxic face in chronic illness (such as in the malignus).

Case examination of the neck examination

The patient head should be turned to the side of examination to
allow the muscle to relax and to have a correct examination.

18
1- lymph nodes: by using tips of the fingers starting with submental,
submandibular, jugulodigastric, juguloomohyoid, supraclavicular,
etc..

2- thyroid gland: by inspection of neck & ask the patient to swallow

or drink water to detect abnormality in this gland.

3- neck pulsation: put patient in 45 c° and observe arterial or venous

pulsation, if there are any suspension or any disfriction this should be
usually associated with disorder or abnormality in these vessels.

Investigation
The 2nd step after examination, invasive:
1- Complete blood count ( CBC )
2- Erythrocyte sedimentation rate ( ESR )
3- Fast blood sugar ( FBS )
4- Renal function test ( RFT )
5- Liver function test ( LFT )
6- General urine examination ( GUE )
7- Serum electrolytes (Na+, K+, Ca+, Mg+, Cl-, ……)
8- Chest x-ray ( CXR )
9- Blood group ( BG )
10- Electrocardiogram ( ECG )
11- Radiologic evaluation (conventional, C.T., MRI, PET scan..)
12- Biopsy (incisional, excisional, punch, ….)
13- Fine needle aspiration cytology FNAC.

Then Diagnosis , Treatment , Follow up…

19
 Lec.2 Nutrition
Define nutrition ?
Nutrition means the Process of providing or obtaining the food
necessary for health and growth.

Before the patient enter the operating theater, the Surgeon should
check the nutrition status for the patient. why?

When the patient is malnutritioned, the nutrition requirement is

important to support wounds healing (if there is no healing, this will
cause complications inside surgical theater or cause post-operative
complications, and maybe staying in hospital for long time).
Because the nutrition requirements are important to
Support wound's healing and hypermetabolism associated with
surgical recovery.
Without adequate nutrition there will be muscle wasting, immune
disfunction (the immunity decrease because WBC depends on
nutrition) that may leading to infection.
*Malnutrition: deficiency of energy or food intake.

Causes of Malnutrition:
1- pre-operative causes: starvation, like self-neglect, poverty or
dysphagia (means difficulty of swallowing caused by a problem or
defect in the esophagus that lead to failure of proper digestion).
2- post-traumatic causes: like surgical intervention or post-operative
complications (especially in GIT procedure like esophagus
intervention, stomach or bowel resection. all of these lead to mal
absorption of nutrient and finally lead to malnutrition)
3- Hyper catabolic: Sever sepsis, burn.

1
Q / why burn cause malnutrition?
A / Because in burnt patient there is excessive loss in fluids and
electrolytes.
each person should eat 3 meals per day, to provide glucose to the
body tissues.

Q / If the person fast for 12 hours (short fasting) what happened ?

A / the last meal will have been absorbed,
Plasma insulin's level fall or decreased,
glucagon level rise or increase.

At the beginning (glucagon is important for facilitate conversion of

200g of liver glycogen to glucose) therefore the liver become an
organ of glucose production under fasting condition.
*many organs including brain tissue, RBCs, WBCs and the renal
medulla can initially utilized only glucose for their metabolic needs
under fasting condition.
*additional stores of glycogen exists in the muscle (500mg of
glycogen) but these can't be utilized directly because there will by
glycogenolysis in which lactate is the product and then the lactate
will reach the liver and converted to glucose.
*with increasing duration of fasting (more than 24 hrs.) glycogen
stores are depleted, so begins the conversion from non-carbohydrate
precursors, gluconeogenesis take place, predominantly in the liver.
*most of this glucose is derived from breakdown of amino acid,
particularly glutamine, alanine, as a result of catabolism of skeletal
muscles.

2
*this Proteins catabolism in simple starvation is readily reserve with
the provision exogenous glucose.
*with further fasting the glycogen in the muscles is depleted, the
next source is fat (Triglyceride) to meet energy requirements, this
breakdown of fat stores occur providing glycerol which can
converted into (fatty acid + glucose) in the liver which can be used as
tissue fuel by almost of the body tissue.
*hepatic production of ketones from fatty acids is facilitated by low
insulin levels and after two to three weeks of fasting condition the
CNS adapt to use ketones bodies as their primary fuel source.

3
 Effects of Malnutrition
Q / what are the effects of Malnutrition ?
1- Poor wound healing (dehiscence)
2- Delay callus formation (callus is very important in union of
fractures of bones).
3- Coagulation disorders; may affect on coagulation pathway.
4- Impaired drug metabolism in the liver.
5- Depress immunity.
6- Decrease tolerance to radiotherapy and chemotherapy.
7- Severe mental apathy.

Indication of nutrition
1- Pre-operative nutritional problems, (Like starvation poverty,
dysphagia).
2- Post-operative complications (ileus more than 4 days, sepsis)
(ileus mean paralysis of bowel i.e. there is no peristalsis action
of the bowel)

3- Intestinal fistula.
4- Massive bowel resection,(means section or cutting of the bowel,
small intestine or large intestine like in case of tumors, CA
colon or tumor in small bowel.
5- Management of malabsorption.
6- Anorexia nervosa, Psychological problems or eating disorders
manifested in patients refuse to eat adequate amount of food.

4
7- Intractable vomiting or continuous vomiting.
8- Maxillofacial trauma because the mouth is the 1st part of GIT
9- Multiple trauma.
10- Malignant disease: in malignant disease the tumor necrosis
factor that release from the tumor cells is responsible for
the nausea and loss of appetite.
11- Burn (as mentioned before).
12- Renal failure, liver failure or disease.

Assessment of the nutritional status of the patient

Q / How can you know that the patient is malnutrition or not ?
A) characteristic appearance or general inspection of the Patient,
lean and hungry apathic, super imposed hectic flush around
cheeks this means that the cheeks are depressed inside
and there is flushing around these depressions.

B) by physical examination:
1- the skin: in skin there is a rash , hyperkeratosis, nail deformity.
2- eyes: keratotoconjectivitis (means inflammation of the cornea and
conjunctiva of the eye and night blindness.

3- in the mouth:
*chelosis (that Problem occurs in the lip characterized by
scaling and fishing of the affected lip caused by fungal
infection)

5
 *glossitis (is the inflammation of the tongue), mucosal atrophy.
4- in hair: recent lossbecause there is deficiency by some minerals
and vitamins.
5- in CNS : Peripheral neuropathy, psychiatric problems.

C) Special test:-
1- Body weight, body mass index (bmi is the weight of patient
(in kg) / height², the normal value of bmi is between (18.5 to 24.9)
less than 18.5 means the patient is malnutritioned.
2- Upper arm cirenmference means the measurement of the
diameter of the upper arm, which should be<23cm in females
and 25 cm in male.
3- Triceps skin fold thickness: this should be 13 mm female, 10 mm in
male because the female have more fatty tissue than male.
4- Serum albumin level should not less than 35g/L
5- Lymphocyte count (have very important immune function and
the account of them should not less than 1500/mm³
6- Candida skin test: because the malntritional patient has immune
defects or disfunction this will lead to opportunistic infection which
will lead to Candida skin infection.
7- N₂ balance Studies.

6
 Nutritional requirement
Q/ what are the nutritional requirement for the metabolic support
of the body ?
A/
1- Calories (energy): provided by CHO & fat . healthy adult need at
rest 1500-2000 nonproteinous calories/day.

2- N₂: it is very important structural unit in the amino acid and

protien, in heathy individual N₂ should be in balanced condition (this
means the intake of N₂ in diet is equal to that exereted from the
body in urine, there are +ve N₂ balance mean intake of N₂ in diet is
greater than that excreted from the body while –ve N₂ means the
opposite)
*-ve N₂ balanced is special test that used for the assessment
of malnutrition.
* Requirements of +ve N₂ balance is 40gm of proteins and this
amount increased in hypercatabolic state

3- H₂O: the daily requirement of water is 2500-3000 ml/day

4-eleetrolytes: N⁺ 100 mmol/dl , K⁺ (60 mmol/dl), Ca⁺² (20mmol/dl),
Mg⁺ (30 mmol/dl), Cl⁻ (100mmol/dl).
5- Vitamins: they are very important in the metabolism process of
the body. there many vitamins:- water soluble vitamins are like C+B
,vit. C daily requirement should be 70 mg/day and vit B12 is
500mg/week IM
*IM= intra muscular
Fat Soluble vitamins like vit. A should be 6000 IU/week, K
8mg/week IM, E 10 mg/day, D 5 μg/day.

7
*deficiency of these vitamins will effect the metabolic process like
Vit A&C affect wound healing
Vit D cause rickets and osteomalacia (means the bone is soft caused
by deficiency of vit. D).
Vit. E ataxia nystagmus( rapid movement of pupil), edema, myopathy
Thiamine (B1) cause encephalopathy.
Vit. B6 cause neuropathy.

6- Minerals: iron 50 μmol/day, zinc 50 μmol/day,

Copper 15 μmol/day, iodine 5μmol/day.

Methods of nutrition:
A) Enteral: means that the foot should enter the GIT
1- mouth: if there is no contraindication for the mouth start with
liquid then semisolid then solid.
2- NG tube (nasogastric tube that extent from nose to stomach):
used for regular gastric aspiration & for feeding of liquid diet.
3- Tube enterostomy: used if NG tube is not possible (the NG tube
should not be use more than 4 weeks because it lead to infection )
& if more than 4 weeks enteral feeding is indicated. Types
-Gastrostomy: is that type that inserts into the stomach
-Jejunostomy: tube inserts into jejunum (first part of small intestine)

8
b) Parenteral nutrition: By IV feeding, it indicated when enteral
feeding is not possible or not enough.
Routes of administration:
1- Central venous line: usually hyperosmolar solution administered
directly in to central vein, so they are rapidly diluted by fast flow of
blood to avoid thrombosis & thrombophlebitis, example Hickman
catheter.
2- Peripheral venous line: Lower osmolality solutions may be
administered through peripheral veins, usually changed 3-4 days
due to infusion thrombophlebitis(infection of the vein).
-TPN:( total parenteral nutrition) means the nutrition by central
venous line.

Constituents of TPN:
1. CHO: Dextrose 20%, 50%, 70%.
2. Fat: Intralipid 10-20%.
3. Protein: Vamine, Freamine, Nephramine, Hepatomine .
4. Water 1500cc/day.
5. Electrolytes K⁺, Na⁺, Cl⁻, Ph⁻, Ca⁺²
6. Vitamins
7. Trace elements: Mg, Fe, Zn, .
8. Albumin: 60 gm/day.
9. Insulin: to keep blood glucose 150-200 mg/dl.
10. Heparin: 1000 U/L protect central line & for lipolysis

9
Complications of TPN:
1- Malposition of catheter tip.
2- Infection specially septicemia.
3- Essential fattyacid deficiency.
4- Hypophosphatemia
5- Jaundice.
6- Metabolic acidosis.
7- Metabolic & electrolytes disturbances.

10
 Lec.3 Post-Operative Care and Management

It is divided into 3 phases:

1- Immediate post-anesthetic phase:

Started from the time of finishing the operation to the time that
the patient become conscious and transferred from recovery
room to the surgical ward at the hospital.
This phase include monitoring of the patient like vital signs and
neurological, cardiovascular, respiratory functions of the patient.
This monitoring done by the surgeon and medical staff. This phase
continue for about 1-3 hours at the recovery room.

2- Intermediate phase:
Start from the time that the patient transferred to the surgical
ward and become conscious to the time that the patient
discharged from the hospital to home.
At this phase, there is also monitoring the functions of the
patient, blood gases, vital sign, fluid, urinary output, in addition to
wound care.

3- Convalescent phase (recovery phase):

Started from the time that the patient discharged from the
hospital to the time that there is a fully healing of the wounds
from the operation.

1
 Immediate post-anesthetic phase
1- Monitoring.
2- Respiratory care.
3- Cardiovascular system care.
4- Renal and bladder care.
5- Drainage tubes.
6- Medication.
7- Special laboratory tests.
These procedures done by the surgeon and medical staff.

1- monitoring: observation in recovery room until the patient is

conscious and his vital signs are stable and this done by the
surgeon and anesthetist, and then order written on the case sheet
and the nursing staff informed about all the function that should
be monitored.

The vital signs include (blood pressure, pulse rate, respiratory

rate, temperature, urinary output), this should be recorded every
15-30 min. then should also be checked every 1 hour on chart.
Continuous ECG sometimes are needed, especially if the patient
has any cardiac problems or cardiovascular instability.

2- Respiratory care: the most important point about this, is

maintain open airway, this done by the following technique:

2
 a) Put the patient at side position till gag reflex become +ve to the
patient in order to allow all the foreign body go out from the
mouth or nose of the patient and clear the air way.
b) Mechanical suction of the blood and mucus secretions, which
may be present in the patient’s mouth and nose.
c) Encourage breathing and cough done by the physiotherapist.
d) Sitting as soon as possible especially if the patient is conscious.
e) E) Turn the patient from side to side especially if the patient is
still at the ICU every 15-30 min. then hourly for first 8-12 hrs. to
prevent (atelectasis) and facilitate lung expansion.

(Atelectasis): means there is a partial or complete collapse of

the lung, this occur because of the smallest cells in the lungs
which are called the alveoli which are either deflated or filled
with fluid, which to lead to lung collapse and pulmonary
complications after surgery.

3- Cardiovascular system (CVS): it should be monitored and

checked in order to prevent the DVT which means deep vein
thrombosis, which means that there a blood clot formed at the
deep veins of the body, usually occur either due to the decrease
in the fluid of the circulation, this condition most commonly occur
at the lower leg. Also give the patient continuous intravenous
fluids to prevent circulatory collapse.

3
4- Renal and Bladder: monitoring of these is done by keep urinary
output(UOP) at least 30 ml/h , because any decrease in this
number means that the patient is not well hydrated, and there is
a hypovolemia and a decrease in the fluids of the body which
effects on kidney and lead to renal failure.

The renal failure can be managed by give the patient IVF(intra

venous fluid) and keep the patient well hydrated and give him
diuretics to stimulate the urination.

Urinary retention: means the patient can’t urinate which can be

treated by tape water see or maybe the use of foley catheter or
suprapubic cystostomy.

5- Drainage tubes:
Drain: is a method to prevent fluid accumulation or drainage of
pus or fluids or air from plural space. Drain should be placed
through a separate incision to prevent wound infections and must
fixed to skin to prevent slipping into abdominal cavity.

There are 2 types of surgical drains:

a) Passive: includes → 1- soft lax(corrugate), 2- penrose.

These are inexpensive, easy to use and allow for fluid
drainage and evaluation, but they are gravity
dependent and can’t be attached to the any
accumulating bag and also they are contraindicated for
us in the chest cavity.

4
 b) Active: includes → 1- closed drain, 2- sump drain.
These prevent the bacterial infection and can be used
for any cavity in the body (abdominal or chest) and
attached to accumulating bag so can be used to
evaluate fluid, but they usually have –ve pressure
which leads to formation of dead space.

6- Medications: should be given to the patient in order to prevent

any infection or to relief the pain, includes → antibiotic,
analgesics, sedation other drugs depending on the type of the
surgery.

7- Special laboratory tests: some patients need for special tests

post-operative according to the type of the surgery and
complications e.g.→ if the pa ent lost blood during surgery PCV,
Hb tests should be done.
Blood chemistry and blood gases also needed, also portable x-ray
in critical patient (like if the patient has any surgery in the lung or
has any pulmonary complications).

5
 Intermediate phase
a) Wound care
b) Drains
c) Respiratory care
d) Fluid and electrolytes
e) Gastrointestinal tract (GIT)
f) Post-operative pain

1- Wound care:
After finishing the operation and in the operating room, sterile
dressing applied to the wounds.
In the 4th post-operative day dressing removed and wound
inspected.
If the healing is normal, patient allowed to bath in 7th post-
operative day.
If wound is contaminated, it is best to leave the skin and
subcutaneous tissue open with creaming the wound daily then do
delayed primary or secondary suturing.
learn patient how to take care of the wound by cleaning it daily
with disinfectant like Detol.
Sutures removed 5-15 days according to site of the operation. Like
if the suture is in the face → the suture removed after 5 days.
Because the face is highly vascularized and so the wounds heal
faster.While in the abdomen → the suture removed after 10 days.

6
2- Drains:
If the patient has drain then the quality and quantity should be
noted, that means if the drain contain fluid in it, the amount and
type of this fluid should be noted (if it has serum or
serogeneous..)
The drain must be removed if there is little or no drainage from
the wound.

3- Respiratory care:
After the general anesthesia and surgery, the changes in the
pulmonary function observed, this due to decrease functional
residual capacity and decrease vital capacity with pulmonary
edema.

4- Fluid and electrolytes:

Any lose in fluid should be replaced for surgical patient. This
include for sensible and insensible loss in adult is about 1500-
2500 cc daily so this should be replaced by giving the patient 4-5
pints of glucose saline daily but without K⁺ at the 1st 24 hrs.
(because after trauma, K⁺ lose out from the cell to the serum, so if
we give K⁺ in the 1st 24 hrs. This lead to hyperkalemia).
Also loss from the drain (like NG tube if loss more than 500
ml/day so we should replace by G/S with K⁺.
Extra need from systemic factor fever, burn. Because both these
leading to the loss of fluid from the body.
Loss from 3rd space sequestration (which means that the fluid
moves out from the cell and accumulate in the interstitial site of

7
 the body usually lead to the formation of tissue edema or ileus).
So this should be replaced to prevent any complications.

5- Gastrointestinal tract:
Peristalsis: (or movement of large intestines) will return within 24
hrs. after surgery, so immediately after surgery put NG tube
(which is a tube that extend from the nose to the stomach) post
op. and connected to suction device with irrigation in order to
prevent the accumulation of any fluid or foreign body inside the
GIT.
Also the patient should be prevented from taking anything by
mouth until the bowel sound become +ve (that means that the
peristalsis return to normal).
Gastrostomy (tube extend from the stomach) and jejunostomy
(tube extend from the jejunum part of large intestine) sometimes
these tubes can be attached to succer, also to prevent
accumulation of fluid or foreign body.
If the bowel sound checked and appears –ve so this indicate there
is a paralytic ileus so this should be notes and checked to treat.

6- Post-operative pain:
This should be treated, it cause:
Increased stress and this lead to delay recovery.
Inability to cough and breath, deeply will lead to retention of
secretion in the lungs and lead to the atelectasis (the collapse of
the lungs partially or completely, this occur because the alveoli
which is the smallest cell in the lung will be deflated or filled with

8
fluid) which will lead to decrease oin pulmonary function and
pneumonia (bacterial infection affect the lung due to atelectasis
and lead to fetal results).
Also pain lead to immobility which lead to venous stasis, DVT
(Deep vein thrombosis) and pulmonary embolism which lead to
sudden death.

Methods of relieving pain

1-Intermittent injection of analgesic drugs:
a- morphine ( 3mg IV diluted in 3ml slowly).
b- pethidine (75 mg IV infusion).
c- pentazocine.
d- tramadol (100mg), or voltarin (75mg) IM.
2- Continuous IV infusion of analgesic drugs.
3- Inhalational analgesia,(given through respiration).
4- Peripheral nerve block.
5- Epidural (extradural) block.
6- Oral analgesia, such as NSAID (given through mouth
like aspirin), pethidine tab and codeine tab.

9
 Convalescent phase (recovery phase)
Instructions of this phase differ according to the type of the operation.

Instruct the patient not to lift heavy weight or to cough heavily or to be

constipated for at least 6 months post op. to prevent hernia.

When the patient has surgery at the abdomen so the muscle of the
abdomen become very weak.

Hernia → means losing of the abdominal muscle, this usually lead to

the internal organs especially the large intestine to go outside the
abdominal wall.

Also prevent heavy fatty meals & gastric irritants in duodenal ulcer &
acute cholycystitis (means acute inflammation of bile duct). Become
these heavy meals will effect on the bile ducts and increase the
inflammation.

Prevent chronic constipation & prolonged standing in varicose veins &

hemorrhoids.

10
 Lec.4 Fluid Therapy

Parenteral administration: is the administration of the fluid by any

route other than alimentary tract (fluid not given through the mouth).

Indication:
1- In patient unable to take fluid for any reason (such as trauma to
the head and neck like if there is a lesion or tumor, or if the
patient is unconscious, or maybe the fluid is not enough for the
patient.
2- In post-operative period (like we mentioned before, the patient
prevented to take anything by mouth, so in post-operative period
the parenteral administration is preferred).

Rule of Approximate Thirds:

2/3 of body weight is water (lean person)

Body water: 2/3 intracellular

1/3 extracellular

Extracellular water: 2/3 extravascular

1/3 intravascular

1
Example: 70 kg patient

Total body water = 2/3 * 70 = 42 L

Intracellular = 2/3 * 42 = 28 L

Extracellular = 1/3 * 42 = 14 L

Extravascular (Interstitial) = 2/3 * 14 = 11 L

Intravascular = 1/3 * 14 = 3 L

Input and output of fluid

Input: means fluid taken by the patient.

Output: means fluid go outside the body of the patient.

Output can be occurs by two ways:

1- Sensible → this can be occur either by urine, stool, vomiting or

sweat.
2- Insensible → occur by lung during the breathing or skin during
sweating.

Normal urine output for any adult person 1 ml/kg/hour,

this increase in infants to reach 1.5-2 ml/kg/hour.
normal daily requirements about 2 liters,
fluid should be isotonic (not hyper → which means increase in the
concentration of the Na⁺ , or not hypotonic → which means
decrease in the concentration of the Na⁺ .

2
First 24 hours after injury or trauma or surgery there is no need for
adding Na to the fluid… why?

Because after 1st 24 hrs. after injury or trauma, the body will start to
release the hormone called ADH (anti diuretic hormone), which is a
hormone made in the hypothalamus in the brain and then stored in the
posterior part of the pituitary gland, it is responsible for the regulation
and balancing of water concentration in the body, so after the trauma
when there is decrease in the level of fluid in the body, it is release and
reaching to the kidney it stimulates the secretion of Aldosterol
hormone, in which secretion of this hormone lead to reabsorption of
water and Na from the kidney to the body again, by this process there
is increase in the levels of Na in the body.

The best fluid that should be given to the patient at first 24hrs.
is (5% Dextrose solution).

Normal water exchange

Average daily loss /ml in sensible way:

Urine → 800-1500 ml/day
Intestinal (vomiting- stool) up to 10000 ml/day sweat.

While in insensible way:

Lungs/skin → 600-900 ml/day .

3
 Cause of fluid loss
Fluid can be loss either:

1- Gastrointestinal loss (vomiting-stool).

2- Fever (sweat).
3- Blood loss (hemorrhage).
4- Burns.
5- Peritonitis → means inflamma on of the peritoneum which is a
membrane present in the abdomen.
6- Fluid shifts → means that fluid go out from the cell to the
interstitial space like in the peripheral edema.
7- Diuretics → such as drugs given to treat hypertension.
8- Inhalation of dry gases.

Signs of hypovolemia
Hypovolemia: means decrease in the volume of the body due to loss of
fluid or blood, signs of hypovolemia include:

1- Tachycardia → means increase heart beat more than normal..

2- Orthostatic hypotension → means hypotension occurs when
there is change in the position from standing up to sitting down or
from sitting down to standing up.
3- Flat neck veins when supine → when patient lying on the bed,
the vein in the neck appear flat, because there is a decrease in the
blood volume in the body.
4- Decreased CVP (cardiovascular pressure).

4
 5- Decrease urine output → due to the decrease in the fluid
concentration in the body.
6- Dry membranes.
7- CV (cardiovascular) collapse → which result from the decrease in
the cardiovascular pressure.

Ringer’s Lactate
Is the fluid that contains lactate, water and also contain trace
amounts of many minerals like K,Ca,Na,Cl …etc.

It is the most commonly used solution in the operating room, so it

is most fluid used during surgeries.

It is slightly hypotonic, 100ml free water/ liter.

It is considered the most physiologic solution when large volumes

are needed. Like in hemorrhage.

Lactate metabolism in the liver and produce bicarbonate, this

considered as advantage… why?

Because the bicarbonate is alkaline substance, so it will keep the

alkalinity of the body and reduce the acidity of the body so it will
preserve the function of all systems in the body and prevent any
complication of the physiologic function of brain, lung… etc.

5
 Normal Saline
It is composed of water and salts (Na+Cl) and it is the fluid given
especially post-operative period for the patient, in 2nd day.

Giving large amounts of N.S. cause dilution hyperchloremic acidosis

( because it contain water and Na+Cl , and giving in large amounts will
lead to increase in the Cl in the body, and the Cl lead to increase the
acidity of the body and cause this condition ), and this considered as
disadvantage of N.S.

If there is a decrease in Cl concentration N.S. in the best choice for

giving.

It is a preferred solution for: Hypochloremic metabolic acidosis.

5% Dextrose in water (Glucose water)

Dextrose means sugar, and it is the best choice to given to the
patient especially at 1st 24 hrs. after surgery… why?

Because dextrose is metabolized leaving a large amount of free water

and this usually leads to replace the fluid that has been lost during
surgery.

Also it is needed in the patient on sodium restriction → that means

when the patient is hypertensive or maybe has hypernatremia(increase
in Na),

So 5% dextrose in water is the best choice.

6
This type of fluid is needed when insulin given (e.g. when the patient is
hyperglycemic and need for insulin, so insulin shouldn’t be given
directly intravenous because this lead to shock).

24 hour Formula
We should know the weight of the patient, and then divide it into 3
parts:

First part: 100 ml for 1st 10 kg ( 100 × 10 ) = 1000 ml

Second part: 50 ml for 2nd 10 kg ( 50 × 10 ) = 500 ml

Third part: 20 ml for remaining kg ( 20 × w ) = y

First part + second part + third part = Z

1000 + 500 + y = Z

(Z) is the volume of fluid that we should give to the patient during 24
hours.

1 ml of fluid = 15 drops
( ∗ )
Formula =
( ∗ )

7
 Example: 82 kg patient
100 ml for 1st 10 kg → 100 × 10 = 1000 ml

50 ml for 2nd 10 kg → 50 × 10 = 500 ml

20 ml for 3rd 62 kg → 20 × 62 = 1240 ml

1000 ml + 500 ml + 1240 ml = 2740 ml

×
= 28 drop per minute (one drop every 2 seconds).
×

Fluid needed post op.

1st day → 2 liter 5% dextrose

2nd day → 2 liter 5% dextrose + 1 liter N.S.

3rd day → 2 liter 5% dextrose + 1 liter N.S. + [20 meq K+ for each liter =(60meq)]

Post-operative fluid therapy

Immediate post op. period: immediately after surgery:

We should make the assessment of vital signs, then start to calculate the fluid
that we should give to the patient in order to maintain the balance of body fluid.

There is no need to give K during 1st 24 hrs. because post op. or post trauma, the
Potassium(K) go outside from the cell to the serum or to the extracellular space of
the body, so there is increase in the levels of the K in the blood.

8
 Late post-operative period
In this period we start to replace sensible and insensible loss
If the patient is vomiting or has diarrhea or has fever we should
calculate the amount of fluid that is lost and replace it per day.
In fever every 1 degree decrease, increased loss by 250 ml/day.

Complications:
1- Volume excess (over hydration):
This occur when high amount of the fluid given to the patient and
usually lead to fluid shifted and go outside from the intracellular
area to the extracellular area and clinically appear as edema.

2- Post op. hyponatremia:

Means decrease in the concentration of Na.

3- Post op. hypernatremia:

Increase in Na⁺ concentration (if Na is given to the patient in the
1st 24 hrs. in which he shouldn’t.

4- High output renal failure:

This occur because of the high fluid given to the patient, so the
output form the kidney or the urine output because high and
usually lead to renal failure.

9
 Lec.5 Blood Transfusion

Blood and fluid, both cause volume expansion , but the difference is
that fluid is crystalloid ( aqueous solution of minerals salt or other
water soluble molecules ), and blood is colloid (contain larger insoluble
molecules such as gelatin and colloid is more expensive than
crystalloid).

Blood transfusion: is the process of transferring blood or blood product

into one circulation intravenously. Transfusions are used for various
medical conditions to replace lost components of blood.

Types of blood
There are many types of blood:

1- Banked whole blood: the average life span of RBC inside the
circulation 120 days, whereas outside the circulation in plastic bags
of blood is 25% of RBC died after 24 hrs.
Another 25% die in 2 weeks old blood,
another 25% die in 4 weeks old blood.
So, older blood is: -more hemolysis
-poor platelets
-poor factor 8
-higher PH

1
2- Fresh whole blood: should be given from donor to recipient
within 6 hrs. , it is rich with factors 8 and 9 (the coagulation factors
that used in coagulation pathway).

3- Packed RBCs: useful in children and elderly patients.

4- Frozen RBCs: (frozen means the storage of RBCs in the

refrigerator), the benefits of this type are less risk of hepatitis and
less antigenicity.

5- Platelets: used for - Thrombocytopenia (deficiency or decrease of

platelets),
- DIC (Disseminated Intravascular Coagulation) in
this condition there is a consumption of
coagulation factors and platelets, so increase
possibility of bleeding tendency. The platelets
given here to control bleeding.
- Massive blood lose (in this condition there is
decrease of platelets count), so should give the
patient platelets to control bleeding.

6- Fresh Frozen plasma (FFP): stored at -40c° to -50c°, it is rich in

coagulation factors, and the volume of single unit of FFP is about
250ml.

7- Purified Protein Fraction (PPF): this protein is 1- good

expander 2-allergy free 3- safe to burn.
Composition of PPF (which is colloid type) → 88% albumin, 12%
globulin.

2
 8- Concentration human albumin: albumin is the main protein in
the human blood and the key to regulate the osmotic pressure of
blood; it is the factor of plasma that maintains and adds volume to
blood. It doesn’t leak into other tissue and keep the fluid inside the
circulation.
Albumin constitute 50% serum protein, it is a good expander, can
be stored for long time.

9- Cryoprecipitate (CPPt): (Frozen blood product) it is prepared by

warming of fresh frozen plasma. Its shape is white sediment, used
to prevent or control bleeding because CPPt is rich in coagulation
factors mostly: Fibrinogen, factor 1 and factor 8, also contain
smaller amount of factor 30 and von willebrand factor,
Volume of single unit of CPPt is about (10-15)ml.

10- Antihemophilic concentrate: factor 8

11- Dissociated human fibrinogen: stored in dry form & when

used mixed with distilled water used for DIC & afibrinogenemia
(deficiency of fibrinogen).

3
 Methods of blood transfusion
1- Intravenous (IV): divided into:
a) Auto transfusion: means that the blood is collected from the
same patient in which before 2 weeks of surgical intervention
the blood is collected and given to him at the time of surgical
intervention.
The benefit of this type is there are no risks of infection
because it is from the same patient, and no risks of allergic
reaction.
b) Isotransfusion: usually from donor to patient we give up 1 liter
in short time without warming, blood given in 3-4 hrs.
Warming is needed in massive blood transfusion, why?
Because if the blood given to patient (with more than 5% blood
lose) cold, it will cause hypothermia, so increase risk of
hemolysis and other complications.

2- Intraperitonial (inside the abdomen), Intramedullary:

Most common in infants (one day or 2 days old) in which there is
no obvious vein so intramedullary transfusion is used into the
medullary cavity of long bones such as the femur of the tibia.

Technique of blood transfusion

1- Blood aspirated from a healthy donor with normal Hb (normal Hb
level is about 11-13 g/dl in females and 13-16 g/dl in males).

4
 500cc taken in a plastic bag with liquid anticoagulant then tests
for HIV & hepatitis virus B&C done, then stored in blood bank for
4weeks at 4c°.

2- Blood grouping and Rh : human RBCs have many different antigens

on their cell surface, 2 groups of antigens are of major important in
surgical practice (ABO group + Rh factor),

Rh+ → 85% of population, Rh- → 15% of popula on,

Cross match is done by:
- long method (it takes 1-2 hrs. which is the best).
- short method (it takes 5-15 min. , used in emergency cases).

Blood group O- blindly could be used for very extreme emergency

cases or massive blood loss, because O- contain no antigen to
cause an allergic reaction,

whereas AB is the universal recipient because they contain no

circulating antibodies.

3- Blood substitutes: can be used until cross matching done (such as

colloid: Dextran, Hemacele, ..)

When giving blood -check name carefully.

-use sterile sets.
-don't warm the blood.

(because warming cause destruction of RBC and hemolysis) if warmed

give the blood in 1-2 hours.

5
 Indication of blood transfusion
Q / Which cases indicated for transfusion ?

A / 1- Replacement of blood loss due to:

o trauma
o hemorrhagic condition
o major surgery with excessive blood loss

2- Improvement of oxygen carrying capacity, such as in cases of

anemia, sickle cell anemia or thalacymea.
3- Replacement of clotting factors, in multifactorial cases give
fresh blood or fresh frozen plasma FFP.
4- Pre-operative correction.
5- Miscellaneous : anemia, debilitation, sepsis.

6
 Complication of blood transfusion
1- Hemolytic reaction: which divided into:
a) Major incompatibility → reaction due to giving mismatched
blood (different group)(ABO incomp.).
b) Minor incompatibility → reaction due to error in minor gp.( Rh.
incomp.)
There is intravascular destruction of RBCs (hemolysis) lead to
liberation of heam from Hb & this will be deposited in the renal
tubules lead to acute tubular necrosis & there will be a collapse
of circulation and lead to renal failure.
Clinical picture: fever, rigor, chills, loin pain, hematuria, later
anuria.
Treatment:
-stop the blood transfusion immediately.
-large dose of Mannitol to enhance diuresis & prevent renal
shut down.
- IV fluid.
-NaHCO3 to alkalinization of urine & dissolve heam from renal
tubules
-some times dialysis needed if above failed, to get rid of
excessive heam inside renal tubules.

2- Allergic reaction: less dangerous due to any Ag in plasma or WBCs

Clinical features include: fever, itching, urticarial rash.
Rx(treatment) include: IM antihistamine , IV hydrocortisone , SC
adrenaline.

7
3- Pyrexial reaction: due to pyrogens in the transfused blood causes
fever & rigor, blood is good culture media of bacteria & sepsis.

4- Bacterial sepsis: when blood kept outside refrigerator for long

time, (bad storage).

5- Infections: such as syphilis malaria, HIV, HBV(which can

transmitted from donor to recipient).

6- Thrombophlebitis: means inflammatory process or inflammation

of the vein, this occurs from the cannula.

7- Air embolism: rare because It needs 80ml to cause embolism.

8
 Lec.6 Medical Emergency in Dentistry

Include 3 conditions:

1- Unconsciousness
The following condition that may lead to loss of conscious in dental
practice include:

A) Syncope:
(fainting) most commonly observed potentially life threating
emergency, or it is the temporary loss of consciousness caused by a
fall in blood pressure followed by spontaneous recovery.

Vasovagal attack: occur when your body over react to certin trigger
such as site of blood or dental syringe (stimulation of vagus nerve)
which cause bradycardia and vasodilatation and therefore leading to
decrease the blood pressure so these is no enough oxygen to the
brain.

Conservative measures of syncope:

a) Trendelenberg position: levels of the legs or feet above the

level of the head.

b) Protect the airway: avoid obstruction of oropharynx.

c) Monitor vital signs: blood pressure, pulse rate, respiratory

rate.

d) Oxygen.

1
After these conservative measures, If not resolved, changing to
pharmacological measures:

If there is low blood pressure we should give him fluid to increase

the volume of blood (give him IV dextrose and Ringer lactate) +
Adrenaline which make tachycardia and vasoconstriction in order to
raise blood pressure (dose of adrenaline 0.5mg IM, IV, SC ).

If the adrenaline is given and the bradycardia remains,

anticholinergic drugs is given: 0.4mg of atropine till 1.2mg .

Syncope is divided into:

Psychogenic Nonpsychogenic
Fright Prolonged sitting or standing
Anxiety Hunger
Emotional stress Exhaustion
Pain Poor physical condition
Sight of Blood Hot humid crowded environment

2
B) Cardiac arrest:
Should ask the patient if he had cardiac problems while taking the
case-sheet history.

Management of cardiac arrest:

A) Airway: secure or protection of the airway.

B) Breathing: mouth to mouth, or by using ambu bag.

C) Circulation: start CPR (cardio pulmonary resuscitation) which

is the frequently chest compression.

30 times make pressure to the sternum with 2times of Breathing

D) Drugs: ( 1- Dextrose + Ringer lactate.

2- Adrenaline 1mg every 5minute.

3- Sodium Bicarbonate 1mEq/Kg (cardiac arrest

cause metabolic acidosis (acid blood) so Na(CO₃)₂
weak base is given to remove the acidity.

4- Atropine 0.5mg every 5minute (anti-cholinergic

drug which block the parasympathetic system).

5- Oxygen 10L/min (mandatory in cardiac arrest).

When there is a loss of consciousness caused by syncope or cardiac

arrest, so paralysis of muscles especially the tongue will happened.
backward displacement of the tongue and obstruction of the
oropharynx and airway.

3
To open the airway you must (Head-Tilt/Chin-Lift) , this cause
anterior displacement of the tongue and open the airway.

C) Diabetic coma:
One of the medical history that should ask the patient about it, is the
diabetes mellitus (type1 which is insulin-dependent diabetes mellitus
or type2 which is non-insulin dependent diabetes mellitus).

Diabetic coma is life threating emergency condition.

Difference between coma and syncope:

Coma: is prolonged state of deep unconsciousness in which a patient

can’t be awaken, failed to response to stimuli such as pain, light and
sound,(without spontaneous recovery).

Syncope: it is the temporary loss of consciousness caused by a fall in

blood pressure followed by spontaneous recovery.

4
Normoglycemia is Normal level of blood sugar between 80-120
mg/dl.

Hypoglycemia between 40-80 mg/dl

Insulin shock (hypoglycemic shock) below 40 mg/dl

Hyperglycemia between 120-400 mg/dl

Between 400-800 mg/dl → Diabetes keto acidosis (DKA), or

Hyperosmolar hyperglysemic nonketotic coma (HHNC).

5
Q / Why insulin shock (hypoglycemic shock) lead to loss of
consciousness?

A/

Because glucose is the primary source of energy to the brain

cells (the main fuel), when these levels decrease below the normal
level lead to insulin shock and the end result is loss of consciousness,
this occur in hypoglycemia, while in hyperglycemia the high levels of
glucose in the blood, the body will try to eliminate the excess glucose
in urine so leads to loss of fluid from the body and cause dehydration
so the blood volume decrease and the oxygen supply to the brain
decreases as well.

Diabetes keto acidosis DKA (ketone bodies):

DKA is common in type 1 diabetes mellitus.

Without enough insulin, the body can’t use glucose for energy and
start using fat for fuel, so ketone is formed and released in the blood
causes DKA and increase the acidity in the blood stream.

So the high blood sugar and dehydration and acidity, all these
together lead to loss of consciousness.

Hyperosmolar hyperglycemic nonketotic coma (HHNC):

There is no ketone body. Most commonly occur in type 2 diabetes
mellitus, in which high blood sugar and dehydration alone (without
acidity) are sufficient to cause unconsciousness.

6
Q / how can distinguish between hypoglycemic shock (diabetic
coma) and hyperglycemic shock in dental clinic?

A/

By giving the patient sweats containing sugar,

if there is a response → means hypoglycemic shock,
if there is no response → means hyperglycemic shock or coma.

D) Adrenal insufficiency:
It’s rare and potentially fetal condition, when the adrenal gland stop
working probably and there isn’t enough cortisone in the body.

Adrenal insufficiency is of two types: Primary Adrenal insufficiency ,

Secondary Adrenal insufficiency.

Benefit or function of cortisone:

Is a hormone that help with variety of body function include:

Maintaining blood sugar, managing the immune system regulating

blood pressure, controlling some of the electrolytes in the body and
stress levels.

Q / Why loss of consciousness occur in adrenal insufficiency ?

A/

Because hypotension and severe vomiting and diarrhea resulting

in dehydration and hyponatremia (low sodium level).

7
Cortisone balances of electrolytes in the body, retention of the
sodium, excretion of calcium and potassium.

When the level of cortisol is decreased in the blood, it will cause

excretion of sodium, so loss of water with sodium elimination, and
cause hypovolemia dehydration, hypotension and loss of
consciousness.

Adrenal crisis: is acute form of adrenal insufficiency.

Q / How can I manage the patient with adrenal insufficiency?

A/

o Hydrocortisone 100mg or Dexamethasone 4mg

(steroids),
o Adrenalin 0.5mg (vasoconstriction and elevation in the
blood pressure),
o Oxygen 10 L/min.

E) Convulsion:
Defined as sudden violent irregular movement of the body caused by
involuntary contraction of muscles and associated especially with
brain disorders, such as epilepsy, the presence of certain toxins or
other agents in the blood.

Condition that may lead to convulsion:

1- hypoglycemia: which cause decrease in the glucose which supply

the brain.

8
2- Cerebrovascular accident (CVA): occur due thrombus or emboli
that closed major artery in the cerebral circulation, also called stroke.

3- Epilepsy: which cause disturbance in the electricity of the brain.

Treatment by valium 5-20 mg IV .
4- Syncope.

5- Drugs.

F) Local Anesthesia and Drug toxicity:

One of the side effects of local anesthesia is the allergic reaction..

9
 2- Respiratory difficulties

a) Respiratory failure (Heart failure)

b) Asthma
c) Foreign body
d) Allergy
e) Hyperventilation

a) Respiratory failure:
1- Chocking ( occur because the tongue will be in its posterior
position and this will obstruct the air way and lead to
respiratory difficulties),
The management is (Head-Tilt/Chin-Lift).

2- Drug overdose (narcotics & sedatives) such as morphine and

pethidine, overdose of these drugs will suppress the central
nervous system, and this will lead to suppression of respiratory
system and finally respiratory failure.

10
b) Asthima: management of asthmatic attack in dental clinic
include:

 Adrenalin 0.5mg (act as bronchodilator)

 Hydrocortisone 100mg
 Aminophylline 250-500mg (act as bronchodilator)
 Ventoline inhaler
 Oxygen

c) Foreign body:
aspiration or swallowing after tooth or root extraction, and during
endodontic or restorative treatment, the endodontic files or dental
burs may be swallowed accidentally.

Management → try to retrieve such foreign bodies from the patient

mouth, if this failed you should call the ambulance as soon as
possible.

d) Allergy: either from drug or from L A .

clinical manifestation of allergic attack of L A include: skin rash,
respiratory difficulties, dizziness.

Management:

 Maintain airway, breathing

 Adrenalin 0.5mg every 5-10 min. (as bronchodilator)
 Hydrocortisone 100mg. (as bronchodilator)
 Theophylline 250-500mg
 Oxygen

11
 Theophylline is more potent and longer acting than
aminophylline used in asthmatic management.

3- Chest pain
Divided into:

a) Myocardial infarction:
also known as heart attack occur when the blood flow decreases or
stop causing damage to the heart muscle, the most common
symptom is the chest pain or discomfort which may troubles the
shoulder, arm, back, neck and jaw. Often it occurs in the center or
left side of the chest and last for more than few minuets.

If prolong ischemia to heart muscle cause permanent damage or

necrosis of this muscle. Management include:

1- Recognition

 Airway
 Breathing
 Circulation

2- Oxygen - 4-5 L by NC or face mask

3- Monitor VS

4- Position to comfort

5- Pain relief , Morphine sulfate 2-5 mg IM/IV every 5-15 minutes

Controls pain and reduces anxiety.

6- Prepare to perform CPR.

12
b) Angina pectoris:
the clinical features of AP is chest pain due to inadequate supply of
oxygen to the heart muscle,

the difference between MI and AP is that in MI there is a prolong

ischemia and permanent damage to the heart muscle, while in AP
the ischemia is transient without damage to the heart muscle.

The pain in AP is severe and crushing and characterized by feeling of

pressure and suffocation just behind the breast bone.

