SURGERY TIKI TAK

A
_________________
__
. TRAUMA:
__________
__________
(1) AIRWAY:
____________
. Establishing & securing the airway is always the
1st step in management.
. Altered mental status is the most common indicat
ion for intubation in a trauma pt.
. As an unconscious pt can't maintain his airway.
. The preferred method of securing an airway -> OR
OTRACHEAL INTUBATION.
. Trauma with cervical spine injury -> FLEXIBLE BR
ONCHOSCPE.
. Extensive facial trauma & bleeding into airway > CRICOTHYROIDOTOMY or TRACHEOSTOMY.
. N.B.
. Pts with cervical spine injury should 1st have s
tabilization of the cervical spine.
. Oro-tracheal intubation with rapid sequence intu
bation is the preferred way,
. to secure an airway in an apnein pt with a cervi
cal spine injury.
. N.B.
. In burn victims, clinical indicators of thermal
inhalation injury to the upper airway,
. or smoke inhalation injury to the lungs include
burns on face, singing of eye brows,
. oropharyngeal inflammation & blistering, orophar
yngeal carbon deposits,
. carbonaceous sputum, stridor, carboxyhemoglobin
level > 10 %.

. H/O of confinement in a burnung buiding.

. The presence of one or more of these indicators
warrants early intubation,
. to prevent upper airway obstruction by edema.
(2) BREATHING:
_______________
. Check oxygen saturation, if SpO2 < 90 %:
-> ++ oxygen concentration & flow rate.
-> Obtain an ABG.
-> Determine the likely cause of hypoxia from H/O.
(3) CIRCULATION:
_________________
* CHEST TRAUMA (Hypovolemic shock - Pericardial ta
mponade - Tension pneumothorax):
___________________________________________________
________________________________
___________________________________________________
________________________________
-> HYPOVOLEMIC SHOCK:
______________________
. The most common type of shock.
. Pale, cold , shivering pt with diaphoresis, hypo
tension & tachycardia.
. Look for a source of bleeding.
. The pt may lose a large volume of blood in the a
bdomen or thigh following femur #.
. N.B.
. When hemorrhage occurs, tachycardia & peripheral
vasoconstriction are the 1st changes.
. These responses act to maintain the blood pressu
re within normal limits.
. PULSE CHANGE IS THE FIRST INDICATOR FOR HYPOVOLE
MIA.
-> Pericardial tamponade:

__________________________
. Cause distended neck veins & high central venous
pressure.
. Enlarged heart on CXR (May be normal cardiac sil
houette).
. Electrical alternans on EKG.
. Pulsus paradoxus on vital signs.
. Tx -> immediate pericardiocentesis tap or perica
rdial window.
. N.B.
. Acute cardiac tamponade:
. occurs due to a sudden rise in intra-pericardial
pressure.
. Should be suspected in all adult pts with blunt
chest trauma.
. Jugular venous distension, Tachycardia & Hypoten
sion despite aggressive fluid resusc.
. CXR findings typically reveal a normal cardiac
silhouette without tension pneumothorax.
-> Tension pneumothorax:
_________________________
. Cause distended neck veins & high central venous
pressure.
. Respiratory distress, tracheal deviation, absent
breath sounds.
. Hyperresonance to percussion.
. Tx -> immediate placing of a large-bore needle o
r IV catheter into the pleural space.
. Chest tube placement.
. Never wait for a CXR for diagnosis.
. N.B.
. Don't be distracted by head trauma or dilated pu
pils in a hypotensive trauma pt.
. Intracranial bleeds are never the cause of hypot
ensive shock.
. The 1st step in management is to identify & cont
rol the site of bleeding.
. N.B.

. Most causes of shock in the setting of trauma ar

e 2ry to hypovolemia from blood loss.
. However, ++ CVP/PCWP or failure of hypotension t
o resolve after a bolus of IV fluids,
. should suggest an alternative diagnosis.
. Myocardial contusion sh'd be suspected in pts w
ith evidence of injury to anterior chest
. MI can be confirmed with +ve cardiac markers & E
KG changes.
. Tension pneumothorax is excluded if there is no
tracheal deviation.
. Hypovolemia is excluded if there is failure to r
espond to an IV fluid bolus.
. N.B.
. High energy blunt trauma to the chest commonly c
auses aortic injury.
. In most cases of aortic rupture, death is the im
mediate result.
. Widened mediatinum, large left sided hemothorax
& mediastinal deviation to right side.
. Disruption of the normal aortic contour..
. Bilateral COLLAPSED neck veins.
. Cardiac contusion & rupture cause pericardial ta
mponade only.
. Muffled heart sounds - Hypotension - DISTENDED N
ECK VEINS.
. N.B. PULMONARY CONTUSION:
____________________________
. Represents pulmonary bruising of the lung.
. Common after high-speed car accidents.
. Clinical manifestations develop in the 1st 24 ho
urs (Often within few minutes).
. Tachypnea - Tachycardia - Hypoxia.
. P/E -> Chest wall bruising & -- breath sounds on
the side of pulmonary contusion.
. CXR -> Patchy irregular alveolar infiltrate.
. ABG -> Hypoxemia.

. It is very important to differentiate pulmonary

contusuion from ARD$.
. ARD$ manifests 24 - 48 hours from the trauma & B
ILATERAL involvement.
. Pulmonary contusion manifests in the 1st 24 hour
s.
. N.B. PNEUMOTHORAX:
. Primary spontaneous pneumothorax -> No preceidin
g event & No H/O of lung disease.
. Secondary spontaneous pneumothorax -> Complicati
on of underlying COPD.
. Tx -> Small ( < 2cm between lung & chest wall on
CXR) -> Observation & oxygen.
. Tx -> Large (Stable) -> Needle aspiration or che
st tube.
. Tension pneumothorax:
________________________
. Life threatening; trapped air with mediastinal s
hift.
. Compromised cardiopulmonary function.
. Chest pain or dyspnea.
. -- Breath sounds / -- TVF / -- chest movement.
. Hyperresonance to percussion on the affected sid
e.
. Tachycardia, hypotension.
. Tracheal deviation away from the affected side.
. Imaging -> Notable visceral pleural line.
. Imaging -> Air in hemithorax -> Contralateral me
diastinal shift.
. Imaging -> Radiolucent costophrenic sulcus.
. Tx -> Urgent needle decompression then chest tub
e placement (Tube thoracostomy).
. Tx -> IV lines & fluid resuscitation follow urge
nt needle decompression.
. N.B.
. ONLY TWO CAUSES OF DISTENDED NECK VEINS -> TENSI
ON PNEUMOTHORAX & CARDIAC TAMPONADE.

. N.B.
. In HEMOTHORAX -> Neck veins are COLLAPSED !
. N.B. FLAIL CHEST:
____________________
. Follows major thoracic trauma.
. Multiple contigious ribs are fracutred in two or
more locations.
. Causing a segment of rins losing its continuity
with the rest of thoracic wall.
. The pt takes shallow breaths due to severe pain.
. The pt compensates for the hypoxemia by hyperven
tillation.
. Tachypnea & PARADOXICAL THORACIC WALL MOVEMENTS.
. Paradox is corrected with positive pressure mech
anical ventillation.
. The isolated thoracic wall segment exhibits para
doxical motion,
. inward motion on inspiration & outward motion du
ring expiration !
. Tx -> Pain control & supplemental oxygen are the
most important steps.
. Positive pressure mechanical ventillation replac
es the negative intrapleural pressure.
. so the flail chest movement will be normal with
the rest of the rib cage on inspiration
. N.B. HEMO-THORAX:
____________________
. After blunt chest trauma, hemorrhagic shock asso
ciated e'
. decreased breath sounds & dullness to percussion
over one hemithorax.
. & contralateral tracheal deviation.
. COLLAPSED NECK VEINS.
. Most common cause is damage to intercostal or in
ternal mmamary artery.
* ABDOMINAL TRAUMA:

____________________
. The 1st step in management is always to control
the site of bleeding if known.
-> Apply direct pressure when the site is visible
(e.g. extremity).
-> Blind clamping & the use of tourniquet is NEVE
R the answer.
. The next priority is FLUID RESUSCITATION.
. Do several things at once in preparation for imm
ediate exploratory laparotomy:
-> Set up 2 large gauge IV lines.
-> Give fluids & blood.
-> Insert Foley catheter.
-> Administer IV antibiotics.
. If surgery isn't needed (blunt trauma),
. fluid resuscitation is the 1st step in managemen
t (Also diagnostic).
. If the pt responds promptly, then he's propably
no longer bleeding.
. N.B.
. Intraosseous cannulation in the proximal tibia i
s used in children (generally < 6ys).
. Give an initial bolus of Ringer's lactate at 20
ml/kg of body weight.
. N.B. BLUNT ABDOMINAL TRAUMA (BAT):
_____________________________________
. After a car accident of a restrained driver.
. Usually occurs when a lap belt (without shoulder
attachment) compresses the abdomen,
. and lacerates solid organs most commonly the spl
een & liver.
. Hypotension, tachycardia, facial lacerations & a
bdominal wall ecchymosis.
. Most reliable symptoms -> Abdominal pain, tendrn
ess & peritoneal signs.
. Intraabdominal injury sh'd be suspected in pts w
ith:

. abdominal wall ecchymosis,abdominal distension &

hyperactive bowel sounds.
. 1st step after fluid resuscitation to determine
if the pt needs exploratory laparotomy.
. All pts with BAT sh'd 1st be assessed for intrap
eritoneal free fluid or hemorrhage.
. Best test is -> BEDSIDE ULTRASONOGRAPHY to detec
t free intraperitoneal fluid,
. in hepatorenal space, splenorenal recess & infer
ior portion of intraperitoneal cavity.
. When combined with pericardial evaluation -> kno
wn as FAST.
. FAST exam -> (Focused assessment with sonography
for trauma).
. It is the best to detect hemoperitoneum, perica
rdial effusion or intraperitoneal fluid.
. If FAST exam is limited or equivocal -> A diagno
stic peritoneal lavage (DPL) is done.
. DPL is done to evaluate for hemoperitoneum.
. Pts with +ve findings on either FAST or DPL -> s
hould undergo exploratory laparotomy.
. Hemodynamically stable pts with -ve findings on
FAST may undergo abdominal CT,
. to determine need for laparotomy.
. Hemodynamically un-stable -> FAST or DPL.
. N.B.
. Blunt abdominal trauma to the upper abdomen can
cause pancreatic contusion,
. crush injury, laceration or transection to the p
ancreas.
. Pancreatic injuries may be MISSED by CT scan dur
ing the 1st 6 hours following trauma.
. Untreated pancreatic injury can be complicated
by retroperitoneal abscess or pseudocyst
. N.B.

. The spleen is the most commonly injured organ fo

llowing blunt abdominal trauma.
. Left upper quadrant abdominal pain.
. Abdominal wall contusion, Lt lower chest wall te
ndrness.
. Lt shoulder pain referred from splenic hemorrha
ge irritating phrenic nerve & diaphragm.
. It is called "KEHR" sign.
. Splenic rupture causes acute left upper quadrant
abdominal pain.
. Delayed hypotension may result due to blood loss
.
. No signs of sepsis will be present.
. Dx -> Abdominal CT with IV contrast.
. N.B.
. Blunt deceleration trauma (Motor vehicle acciden
t or fall from > 10 feet):
. Blunt aortic trauma must be ruled out.
. CXR is the initial screening test -> WIDENING of
the mediastinum.
. N.B.
. Duodenal hematoma:
_____________________
. mostly follow abdominal blunt trauma in children
.
. The hematoma may cause duodenal obstruction with
nausea & vomiting.
. Epigastric pain & vomiting due to failure to pas
s gastric secretions past obstruction.
. Tx -> NASOGASTRIC SUCTION & PARENTERAL NUTRITION
.
. Most hematomas will resolve spontaneously in 1-2
weeks.
. N.B.
. Any gun shot wound below the 4th intercostal spa
ce (level of the nipple) is:
. considered to involve the abdomen & requires an
exploratory laparotomy in unstable pts.

. N.B.
. All hemodynamically UN-STABLE pts with penetrati
ng abdominal trauma,
. must undergo immediate exploratory laparotomy to
diagnose & treat source of bleeding
. as well as to diagnose & treat perforation of an
y abdominal viscus to prevent sepsis.
. N.B.
. Abdominal CT used to detect intra-abdominal inj
ury in hemodynamically stable trauma pts
. In hemodynamically un-stable pts, a FAST U/$ sho
uld be the initial test.
. DPL Diagnostic peritoneal lavage is used in hemo
dynamically unstable pts if -ve FAST.
. N.B.
. DIAPHRAGMATIC TRAUMA:
________________________
. Blunt abdominal trauma -> Mild respiratory distr
ess & Abnormal CXR.
. Sudden ++ in intra-abdominal pressure -> Large r
adial tears in the diaphragm.
. Rupture is more common on LEFT side bec. the rig
ht side is protected by the liver.
. Dx -> CXR -> Hemi-diaphragmatic elevation.
. Dx -> CXR -> Naso-gastric tube in the pulmonary
cavity = Diaphragmatic hernia.
. Dx -> CT is the next best step (to Confirm).
. The small bowel may be present in the thoracic c
avity.
. Tx -> Surgical repair & exploration for other tr
aumatic injuries.
. N.B.
. TRACHEO-BRONCHIAL RUPTURE:
_____________________________
. Due to rapid decceleration blunt chest trauma.
. 1st manage the ABCs.
. Dx -> CXR -> Persistent pneumothorax & pneumome
diastinum despite chest tube placement !
. Subcutaneous emphysema (Palpable crepitus below

the skin).
. The RIGHT MAIN BRONCHUS is the most commonly inj
ured.
. Dx -> High resolution CT scan (Confirm).
. Tx -> Surgical repair.
. BLUNT ABDOMINAL TRAUMA MANAGEMENT:
_____________________________________
_____________________________________
. HEMODYNAMICALLY UN-STABLE PATIENT:
_____________________________________
-> Cervical spine immobilization.
-> Intravenous hydration.
-> FAST (Focused assessment with sonography for tr
auma).
-> If FAST is +ve for blood & pt is still UNSTABLE
AFTER A TRIAL OF FLUID RESUSCITATION,
-> URGENT LAPAROTOMY with surgical repair is indic
ated.
. HEMODYNAMICALLY STABLE PATIENT:
__________________________________
-> CT scan abdomen with contrast (to detect the a
mount of bleeding & the site of injury).
-> The surgeon can then select either laparotomy o
r admission & observation.
. MANAGEMENT OF BLUNT ABD
OMINAL TRAUMA
_________________________
______________
. in HEMODYNAMICALLY UN
-STABLE PT
_______________________
___________
|
FAST EXAMINAT
ION
_____________

___
|
_____________________________
_______________
|

|
+ve

inconclusive

-ve
|

|
LAPAROTOMY <--POSITIVE--- DPL ---NEGATIVE---> Signs of
____________
_____
extra-abdominal
hemorrhage (Pelvic/long bone #)
|
___YES_____________NO_____
|

|
STA

BILIZE

STABILIZE
ANGIOGRAP

HY & SPLINT

then CT ABDOMEN

* VASOMOTOR SHOCK:
___________________
. Hypotension & tachycardia in pts who are warm &
flushed (Not pale & cold!).
. Look for a H/O of medication use (penicillin all
ergy).
. H/O of spinal anesthesia or exposure to allergen
(bee stings).
* TRAUMA TO LOCALIZED SITES:

_____________________________
. All penetrating wounds with damage to internal o
rgans will need to go to the OR.
. If the case describes an object embedded in the
pt, NEVER to remove it.
. Never remove it in the ER or at the scene of th
e accident (Only in the operating room).
* HEAD TRAUMA:
_______________
. "No" surgical intervention is needed for ..
. an asymptomatic head injury with a closed skull
# (No overlying wound) alone.
. The next step of management is to clean any lace
rations.
. Surgery "Repair or craniotomy" is always done fo
r ..
. COMMINUTED or DEPRESSED SKULL # even if the pt i
s asymptomatic !
. Send the pt to the OR.
. For head trauma & loss of cosciousness
. The 1st step of management is ordering a HEAD &
NECK CT with "OUT" contrast.
. If the head CT & neurological exam are normal,
. he can go home if someone can closely observe hi
m over the next 24 hours.
. i.e. wake him up frequently & watch for changes
in mentation.
. Give tetanus toxoid & prophylactic antibiotics t
o all pts with open skull #s.
* BASAL SKULL #:
_________________
. Ecchymosis around both eyes (Racoon eyes).
. Ecchymosis behind the ear (Battle's sign).
. Clear fluid drippling from the ear or nose (CSF
leak).

. CT scan of head & neck -> Basal skull #. "X-ray

is a wrong answer".
. A CSF leak will stop by itself & requires no spe
cific management.
. Prophylactic antibiotics are NOT indicated !!
. Facial palsy may occur 2-3 days later due to neu
roapraxia (Use Steroids).
* EPI-DURAL HEMATOMA:
______________________
. Side head trauma & rupture of middle meningeal a
rtery in the foramen spinosum.
. H/O of head trauma & SUDDEN LOSS OF CONSCIOUSNES
S.
. Accumulation of blood in the potential space inb
etween the cranium & dura matter.
. Honeymoon period (The period when the pt immedia
tely awakes & appears normal).
. Pt typically has ipsilateral pupil dilatation du
e to oculomotor nerve compression.
. Then the pt quickly deteriorates, so .. It is im
portant to manage quickly.
. Dx -> CT scan -> BICONVEX LENS shaped hematoma w
ith or without midline deviation.
. Tx -> EMERGENCY CRANIOTOMY.
. If the pt is treated, the prognosis is good.
. If not, the prognosis is fatal within hours.
. Epidural hematoma results from rupture of middle
meningeal artery,
. higher arterial pressure can rapidly expand the
hematoma -> Compress the temporal lobe.
. Fluid resuscitation ++ the rate at which the epi
dural hematoma expanded.
. Hypertension, bradycardia & respiratory depressi
on (Cushing's reflex) = ++ ICP.
. The uncus is the innermost part of the temporal
lobe & herniated through the tentorium,
. leading to the following pressure effects:
. TRANS-TENTORIAL (UNCAL) HERNIATION:

______________________________________
______________________________________
. Compression of the contralateral crus cerebri ag
ainst the tentorial edge:
___________________________________________________
_________________________
. Ipsilateral hemiparesis.
. Compression of the ipsilateral oculomotor nerve
(CN 3) by the herniated uncus:
___________________________________________________
______________________________
. Loss of parasympathetic innervation causes mydri
asis.
. Loss of motor innervation causes ptosis & down-o
utwards gaze of the ipsilateral pupil,
. due to un-opposed trochlear (CN 5) & abducent (C
N 6).
. Compression of the ipsilateral posterior cerebra
l artery:
___________________________________________________
_________
. causes ischemia of the visual cortex -> Contrala
teral homonymous hemianopia.
. Compression of the reticular formation:
__________________________________________
. Altered level of consciousness; coma.
* "S"UB-DURAL HEMATOMA:
________________________
. Low pressure bleeding from the "VENOUS SYSTEM".
. Accumulation of blood in the subdural space betw
een the dura & arachinoid membrane.
. Head trauma with FLUCTUATING CONSCIOUSNESS i.e.
. gradual headaches, memory loss, personality chan
ges, dementia, cofusion & drowsiness.
. Dx -> CT scan -> "S"EMILUNAR, CRESCENT shaped he
matoma e' or e'out midline deviation.

. Tx -> CONSERVATIVE management with STEROIDS.

. Emergency craniotomy is done if there are latera
lizing signs & midline displacement.
* DIFFUSE AXONAL INJURY:
_________________________
. Results from ACCELERATION-DECELERATION injuries
to the head.
. The pt will be deeply unconscious.
. Dx -> CT -> Normal or diffuse small bleeds at t
he junctions of the grey & white matter.
. CT -> Numerous punctate hemorrhages.
. Prognosis is terrible !
. Surgery can't help.
. Therapy is directed at preventing further injury
from ++ ICT.
* ELEVATED INTRACRANIAL PRESSURE (++ ICP):
___________________________________________
. Briefly depressed consciousness after head traum
a.
. Improvement.
. Progressive drowsiness.
. ++ ICT is a medical emergency.
. GRADUAL DILATATION OF ONE PUPIL & DECREASING RES
PONSIVENESS TO LIGHT is an imp. sign.
. It indicates clot expansion on the ipsilateral h
emisphere.
. Dx -> Head CT -> Midline shift or dilated ventri
cles.
. Don't think about performing a lumbar tap in any
pt before getting a head CT 1st !
. If you perform a lumbar puncture on a person wit
h ++ ICT, you'' herniate the brain !
. Tx -> Head elevation - Hyperventillation - Avoid
fluid overload.
. Tx -> Mannitol & furosemide (use very cautiousl
y as they can reduce cerbral perfusion).
. Tx -> sedation & hypothermia may lower oxygen de
mand.

. N.B. Lowering ICP is not the ultimate goal; pres

erving brain perfusion is.
. Systemic hypotension or excessive cerebral vasoc
onstriction may be counterproductive.
. N.B. Steroids are good for cerebral edema 2ry to
tumors & abscesses,
. But they have no role in head trauma pts !
. N.B. Pts with mild to moderate traumatic brain i
njury:
. can be discharged under the care of an adult if
they have a NORMAL CT.
. The caretaker sh'd be given printed instructions
detailing signs & symptoms that,
. warrant immediate return to the hospital.
__________________________________________________
________________________________________
. ACUTE ABDOMEN:
_________________
_________________
. 4 main causes -> Perforation - Obstruction - Inf
lammation/Infection - Ischemia.
. When is "SURGEY" the answer ?
________________________________
1. Peritonitis (Exclude primary peritonitis).
2. Abdominal pain/tendrness + sepsis signs.
3. Acute intestinal ischemia.
4. Pneumoperitoneum.
. In all of the above cases, make sure pancreatiti
s is 1st ruled out !
. N.B. Primary peritonitis is spontaneous inflamma
tion with nephrosis in children.
. or .. An adult with ascites & mild abdominal pa
in (even there is fever & leukocytosis).

. When is "MEDICAL ttt" the answer ?

_____________________________________
1. Primary peritonitis.
2. Pancreatitis.
3. Cholangitis.
4. Urinary stones (Look for stones on X-ray).
5. Things that can mimic an acute abdomen:
-> Lower lobe pneumonia (Look for infiltrate on C
XR).
-> Myocardial ischemia (Look for EKG changes).
-> Pulmonary embolism (Look for immobilized pt).
6. Ruptured ovarian cyst.
. N.B.
. Cholangitis is a GIT medical emergency & interve
ntion with ERCP is the ttt of choice.
. NON-surgical causes of an acute abdomen:
___________________________________________
1. Myocardial infarction - acute pericarditis.
2. Lower lobe pneumonia - pulmonary infarction.
3. Hepatitis - GERD.
4. DKA - Adrenal insuffeciency.
5. Pyelonephritis - Acute salpingitis.
6. Sickle cell crisis.
7. Acute porphyria.
. N.B.
. Be sure to differentiate GERD from peptic ulcer
perforation (surgical emergency).
* 1 * PERFORATION:
___________________
___________________
(1) GASTRO-INTESTINAL PERFORATION:
__________________________________
. Acute abdominal pain that is sudden, severe, con
stant & generalized.
. Pain is excruciating with any movement (may be b
lunted in elderly pts).

. Most common causes of GIT perforations:

(a) Diverticulitis: Elderly pt with lower abdomin
al pain & fever.
(b) Perforated peptic ulcer: Epigastric pain waki
ng up the pt at night.
(c) Chron's disease.
. Dx -> Supine & erect abdominal x-ray (free air u
nder diaphragm).
. Tx -> Nothing by mouth (NPO) & IV fluid hydratio
n.
. Tx -> IV antibiotics such as flagyl & gentamycin
.
. Tx -> IV 2nd generation cephalosporins (Cefoteta
n or cefoxitin).
. Tx -> Emergency surgery.
(2) ESOPHAGEAL PERFORATION:
___________________________
. Most common cause is IATROGENIC.
. Pain in chest or upper abdomen.
. Dysphagia or odynophagia.
. S.C. emphysema shortly after endoscopy.
. It is a surgical emergency.
. Dx -> GASTROGRAFFIN CONTRAST ESOPHAGOGRAM is the
best (Do NOT use Barium xx).
* 2 * OBSTRUCTION:
___________________
___________________
. Severe colicky pain.
. Absence of flatus or feces.
. Nausea & vomiting.
. Constant movement as the pt tries to find a comf
ort position.
. H/O of prior surgery (Think adhesions).
. H/O of elderly pt with anemia, weight loss & mel
anotic stools (Think tumor).
. H/O of recuurent lower abdominal pain (Think div
erticulitis).

. H/O of hernia (incarcerated hernia).

. H/O of sudden abdominal pain in elderly pt (Thin
k volvulus).
. Dx -> CBC & ++ lactate level.
. Dx -> Supine & erect abdominal X-ray:
-> Dilated loops of bowel, absence of gas in
rectum, bird's beak sign for volvulus.
. Tx -> NPO, (NG) suction & IV fluid hydration.
. Consider Gastrograffin contrast study (Until per
foration has been ruled out).
. Volvuls -> Perform procto-sigmoidoscop with rigi
d instrument.
-> Leave the rectal tube in place.
-> Perform sigmoid resection for recurre
nt cases.
. Abdominal hernia -> Perform elective repair for
all abdominal hernias.
-> except umbilical hernia in p
ts < 2 ys.
-> except esophageal sliding he
rnia.
. All other obstructions -> Perform emergency surg
ery.
. N.B.
. In a pt with a hernia, immediate surgery is the
answer if the case describes:
. fever, leukocytosis, constant pain & signs of pe
ritoneal irritation (Strangulation).
. N.B.
. Complete small bowel obstruction
. Nausea - vomiting - Abdominal bloating - Dilated
loops of bowel on abdominal x-ray.
. Adhesions are the most common etiology.
. N.B.
. SMALL BOWEL OBSTRUCTION:

___________________________
. Colicky abdominal pain & vomiting.
. No bowel movement or passing gas (Obstipation),
abd. distension & diffuse tendernesss.
. The contents of the vomitus are typically biliou
s in proximal SBO.
. The contents of the vomitus are feculent with mo
re distal obstructions.
. Hyperactive bowel sounds due to peristaltic rush
.
. Dx -> Abd. x-ray -> DILATED BOWEL LOOPS with MUL
TIPLE AIR FLUID LEVELS.
. Tx -> Complete bowel rest - Decompression e' nas
ogastric tube.
. Tx -> Pain control - Fluid resuscitation.
. Tx -> If no improvement -> Surgical intervention
to avoid strangulation.
. Strangulation signs (fever - tachycardia - leuko
cytosis - Metabolic acidosis).
. N.B.
. Immediate surgical intervention is indicated for
pts with intestinal obstruction who,
. develop clinical or hemodynamic instability, fai
l to improve after conservative ttt,
. or develop syms of strangulation (fever-tachycar
dia-leukocytosis-Metabolic acidosis).
* 3 * INFLAMMATION:
____________________
____________________
. Causes (Acute diverticulitis - Acute pancreatiti
s - Acute appendicitis).
. Gradual onset of constant abdominal pain that sl
owly builds up over several hours.
. Initially ill defined pain that becomes localize
d to the site of inflammation.
. Note that signs of peritoneal irritation are ABS
ENT in pancreatitis.
(1) ACUTE DIVERTICULITIS:

__________________________
. Acute abdominal pain in the LEFT LOWER QUADRANT
(LLQ).
. Middle age or older pt with fever, leukocytosis
& peritoneal irritation in the LLQ.
. Palpable tender mass in the LLQ.
. In women, think about fallopian tubes & ovaries
as potential sources.
. Dx -> CT -> Abscess & free air.
. Never order contrast studies or endoscopy in acu
te phase.
. Tx -> If there is no peritoneal signs -> Manage
as outpatient with antibiotics.
. Localized peritoneal signs & abscess -> Admit pt
- NPO - IV fluids - IV antibiotics.
. Generalized peritonitis or perforation -> Emerge
ncy surgery.
. Recurrent attacks of diverticulitis -> Elective
surgery.
. N.B. When diagnosing acute diverticulitis,
. don't forget to order a urine pregnancy test on
all women of childbearing age.
. Complicated diverticulitis: Associated e' absce
ss, perforation, obstruction or fistula.
. Fluid collection < 3cm -> IV antibiotics & obser
vation.
. Fluid collection > 3cm -> CT guided percutaneous
drainage.
. If no response within 5 days -> Surgery for drai
nage & debridement.
(2) ACUTE PANCREATITIS:
________________________
. Alcoholic pt who develops an acute (over several
hours) upper abdominal pain,
. radiating to the back, with nausea & vomiting.
. It may be edematous, hemorrhagic or suppurative
(pancreatic abscess).
. Late complications include pancreatic pseudocyst
& chronic pancreatitis.

.
12
.
.

Dx -> Serum or urinary amylase or lipase (serum

- 48 hs, urinary 3rd - 6th day).
Dx -> CT if diagnosis is uncertain.
Tx -> NPO, NG suction & IV fluids.

. N.B. Look out for the risk factors for acute pan
creatitis:
-> Alcoholism.
-> Gall stones.
-> Medications (Didanosine, pentamidine, Flagyl, T
etracycline, Thiazides & Furosemide).
-> Hypertriglyceridemia.
-> Trauma.
-> Post-ERCP.
. N.B. COMPLICATIONS:
-> Abscess:
. Often appears 10 days after onset with persiste
nt fever & high WBC count.
. Surgical drainage is the ttt.
-> Pseudocyst:
. Appears 5 weeks after initial symptoms.
. when a collection of pancreatic juice causes an
orexia, pain & a palpable mass.
. If < 6 cm & present < 6 weeks -> OBSERVATION.
. If > 6 cm or present > 6 weeks -> Percutaneous
drainage or endoscopic drainage.
-> Chronic damage:
. causes diabetes & steatorrhea.
. Treat with insulin & pancreatic enzyme suppleme
ntation.
. N.B. The most common causes of acute pancreatiti
s are gallstones & alcohol use.
. Identifying the underlying cause can prevent rec
urrent pancreatitis.
. ULTRASOUND is the preferred test to detect gall
stones.
. Stable pts sh'd undergo cholecystectomy for bili

ary pancreatitis prior to discharge.

(3) ACUTE APPENDICITIS:
________________________
. Begins with anorexia.
. Followed by vague peri-umbilical pain.
. several hours later, it becomes sharp, severe, c
onstant & localized to RLQ of abdomen.
. RIGHT LOWER QUADRANT PAIN.
. Tenderness, guarding & rebound tendrness are fou
nd on the right & below the umbilicus.
. Dx -> Fever, leukocytosis 10000 - 15000 with neu
trophilia & immature forms.
. Dx -> Reactive thrombocytosis.
. Dx -> Abdominal U/$ or CT scan if clinically unc
lear.
. Tx -> IV antibiotics before appendectomy.
. Tx -> If appendix is perforated -> Continue IV u
ntil fever & WBC count normalize.
. N.B. APEENDICEAL PERFORATION complicated by PSOA
S ABSCESS:
___________________________________________________
__________
. Localized Rt lower quadrant findings > 5days aft
er onset of appendicitis.
. perforation occurs with abscees formation.
. Psoas abscess -> Flexion of the hip against resi
stance (Psoas sign).
. Tx -> IV hydration - Antibiotics - Bowel rest Interval appendectomy after 6-8 weeks.
. N.B. APPENDICEAL PERFORATION complicated by PELV
IC ABSCESS:
___________________________________________________
___________
. Rupture of appendix with pelvic abscess formatio
n.
. Drainage of fluid into the dependent recto-vesic
al pouch.
. Tender, fluctuant mass palpable only e' the tip

of finger = recto-vesical pouch abscess

. Fever, lukocytosis, painful defecation & diarrhe
a.
. Tx -> Abscess drainage.
. N.B. CHRONIC ULCERATIVE COLITIS (CUC):
_________________________________________
. CUC is managed medically.
. Elective surgery is done in the following condit
ions:
-> Disease is present > 20 ys "High incidence of m
alignant degeneration".
-> Multiple hospitalizations.
-> Pt needs chronic high dose steroids or immunosu
ppressants.
-> Toxic megacolon (Abd. pain - fever - leukocytos
is - epigastric tendrness).
-> Massively distended transverse colon on X-rays
with gas within the wall of the colon.
* 4 * ISCHEMIA:
________________
________________
. Acute mesenteric ischemia in older pts.
. H/O of arrhythmia (Af -> Absence of P waves with
irregular rhythm).
. Coronary artery disease.
. Recent MI.
. Severe acute onset abdominal pain that is out of
proportion to exam.
. Dx is clinical but look for acidosis & sepsis si
gns.
. If ischemia is suspected, don't w8 for lab findi
ngs (acidosis or ++ lactate),
. Go straight to surgery or order angiography.
. If diagnosis is during SURGERY -> Perform embol
ectomy & revascularization or resection.
. If diagnosis is during ANGIOGRAPHY -> Give vasod
ilators or thrombolysis.
. Acute embolic mesenteric ischemia may progress t
o bowel infarction.

. N.B. INTRA-ABDOMINAL ABSCESS:

________________________________
. H/O of previous operation, trauma or intra-abdom
inal infection/inflammation.
. Abscesses can occur anywhere in the abdomen or r
etroperitoneum.
. Dx -> CBC & contrast CT of abdomen or pelvis.
. Tx -> Drain an intraabdominal abscess (either su
rgically or percutaneously).
. Tx -> Give antibiotics to prevent spread of infe
ction (Doesn't cure abscess).
. Ex. PSOAS ABSCESS:
. It is not an exclusive complication of appendici
tis.
. It may present alone (Absence of rebound tendern
ess of appendicitis !).
. Presence of multiple furuncles on the inner thig
hs is a clue of septic focus !
. Dx -> CT Abdomen.
. Tx -> Surgical or percutaneous drainage.
. N.B. BOWEL ISCHEMIA:
_______________________
. One of the complications of abdominal aortic ane
urysm repair surgery.
. Due to inadequate colonic collateral arterial pe
rfusion to the left & sigmoid colon.
. Due to loss of the inferior mesenteric artery du
ring aortic graft placement.
. Abdominal pain (Dull pain over ischemic bowel) &
bloody diarrhea (Hematochezia).
. Fever & leukocytosis.
. Colonoscopy -> Discrete segment of cyanotic & ul
cerated bowel.
. Prevention -> Checking sigmoid colon perfusion f
ollowing graft placement.
. SURGICAL JAUNDICE:
____________________

____________________
* OBSTRUCTIVE JAUNDICE CAUSED BY STONES:
_________________________________________
. Obese, fecund woman in her 40s.
. Recurrent episodes of abdominal pain.
. High alkaline phosphatase.
. Dilated ducts on sonogram.
. Non-dilated gall bladder full of stones.
. Dx -> Abdominal U/$.
. Dx -> Confirm e' endoscopic ultrasound (EU$).
. Dx -> Confirm e' Magnetic resonance cholangiopan
creatography (MRCP).
. Tx -> Perform Endoscopic retrograde cholangiopan
creatography (ERCP).
. Tx -> Cholecystectomy sh'd follow ERCP.
. N.B. ERCP & EU$ are never the 1st step in diagno
sis.
. N.B. ERCP is mostly a management step on exam.
* OBSTRUCTIVE JAUNDICE CAUSED BY TUMOR:
________________________________________
. Progressive symptoms in the preceeding weeks & w
eight loss.
. Adenocarcinoma at the head of pancreas.
. Adenocarcinoma at the ampulla of Vater.
. Cholangiocarcinoma arising in the common bile du
ct itself.
. Dx -> Abdominal U/$.
. Dx -> CT scan.
. Dx -> For lesions on CT -> Obtain a tissue diagn
osis via EU$.
. Dx -> If no lesions on CT -> Order MRCP.
. MRCP -> will show the ampullary or common bile d
uct tumors not seen on CT scan.
. Obtain tissue diagnosis via ERCP.
. Tx -> Surgical resection.
. GALL STONES:
_______________

_______________
(1) BILIARY COLIC:
___________________
. TEMPORARY occlusion of the CYSTIC DUCT.
. Colicky pain in the upper right quadrant RUQ.
. Radiating to the right shoulder & back.
. Often triggered by fatty food.
. Episodes are brief (20 mins).
. No signs of peritoneal irritation or systemic si
gns.
. Dx -> U/$.
. Tx -> Elective cholecystectomy.
. N.B. Ingestion of a fatty meal causes the gall b
ladder to contract.
. so .. it presses the gall stones against the cys
tic duct opening,
. increasing the intra gall bladder pressure causi
ng VISCUS DISTENSION & colicky pain.
. Subsequent gall bladder relaxation alows the st
one to fall back from the duct,
. causin the pain to resolve completely.
. Biliary colic pain may be referred to right shou
lder.
. N.B. Pain of biliary colic is distinguished from
that of acute cholecystitis by:
. its intermittent nature & relation to meals as w
ell as absence of fever.
(2) ACUTE CHOLECYSTITIS:
_________________________
. PERSISTENT occlusion of the CYSTIC DUCT.
. Caused by a stone.
. Constant pain.
. Fver, leukocytosis & peritoneal irritation in th
e RUQ.
. Dx -> U/$ (Gall stones - Thick walled gall bladd
er - Pericholecystic fluid).
. Tx -> NG suction - NPO - IV fluids - IV antibiot
ics.

. Tx -> Followed by elective cholecystectomy after

6 - 12 wks.
. Tx -> Emergency cholecystectomy is needed if the
re is:
. generalized peritonitis or ephysematous cholecys
titis (i.e. perforation or gangrene).
(3) ACUTE ASCENDING CHOLANGITIS:
_________________________________
. Obstruction of the COMMON BILE DUCT causes obstr
uction & ASCENDING INFECTION.
. High fever & very high WBC count.
. High levels of alkaline phosphatase.
. High levels of total & DIRECT bilirubin.
. Mild elevation of transaminases.
. Tx -> IV antibiotics.
. Tx -> Emergency decompression of the common bile
duct is life saving !
. Decompression by ERCP or PTC (Percutaneous trans
hepatic cholangiogram) or surgery.
. Tx -> Cholecystectomy must follow.
. N.B.
. A pregnancy test sh'd be performed in any woman
of childbearing period age before,
. ordering diagnostic tests such as x-rays or comp
uted tomography scans.
. PRE-OPERATIVE & POST-OPERATIVE CARE:
______________________________________
______________________________________
* PRE-OPERATIVE ASSESSMENT:
____________________________
{1} CARDIAC RISK:
__________________
. Ejection fraction < 35 % -> Prohibits non-cardia
c surgery.
. JVD (sign of CHF) -> Give ACEIs, BB, Digitalis &
Diuretics prior to surgery.

. Recent MI -> Defer surgery for 6 months post MI.

. Severe progressive angina -> Cardiac catheteriza
tion for coronary revascularization.
{2} PULMONARY RISK:
____________________
. Smoking (Compromised ventillation = High pCO2 &
FEV1 < 1.5):
-> Order PFTs to evaluate for FEV1.
-> If FEV1 is abnormal -> Obtain ABG.
-> Cessation of smoking 8 weeks prior to surgery
.
{3} HEPATIC RISK:
__________________
. Bilirubin > 2 mg/dl.
. Prothrombin time > 16.
. Serum albumin < 3.
. Encephalopathy.
-> 40 % mortality with any single risk factors.
-> 80 % mortality if 3 or more risk factors are pr
esent.
{4} NUTRITIONAL RISK:
______________________
. Loss of 20 % of body weight over several months.
. Serum albumin < 3.
. Anergy to skin antignes.
. Serum transferrin < 200 mg/dl.
-> Provide 5-10 days of nutritional supplements (p
referrably via gut) before surgery.
.
on
.
.

N.B. DIABETIC COMA is an ABSOLUTE contraindicati

to surgery.
1st stabilize diabetes.
Rehydrate & normalize acidosis prior to surgery.

. N.B.
. If a pt presents with an acute abdomen due to pe
rforation of hollow abdominal viscus,
. (Rebound tendrness & subdiaphragmatic free intra
peritoneal air on abdominal x-ray),
. the pt will require IMMEDIATE LAPARATOMY !
. Pre-operative naso-gastric tube decompression is
a must.
. Give IV fluids & IV antibiotics.
. In a pt on warfarin due to Af, Warfarin induced
anti-coagulation must be reversed !
. Bec. if it isn't reversed, it will lead to intr
a & postoperative bleeding complications
. The most rapid mean of normalizing PT: restorat
ion of vit K dependent clotting factors.
. through infusion of FRESH FROZEN PLASMA.
. POST-OPERATIVE COMPLICATIONS & MANAGEMENT:
____________________________________________
____________________________________________
{1} MALIGNANT HYPERTHERMIA (Exceeding 104 F):
______________________________________________
. Shortly after the onset of the anesthetic (Halot
hane or succinyl choline).
. Tx -> IV DANTROLENE, 100% oxygen, Acidosis corre
ction & cooling blankets.
. Watch for development of myoglobinuria.
{2} BACTEREMIA (Exceeding 104 F):
__________________________________
. Within 30-45 mins of invasive procedures (UTI in
strumentation).
. 3 successive blood cultures.
. Start empiric antibiotics.
{3} POST-OPERATIVE FEVER (101 - 103 F):
________________________________________

* ATELECTASIS (Day 1):

________________________
-> Lobar or segmental collapse of the lung -> -- l
ung volume.
-> Due to impaired cough & shallow breathing.
-> Due to accumulation of pharyngeal secretions.
-> Due to the tongue prolapsing posteriorly into t
he pharynx.
-> Due to airway tissue edema or residual anesthet
ic effects.
-> Causes significant ventillation - perfusion mi
s-match -> hypoxemia & ++ breathing work
-> Atelectasis is MOST SEVERE at the SECOND POSTOP
ERATIVE DAY NIGHT.
-> As a compensation for hypoxia -> Hyperventilati
on -> Respiratory alkalosis & -- pCO2.
-> Ex -> pH 7.49, pO2 70 mmHg, pCO2 50 mmHg.
-> Prevention: Breathing exercises - Incentive sp
irometry - Forced expiratory techniques.
. N.B.
. Moving from supine to sitting position ++ the fu
nctional residual capacity FRC by 25%.
. ++ FRC prevents post-operative atelectasis.
* "WIND" PNEUMONIA (Day 3):
____________________________
-> CXR -> Infiltrate.
-> Sputum culture.
-> Antibiotics (Hospital acquired pneumonia).
-> Prevention : Post-operative breathing exercises
& incentive spirometry.
* "WATER" URINARY TRACT INFECTION (Day 3):
___________________________________________
-> Urinalysis & urinary culture.
-> Antibiotics.
* "WALKING" DEEP VENOUS THROMBOPHLEBITIS (Day 5):
__________________________________________________
-> Doppler U/$ of deep veins of legs & pelvis.
-> Anticoagulation.

* "WOUND" WOUND INFECTION (Day 7):

___________________________________
-> Antibiotics if only cellulitis.
-> Incision & drainage if abscess is present.
* DEEP ABSCESSES (SUBPHRENIC - PELVIC - SUBHEPATIC
) (Day 10 - 15):
___________________________________________________
________________
-> CT scan of the appropriate body cavity is diagn
ostic.
-> Percutaneous radiologically guided drainage is
therapeutic.
{4} PERIOPERATIVE MYOCARDIAL INFARCTION:
_________________________________________
. Precipitated by hypotension when intraoperative.
. Postoperative MI seldom presents with chest pain
.
. Thrombolytics are contraindicated even in postop
erative setting !
. Mortality rate is higher than for non surgery re
lated MI.
{5} PULMONARY EMBOLUS (Day 7):
_______________________________
. Tachycardia - SOB - Hypoxia & ++ A-a gradient.
. Dx -> CT angiogram.
. Tx -> Anticoagulate with heparin.
. IVC filter if recurrent PE.
{6} ASPIRATION:
________________
. SOB - Hypoxia - Infiltrates on CXR.
. Lavage & remove gastric contents.
. Bronchodilators & respiratory support.
. Steroids don't help.
{7} INTRA-OPERATIVE TENSION PNEUMOTHORAX:
__________________________________________

. Positive pressure breathing; pt becomes progress

ively more difficult to bag.
. BP steadily declines & CVP steadily rises.
. Insert needle to decompress & place chest tube l
ater.
{8} POST-OPERATIVE CONFUSION:
______________________________
. Suspect hypoxia 1st ! (Check ABG).
. Consider sepsis then ! (Get blood cultures & CBC
).
{9} ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$):
________________________________________________
. Bilateral pulmonary infiltrates & hypoxia with n
o evidence of CHF.
. Tx -> PEEP = Positive end expiratory pressure.
{10} DELIRIUM TREMENS (Day 2-3):
_________________________________
. