MED BEAR SURGERY NOTES

CONTENT PAGE No. Title Page Number 1 Trauma (Multi-Speciality) Approach 3 ƒ Advanced Trauma Life Support Algorithm | Burns Injury Management ƒ Disseminated Intravascular Coagulation (DIC) – Acute ƒ Abdominal Trauma ...

CONTENT PAGE No. Title Page Number 1 Trauma (Multi-Speciality) Approach 3 ƒ Advanced Trauma Life Support Algorithm | Burns Injury Management ƒ Disseminated Intravascular Coagulation (DIC) – Acute ƒ Abdominal Trauma ƒ Cardiothoracic Trauma ƒ Neurosurgical Trauma ƒ Musculoskeletal Trauma ƒ Shock | Types Of Shock | Management ƒ Perioperative Care – fluid & maintenance | CVP monitoring & ventilation | acid base & electrolytes | nutrition – re-feeding syndrome, enteral and parenteral nutrition ƒ Perioperative Care – an anaesthetist’s perspective ƒ Post-Operative Complications ƒ Surviving Sepsis 2 Acute Abdominal Pain 30 ƒ Approach To Acute Abdomen ƒ Classical Signs In Patients With Abdominal Pain ƒ Life-Threatening Causes Of Severe Epigastric Pain ƒ History Taking | Physical Examination | Investigations ƒ Differential Diagnosis Of Abdominal Pain ƒ Differential Diagnosis Of Palpable Abdominal Mass ƒ Intestinal Obstruction ƒ Ischemic Bowel ƒ Acute Appendicitis 3 Surgical Anatomy 45 ƒ Anatomy Of The Abdomen ƒ Abdominal Scars ƒ Clinical Effects of Tumour 4 Oesophageal Diseases 47 ƒ Anatomy Of The Oesophagus ƒ Physiology Of The Oesophagus ƒ Approach To Dysphagia ƒ Achalasia ƒ Gastroesophageal Reflux Disease (GERD) ƒ Barrett’s Oesophagus ƒ Cancer Of The Oesophagus 5 Upper Bleeding GIT And Its Causes 62 ƒ Approach To Bleeding Upper GIT ƒ Portal Hypertension ƒ Ascites ƒ Variceal Bleeding ƒ Peptic Ulcer Disease ƒ Gastric Cancer 6 Colorectal Diseases 84 ƒ Approach To Bleeding Lower GIT ƒ Colorectal Carcinoma ƒ Stoma Principles ƒ Associated Conditions ƒ Diverticular Disease ƒ Meckel’s Diverticulum ƒ Inflammatory Bowel Disease | Crohn’s Disease | Ulcerative Colitis 7 Anal & Perianal Disorders 110 ƒ Haemorrhoids ƒ Anal Fistula ƒ Anal Fissures ƒ Anorectal Abscess 8 Surgical Diseases Of The Liver 115 ƒ Surgical Anatomy Of The Liver ƒ Operative Conduct ƒ Causes Of Hepatomegaly ƒ Disease Of The Liver ƒ Liver Haemangioma ƒ Hepatocellular Carcinoma ƒ Screening For Chronic Hepatitis Carriers ƒ Liver Metastases ƒ Hepatic Abscess (Pyogenic) / Hepatic Abscess (Amoebic) ƒ Hepatic Cysts 9 Pancreatic Diseases 127 ƒ Embryology And Anatomy (Pancreas) ƒ Acute Pancreatitis ƒ Chronic Pancreatitis ƒ Pancreatic Cancer 10 Diseases Of The Biliary System 139 ƒ Approach To Obstructive Jaundice ƒ Cholelithiasis ƒ Acute Calculous Cholecystitis ƒ Choledocholithiasis ƒ Mirizzi’s Syndrome ƒ Carcinoma Of The Gallbladder ƒ Cholangiocarcinoma ƒ Periampullary Tumours ƒ Benign Strictures And Bile Duct Injury 11 Disease Of The Breast 154 ƒ Anatomy ƒ Approach To Breast Lump ƒ Approach To Nipple Discharge ƒ History / Physical Examination / Investigations ƒ Breast Cancer / Therapeutic Option / Treatment By Tumour Stage / Follow-up / Breast Screening ƒ Paget’s Disease Of The Nipple ƒ Gynaecomastia3 12 Head And Neck 167 ƒ Neck Masses ƒ Causes Of Midline Mass ƒ Causes Of Anterior Triangle Mass ƒ Causes Of Posterior Triangle Mass ƒ Cervical Lymphadenopathy 13 Salivary Gland Swellings 174 ƒ Salivary Gland Tumour ƒ Complications of Parotidectomy ƒ Sialolithiasis 14 The Thyroid Gland 179 ƒ Approach To Thyroid Problems ƒ History Taking / Physical Examination ƒ Part 1: Relevant Anatomy (Embryology, Anatomy, Physiology) ƒ Part 2: Approach To The Solitary Thyroid Nodule ƒ Part 3: Thyroid Cancers ƒ Part 4: Surgery In Benign Thyroid Disease 15 Peripheral Arterial Disease 189 ƒ Arteries Of The Lower Limb ƒ Forms Of Peripheral Arterial Disease ƒ Diagnosis of PAD & Natural History of ATH LL PAD Syndromes ƒ Peripheral Arterial System (Hx / PE / Inv / Mx) ƒ Acute Limb Ischemia ƒ Chronic Limb Ischemia ƒ Non-Critical Limb Ischemia With Claudication ƒ Critical Limb Ischemia ƒ Arteriovenous Access ƒ Branches Of The Aorta 16 Aneurysm 205 ƒ Aortic Dissection ƒ Abdominal Aortic Aneurysm 17 Peripheral Venous Disease 209 ƒ Anatomy Of The Venous System Of The Lower Limb ƒ Chronic Venous Insufficiency ƒ Varicose Veins ƒ Venous Ulcers 18 Urological Disease 214 ƒ Classification Of Anemia ƒ Approach To Gross Haematuria ƒ Renal Cell Carcinoma ƒ Bladder Cancer ƒ Urolithiasis ƒ Approach To Acute Urinary Retention ƒ Benign Prostate Hyperplasia ƒ Prostatic Cancer ƒ Adrenal Tumours 19 Hernia 237 ƒ Inguinal Hernia (Direct And Indirect) ƒ Approach To Inguinal Hernia Examination ƒ Approach to Inguinal Lymphadenopathy ƒ Femoral Hernia ƒ Incisional Hernia ƒ Umbilical Hernia / Paraumbilical Hernia 20 Scrotal Swelling 244 ƒ Approach To Scrotal Swelling ƒ Scrotal Anatomy ƒ Examination Of The Scrotum ƒ Testicular Tumour ƒ Hydrocele ƒ Epididymal Cyst ƒ Testicular Torsion (Surgical Emergency) ƒ Varicocele ƒ Scrotal Abscess ƒ Fournier Gangrene 21 Appendix 248 ƒ Lumps & Bumps ƒ Surgical Instruments & Procedures4 TRAUMA (MULTI-SPECIALITY) APPROACH ADVANCED TRAUMA LIFE SUPPORT ALGORITHM TRAUMA DEATHS (TRIMODAL DISTRIBUTION): - Immediate death occurring at time of injury – i.e. due to devastating wounds/lacerations - Early death occurring within the 1st few hours of injury – i.e. tension pneumothorax, blood loss, IC bleed - Late death occurring days / weeks after initial injury – i.e. 20 complications – sepsis, ARDS, SIRS, MOF MAIN PRINCIPLES: - Treat greatest threat to life first - Definitive diagnosis is less important - Time is important – the “golden hour” after trauma is when 30% of trauma deaths occur, and are preventable by ATLS APPROACH (INITIAL ASSESSMENT) 1. Preparation and Triage 2. Primary survey (ABCDE) and Resuscitation of Vital Functions 3. Re-evaluation of the patient and taking a History of the event 4. Secondary survey (head-to-toe evaluation) 5. Post-resuscitation monitoring and re-evaluation 6. Optimise for transfer and definitive care PRIMARY SURVEY (ABCDE) AND RESUSCITATION 1. AIRWAY ASSESSMENT WITH CERVICAL SPINE CONTROL - Ascertain pathway ƒ (1) Foreign Bodies, (2) Facial/Mandibular #, (3) Laryngeal/Tracheal # - Assess for airway obstruction ƒ Engage the patient in conversation – a patient who cannot respond verbally is assumed to have an obstructed airway till proven otherwise ƒ (1) stridor, (2) retractions, (3) cyanosis - Establish a patient airway ƒ Jaw Thrust – displace tongue anteriorly from the pharyngeal inlet relieving obstruction ƒ Simple Suctioning / Clear Airway of Foreign Bodies ƒ Nasopharyngeal airway / Oropharyngeal Airway ƒ Establish a definitive airway a. Tracheal Intubation (refer anaesthesia notes for more details) o Orotracheal route using rapid-sequence induction (RSI) o Pre-oxygenate patient with 100% Oxygen o In-line cervical spine stabilisation wither anterior portion of cervical collar removed o Sellick Manoeuvre to prevent aspiration (there is increasing controversy as to the utility of cricoid pressure due to concerns about its efficacy and potential for obscuring the view of the vocal chords) o Drugs – short acting sedative or hypnotic agent (i.e. etomidate 0.3mg/kg IV or midazolam 1-2.5mg IV) and paralytic agent administered immediately after the sedative (succinylcholine 1- 1.25mg/kg IV or rocuronium 0.6-0.85mg/kg IV) o ETT tube inserted through vocal chords and adequacy of ventilation is assessed b. Needle Cricothyroidectomy with jet insufflation of the airway c. Surgical Cricothyroidectomy - In a multi-system trauma patient assume cervical spine injury till proven otherwise ƒ NEXUS C-Spine Clearance (NSAID) a. No focal Neurological deficit b. No Spinal (posterior midline cervical) tenderness c. Patient is Alert and orientated to time / place / person d. No evidence of Intoxication e. No painful Distracting injuries (i.e. long bone fracture)