Treatment:

 Stop procedure
 Position patient to comfort
 Oxygen 2-3 L per NC or face mask
 Nitroglycerin 0.4 mg SL (sublingual tablet)(cause relaxation of
vascular smooth muscles and this lead to increase blood supply
to the heart muscle:
 Repeat every 5 minutes x 3 total doses
 If no response, assume MI or unstable angina
 transfer to ER

To distinguish between angina pectoris patient and myocardial

infarction is by giving the patient Nitroglycerin 0.5 mg SL tablet, and
if

there is a response → means angina pectoris

There is no response → means MI or unstable angina and should
prepare to CPR and then transfer to ER.

13
 Lec.7 Wounds, surgical; traumatic

Surgical incisions
Incision: A cut produced surgically by a sharp instrument that creates
an opening into an organ or space in the body.

These are a multiple rules to create incisions in a correct position:

 Accessibility: that means the incision should provide the

availability to access an organ or space that need to be operated.

 Extensibility: that means the incision have the ability to increase

its extension when it is necessary.

 Security: the incision should be placed on a patient’s body on

side that will be providing security when it is sutured post-
operatively. That means the incision should be placed on the body
in an area that after the end of surgery and when make the
sutures, so the wounds should be secure enough and not to be
opened post-operatively for any reason.

 Esthetic: When these is a previous scar on the side that is need

to be operated, at first we should remove this scar and then place
the incision on that side.

1
  Rapidity: the incision should be placed rapidly to save the time
but without harrying up or unsuitable placement of the incision.

 Parallel to skin incision: the incision should be placed on the

side of the body and should place parallel to skin creases, this
have an advantage include:

1) allow normal and fast healing.

2) decrease the scars that formed after the healing.

 Built of the patient: incision should be suitable with the built of

the patient, for example if the patient is tall and thin so the
abdomen usually take the shape of rectangle, so the vertical
incision in this type is better than horizontal, while if the patient is
short and fat, the abdomen will be round in shape, and in this
type of abdomen the horizontal incision is better and provide
accessibility better than the vertical ones.

There are some principles that should be done by the surgeon

in order to produce suitable and correct incision, these
principles include:

1) A sharp knife should always be used, not use dull knife because a
dull knife lead to the formation of unorganized incision and
affects on the healing and lead to the more scar formation.

2
2) One stroke throughout the required distance: that mean the
surgeon should make the incision in one single cut or one single
move, not in the interrupted multiple moves because these
multiple moves lead to the unorganized incision and lead to ugly
scar formation.

3) The blade should be held perpendicular to the skin surface.

4) A fresh new knife used to incise deeper layer that means one knife
used for the outer layers and other knife which is new and fresh
should be used for a deeper layer, for example on knife should be
used for the extra oral skin face while a different and new knife
used in oral mucosa, this usually in order to avoid contamination
and infection formed post-operatively.

5) Adequate length should always be used, because short incision

not allow the correct access to the organ that need to be
operated, while too long incision usually affect on the healing and
increase the time that need for healing (slow healing) and more
scar formation.

3
 Types of surgical incision
According to the site that they will be placed on it, It divided into many
types:

1- Abdominal incisions:
A) vertical → midline incision, like the incision placed in the
epigastric area.
Paramedian incision, that mean on each side of the
midline.
Pararectus incision, that mean each side of the
rectus muscle (it is a muscle present on the
abdominal wall and it is vertical muscle so the
incision placed parallel to it in order to allow for
easy access to the organ present in the abdomen.

B) transverse → or horizontal incision like:

pfannenstiel incision (incision used for caesarean).

C) oblique → gridiron incision (has other name: McBurney)

Subcostal incision, is used for the access to chest
wall while the gridiron is used for appendectomy.

We should know that each of which of this incision is 2 incisions that

mean paramedian at each side 2, pararectus 2, except the midline it is
one incision and pfannenstiel 1 and gridiron 1.

4
*Gridiron: other name is McBurney it is used for appendectomy (means
the removal of appendix which present on the right side of the body
and it is one 1 in number so gridiron is one incision present on the right
side exclusively of the body.

2) Abdominal thoracic:
Which allow access for organs present in the thoracic (chest) and the
abdomen.

3) Head and neck and face:

A) Bicoronal → it is incision extend from the top one ear to the

top of other ear through the head, and this usually
allow the access to the bones of the face like
frontal, supraorbital, ethmoidal and lacrimal bone.

B) Submandibular → is the incision placed in the submandibular

triangle on the neck and usually allow the
access to the submandibular area and
submandibular salivary gland with
submandibular lymph node.

5
C) Weber Fergusson → is the incision placed on the maxilla and
the upper side of the face in order to
allow for access to the maxilla and make
maxillactomy. This incision extend from or
around the lower side of the eye and then
to the side of the nose and extend to the
upper lip.

D) tracheostomy → it is incision placed in the neck in the

tracked area in order to make tracheostomy
and allow for normal breathing of the
patient especially the traumatized patient.

E) Radical neck MacAfee → the incision placed on the neck, it is

2 parallel horizontal incisions with
4cm space between them and used
for radical neck dissection,
when there is a tumor in the head
or mouth and neck.

F) thyroidectomy → is an incision placed in the thyroid in the

neck in order to remove the thyroid gland.

6
4) Breast:
A) Mastectomy → is an incision around the breast used either
to remove the whole breast or remove only
part of breast when there is a tumor in the
breast.

B) Circumareolar → incision around the areolar.

5) Chest wall and back incision:

Like the incision present in the lumber area for kidney removal.

7
 Surgical & Traumatic Wounds

Wounds: is a break or loss of continuity of skin or mucus membrane or

both of them.

Causes: * latrogenic → like surgical incision.

* traumatic → RTA (road trophic accidents), assault, war injury.

Types of wounds:
1- Incised wound: usually due to sharp instrument relatively considered
as a clean wound ( clean wound means less
opportunity of developing infection.

2- Lacerated wound: due to RTA, machinery accidents.

3- Crushed wound: due to the war injury.

4- Puncture wound: divided into penetrating or perforated wounds,

The difference between them is the following:

The perforating wound or injury is an injury in which an object

enters the body and pass all the way through the body and usually

8
 has entrance and a larger exit, while the penetrating injury is an
injury in which the object enters the body but doesn’t pass out
through the body, and has only one open (entrance) and hasn’t
exit open.

5- Avulsed wound: is usually occur or shown in the shell injury.

Classification of surgical wounds

according to degree of contamination

Class ɪ : clean wound, like surgical incisions that are made electively
during surgical procedures in an aseptic environment. (that means the
wounds or the surgical incisions and the environmental are both sterile)

Class ɪɪ : clean contamination wound, the kind of aseptic elective

surgical incision that is made in a contaminated environment, that’s
mean the incision or the wound is clean and sterile, but the
environment is contaminated, like oral cavity, as it normally contains
huge number oral flora carried in saliva, so oral cavity considered as a
contaminated environment and any operation that’s made in the oral
cavity considered as class ɪɪ clean-contaminated wound.

9
Class ɪɪɪ : contaminated wounds and those usually are not elective
but traumatic in origin like fresh skin lacerations, opened fractures and
penetrating wounds, so all the penetrating wound considered as class 3

Class ɪv : it is a dirty contaminated wound, usually contains

devitalized tissue or preexisting infection prior to operation.

Treatment of wounds
The wounds can be treated by:

1- Primary suturing: means suture of the wound and it is done for clean
wound or inside wounds.

2- delayed primary suturing: done if the wound is lacerated or heavy

infected, so if the wound is heavy infected and there is a pus formation
so we shouldn’t make the suturing immediately but we wait until all the
infection gone and then make the primary suture.

3- Secondary suturing: this is done if we had done primary suturing and

infection developed pus under skin so we need to open this suture and
frequent dressing then resuturing again.

10
4- Skin graft: this is needed for a big wound and impossible to
reapproximate the wound edges so it is important to cover the
denuded area to prevent bacterial infection and fluid loss. This most
commonly occur in the burns or there is a traumatic wound with the
loss of the some of the soft tissues so the skin graft is needed.

Surgical healing
Pathology of wound healing: including four 4 stages in wound healing:

1- Small blood or fibrin clot:

After any injury, bleeding will occur, and to stop bleeding, platelets
aggregate, and then adhesion of the platelets occur. The platelets stick
on the damaged endothelial lining vessels and form fibrin clot and stop
bleeding. When bleeding stops, the next phase will start..

2- Inflammatory phase:

it take 0-3 days, start immediately after the wound till the 3rd day.
The inflammatory phase characterized by:

Platelet produce 2 substances,

(*inflammatory phase means producing of inflammatory cells).
After the adhesion of the platelets and their formation of a clot to
stop the bleeding, it will start to produce:

1- Cytokines ( include platelet dried growth factor, platelet factor ɪv,

and transforming growth factor β ).

11
 2- Amines ( include histamine, serotonin, prostaglandin).

*the function of these two substances is to increase the cells

permeability in order to allow the inflammatory cells to come to the
wound area.

Inflammatory cells are macrophage and lymphocyte (poli morpho

nuclear lymphocyte).

Macrophage function is to remove devitalized tissue and

microorganisms, and regulate fibroblast activity in the proliferative
phase of healing.

3- proliferative phase:

It takes 3days-3weeks and characterized by:

a) fibroblast activity: fibroblast produce collagen and ground

substance, fibroblast in order to produce collagen they need
vitamin C , so any deficiency in this vitamin will affect healing of
wounds.

b) growth of the new blood vessels at capillary lobes, this process is

called angiogenesis.

c) re epithelialization of the wound surface: in which the epithelium

start to form which start from the edges of the wound to the
center until the wound is closed completely.

12
Proliferative phase divided into:

 Early part: which characterized by formation of the granulation

tissue, (so the wound become weak easily traumatized, red in
color) because the granulation tissue is a weak tissue contain
collagen and new blood vessels( its collagen is immature and
randomly organized).
Immature collagen is type 3 collagen.
 Later part: the wound start to be stronger because of the increase
in the tensile strength of the wound. (increase of the collagen and
it start to become organized but it still immature).

4- Remodeling phase:

The immature collagen turns into mature in this phase, remodeling

phase takes 3 months or more. It is characterized by maturation of
collagen (means transforming of collagen from type 3 to type 1).

Types of wound healing: the wounds can be heal either by:

a) Primary intension: it is occur when the wound is clean and small and
the wound’s edges can be brought together easily and in anatomical
layers and approximated by sutures, staples, clips, adhesive glue,
steristrips. This type of healing usually is occur with normal healing
without fibrous tissue formation and less scar formation, so it’s better
than secondary intension..

b) Secondary intension: seen when the wound layers can’t be

approximated due to a big wound or skin loss or presence of ulcer so it

13
will be heal by contraction epithelization granulation tissue formation
with the fibrosis and slow healing occur with the formation of large and
ugly scar.

Factors affecting the wound healing

1- General factors:
a) hypovitaminosis A and D, because both of them usually affect
on the connective tissue formation .

b) malnutrition, uremia, jaundice, diabetes mellitus, because

these diseases affect on the balance of the body and then affect
on the formation of connective tissue and wound healing.

c) hematological diseases leukemia, lymphoma.

d) malignant diseases like catchexia, chemotherapy.

e) chronic generalized diseases TB, ulcerative colitis. Because

these diseases usually decrease the immunity and increase the
infection opportunity and this usually affect on the normal wound
healing.

14
2- Local factors:
Which are the factors associated with the wound itself, include:

a) Poor blood supply: as decrease in the blood supply lead to

increase the time for healing because it affect on the platelets
aggregation and then affect on the phases of the wound healing
and increase the time for healing.

b) Hematoma formation: as hematoma lead to decrease in the

blood supply to the wound so increase the time for healing.

c) Infection.

d) Tension in the wound.

e) Bad surgical technique.

f) Foreign body: as foreign body lead to infection and the infection

affect on the wound healing.

Scar : is a remnant of wound healing.

Stages of scar:
Stage 1 ( 1-4 weeks): in which the scar is fine, soft, weak and
easily traumatized ( because of the granulation tissue because
this tissue consist of immature collagen type 3 in which it is not
organized).

15
Stage 2 (4-12 weeks): in which the scar is red, thick, strong,
contracted, raised above the level of the skin and itching
(because of the high blood vessel formation so it appears red,
also it's itching because the new blood vessel formation means
the presence of amines (histamine & prostaglandin).

Stage 3 (12-40 weeks): the scar in this phase will tend to relax
and transformed into the natural skin so it become white soft
(because the collagen will transformed from immature type 3
to mature type 1 and begins to become more organize.
After 1-2 years very fine not obvious scar.

Factors affecting scar:

1- Age: best in extreme age, worse in children.

2- Race: better in white, worse in dark skinned,(because the dark

skinned usually have more ability to form the keloid or
hypertrophic scars which they are bad scars.

3- Position: in the body: good in face (because it is rich in blood supply

so the wound healing is better and faster, so the scar
formation is less). Bad in sternum because of the decrease
in the blood supply in this area).

16
4- Direction of the wound: the incision should be placed parallel to the
skin creases because it leads to decrease in
the scar formation, while if it's not parallel,
it lead to formation of an ugly scar.

Complications of scar:
1- excessive contracture deformity: if the scar occur on the joint, so it
can affect on the mobility of the limb and lead to the contracture
deformity.

2- may adhere to the nerve: and lead to the neuroma which is painful
and lead to limitation of the mobility.

3- keloid.

4- hypertrophic scar.

5- unstable scar.

6- malignant changes epithelioma scar.

The two most common complications of the scars are:

Hypertrophic scar: there is excessive fibrous tissue formation in

young people especially after burn, if stage 2 of the scar formation
persists more than 6 months, Hypertrophic scar will happen. Avoided
by pressure bandage which flattens the scar.

17
Keloid scar: it is a persistent of Hypertrophic scar more than one year
extending to the neighboring skin, it is most commonly occur in the
sternum and shoulder, while the hypertrophic scar most commonly
occur on the face. The best treatments are radiation, steroid injection,
shaving with skin graft.

*The hypertrophic scar not extending to the neighboring skin.

*The keloid scar most commonly occurs in the dark skinned patient.

18
 Lec.8 Surgical infections ɪ

Types of wounds
1- Incised wound: they considered as clean wounds and form about (2-
3%) of all wounds.

2- Clean contaminated wounds: which is form about (20-25%) of all

wounds, this include the lacerated wounds (occur by machinery
instrument).

3- Infected wounds: form about 30% of all wounds, like bullet wounds,
in which it has inlet and outlet (entrance and exit), the outlet is larger
than inlet and this considered as perforated wound while the
penetrated wound has only inlet without outlet.

Perforated → inlet + outlet

Penetrated → inlet only

*inlet is small while the outlet is large and more disruptive.

1
 Surgical infections

These are any type of infection that occurs after the surgery or post-
operatively and usually these types of infections are very hard to treat
conservatively, that means it is respond to only use of disinfection and
dressing, but usually needs for more aggressive treatment because
these infection are aggressive and maybe associated with the pus and
abscess formation, so aggressive treatment like excised or drained. e.g
abscess, empyema, gas gangrene.

There are many factors increase the percent of surgical infection

formation and they are either:

 General factors: these factors associated with the general health

of the patient (general status), like: chronic disease, anemia,
uncontrolled DM, patient on steroid therapy, Agranulocytosis,
hypogammaglobulinemia

 Local factors: associated with the site of the operation itself, like
hematoma formation, crush injury, bone injury, foreign body, all
these factors increase the risk of formation of infection post-
operatively.

2
 Hospital infection (Nosocomial)
These infections called hospital infections because they occur or come
from the hospital and usually the wound is clean post-operatively but
after few days the infection start to occur in this wounds, because the
microorganism (M.O.) transmit from the hospital, so these infections
result from transmission of pathologic microorganism to previously
uninfected wound, and this type of microorganisms are very aggressive
and resistance to any antibiotic, because the patient previously
received prolonged antibiotic treatment, so when the patient is in the
hospital post-operatively, usually receive antibiotic and with the
prolonged use, the infection if it is developed, the microorganism
become very aggressive and resistance to the most of the antibiotics.

The microorganism can be found in the ward, operation theatre,

surgeon assistant, or medical staff like nurses or from other patients in
the same hospital or same ward or room, or maybe auto-infection from
the patient himself in which the wound is contaminated by his cough
droplet.

The most common microorganisms associated with hospital infections

are:

1- Staphylococcus: which is G+ cocci facultative anaerobic found in

nose & throat, hospital tools, clothes. It produces coagulase,
staphylokinase, hyalourinidase, enterotoxin. It causes many lesions
such as boil, carbuncle, abscess and wound infection.

3
Boil → is a painful and pus-filled mass that is formed
under the skin and usually appear as inflamed and
painful mass maybe associated with hair follicle, when
this boil aggregated and there is more than one boil
so it called carbuncle.

Carbuncle → is a cluster of boil, also appear as a boil

filled with pus and painful and associated with the skin
and maybe with the hair follicle.

Abscess → is also a collection of pus.

2- Streptococcus: it is G+ cocci, can be aerobic & facultative

anaerobic, there are 3 types of it:

 α- hemolytic : such as Streptococcus viridance,

 β- hemolytic : such as Streptococcus pyogens,
 γ-hemolytic : such as Streptococcus fecalis)

It produces streptokinase, hyalourinidase, streptolysin, exotoxin.

(the difference between the products of staph. & strep.).

Also found in mouth, pharynx, throat and can cause many lesions :

1- Erysipelas: which is infection present on the superficial layer

of the skin (the upper derm) so it is a streptococcus infection
in which it can also affect the superficial lymphatic vessel, and
appear as a painful, red inflammation on the skin).

4
2- Scarlet fever: which is infection caused by
streptococcus bacteria and usually occur when the
patient have the bacterial infection on the throat and
not treated so it can develop to scarlet fever which
characterized by the high fever and rash over all the
body.

3- Rheumatic fever: when the scarlet fever or sore throat not treated
well, it will develop to rheumatic fever which a disease that affect the
heart, joints and brain in addition to the skin and it’s usually appear as a
rash on the skin.

4- Tonsillitis.

5- Impetigo: is a bacterial infection caused by

streptococcus bacteria that involve also the superficial skin
it’s similar to Erysipelas but differ from Erysipelas in that it
appears as a yellowish crust on the skin, especially around
the nose and the mouth of the children and appear as a yellowish
crusted lesion.

6- Glomerulonephritis: is the inflammation of the glomerulus in the

kidney.

7- Necrotizing Fasciitis: this is a very important and dangerous and

serious condition that occur in the patient as a hospital infection, this
disease also called (flesh eating disease) because it result in the
destruction, devitalization and death of parts of the body’s soft tissues,
it is a severe disease characterized by sudden onset and then spread
rapidly, it is start with the vesicles on the skin, appear red in color then

5
become yellowish and then become purple in color after that the skin
start to develop the black color due to the bacteria starting to eat the
subcutaneous tissue and also lead to the destruction in the muscle and
even can reach to the bone, so the treatment should be start very fast,
otherwise it can lead to the death, the medical image is very important
in diagnosis this disease, and usually there are many of the risk factors
to this disease include the decrease in the immune system and also
some disease such as diabetes, cancer, obesity and alcohol or drug
abuse, it is usually treated by the surgery, by removal of all devitalized
tissue until the blood is appear and then by dressing and disinfection
daily with the severe doses of intravenous antibiotics.

3- (G -ve bacilli): rod facultative anaerobic produce endotoxin found

in the large bowel (large intestine). Like E.coli, proteus, pseudomonas,
klebsiella, bacteriods.

4- Clostridia: large G +ve rods, drum stick appearance spore forming,

obligatory anaerobic normal inhabitant in the intestine and the soil.
Like it types: Cl. Tetani, Cl. Welchii, Cl. Sporogenes.

6
 Tetanus
It’s occur as a bacterial infection caused by Cl. Tetani, as it founds in the
soil so if there is a soil or maybe there is a dirt in the wound, bullet,
shell piece, clothes piece, can develop the tetanus. It has powerful
exotoxin cause tissue and CNS damage. At first when Cl. Tetani enter
the body from the dirty wound, it start to act on the neuromascular
junction so cause destruction to this junction, this usually lead to the
damage of this junction and lead to complete contraction of the whole
muscles of the body. usually started with the face, so the contraction or
spasm of the muscle in the face lead to feature called resus sardonicus.

(it means that the patient look like smiling, because of the contraction
of the muscles of the face also there is a trismus, stiff jaw, lockjaw that
means the patient can’t open his mouth also because of the contraction
of the face muscles).

Also there is inability to swallow the teeth, which is called dysphagia

(inability to swallow the food because of the contraction of the muscles
of the pharynx and esophagus). Also the most important feature is the
difficulty in breathing because of contraction of the intercostal muscle
which aids in the breathing process and if not treated it heads to
death.

Sings of Tetanus : increase in temperature, stiff jaw, dysphagia, tonic

muscle spasm in the face resus sardonicus, difficult breathing, reflex
contraction, death from asphyxia.

7
 Treatment of Tetanus
either by:

1- Prophylactic management:
means prevent of the tetanus development, either by:

a) active immunization: that mean take the vaccine, which is the

absorbed toxoid which is safe and taken by I.M. injection in the
deltoid muscle.

b) Passive immunization: it is used when the patient come with

the dirty wound or crush injury and has not taken active
immunization previously, so in this case we should give the
patient about 1500 IU of ATS inj.(1500 international unit of
anti-tetanus injection) also in the deltoid muscle I.M. or given
anti-tetanus globulin about 250 IU I.M.

2- Symptomatic treatment of spasm:

If the patient come with crushed or dirty wound and without
immunization and developed tetanus, we should treat the symptoms
(as we said previously the most important feature is difficulty in
breathing because of the muscle contraction), so we should start with
artificial respiration or called the ventilation in order to give the oxygen
required that is necessary to live, after that we should treat the
contraction which is treated by anticonvulsant muscle relaxed drug and
lastly give antibiotic (the best antibiotic to treat bacterial tetanus is
penicillin, and the better one is the Metronidazole).

8
 Gas gangrene
Caused by Cl. welchii or sometimes Cl. Septicum, it also come from the
wound that is infected and dirty and the most commonly occur in the
thigh and buttock, and also the lower part of the abdomen because
these areas are more contaminated with the fecal, especially in the
patient that have inability to move and go to the bathroom.

It can also be occur due to the trauma or war injury or maybe there are
some diseases like diabetes mellitus(DM) and atherosclerosis or other
causes..

This infection start as a simple skin infection and in which the skin
appears as red in color and there is a seropurulent discharge but no gas
or toxin present.

At this stage, this disease can be treated by giving antibiotic..

If the disease in not treated or insufficiently treated or if the ineffective

antibiotic given so the bacteria start to form the cellulitis and then go
from the skin to the subcutaneous tissue and start to digest the tissue
and produce the gas and toxins, so at this stage by the examination we
can feel the gas crepitation under the fingers.

After that, this infection develop to involve the more deeper tissues
like the muscles, so the bacterial start to eat and digest the muscles and
lead to muscle necrosis which is called the Cl. myonecrosis or myositis
and the considered as a very aggressive and serious stage and actual
gas gangrene is developed.

9
Clinical picture:
It started with edema, swelling, inflamed red in color, painful skin at
this stage which considered early stage should treated with antibiotics
in order to prevent the progression of the case.

If it’s untreated, it will develop to the next stage in which there is a gas
formation which have a sweet smell gas, also there is a pus formation
which has brownish color like a chocolate, so it called chocolate color
pus. Also there is a toxemia (toxicity), increase in temperature and
tachycardia.

Management:
1- prevention: of the progression of the disease and start when there is
early stage of the disease we should excise all the dead tissue until
fresh blood appear, and then give the prophylactic AB with antigas
gangrene serum about 22500 IU.

While if the early stage is not treated so it will develop to the more
serious stage and the gas gangrene can be develop so in this stage we
need for very fast treatment.

2- Treatment:

a) first we need very fast treatment that starts with the blood
transfusion with adequate excision of dead tissue and muscle
(blood transfusion needed because when we remove the whole
dead tissue, much bleeding occur), and also sometimes leg

10
 amputation needed especially when the infection reaches to the
bone or when there is no respond to treatment.

b) broad spectrum AB (like penicillin, metronidazole, garamycin).

c) Antigas gangrene serum (AGS)

d) Hyperbaric oxygen to treat these infections.

Apportunistic infection
Infections caused by microorganisms(M.O.) and usually occer when
there is a reduce in defense mechanisms of the patient (any decrease in
the immune defense mechanisms of the patient for any reason, these
M.O. cause this type of infections.

There are many M.O. cause this infection and the commonest M.O. are
G -ve (e.g E.coli, pseudomonas which is most commonly associated with
the respiratory track infection, Klebsiella which is associated with the
pusformation, proteus ).

They originate either from the patient own GIT, that means this
infection results and cause by M.O. present in the patient GIT).
Or maybe cross infection from other patient in the same hospital and
spread by hands of the attendants.

The other type of bacteria cause this infection are G +ve M.O. like
Staphylococcus epidermidis which is derived from skin (present on the
skin and when there is a decrease in the immune defense mechanism

11
of the patient so it leads to Apportunistic infection) like local infection
or even bacteremia, also can be associated with the IV (intravenous) or
CV (central venous) line or maybe prosthesis to the heart or joint, or
maybe upper renal tract catheterization. And also following
splenectomy lead to Strep. Pneumonia.

Other types:

Viruses (herpes, CMV, V-zostar).

Fungal ( Candida, Aspargilosis, mucourmycosis).
Protozoa ( cryptosporidial diarrhea, pneumocystis carinii pneumonia).

Apportunistic infection caused either by:

A) reduced host defense (immune decreased) and can be seen in the
following causes:

1- immune suppressive therapy: if the patient take any immune

suppressive drug such as the patient with the organ transplantation so
these drugs lead to decrease in the immune defense and increase in the
formation of Apportunistic infection.

2- cytotoxic & steroid therapy.

3- radiotherapy for neoplasm: some patients with the cancer usually

treated with either by radiotherapy or may be treated by therapy
considered as a palliative treatment, so these patients have high
percent of Apportunistic infection. Because the radiotherapy affect on
the immune system by killing or destruction of the cells of the
immunity.

12
4- sever burn.
5- starvation.

6- long term use of AB. : because the prolong use of antibiotics usually
lead to the alteration in the normal flora of the bacteria or
microorganism present in the body, so increase Apportunistic infection.

7- AIDS: that is caused by HIV virus because this virus usually affect on
the immune system.

8- very old and very young: because very old associated with the same
chronic disorders or disease like D.M. or hypertebsion. And the very
young (premature baby) because they have immature or premature
immunity.

B) maintained invasive therapeutic procedure :

These three procedure will decrease the immune defence mechanism

and increase the Apportunistic infection.

1- I.V. cannulation

2- intravesical catheterization

3- trachiostomy & pulmonary ventilation.

13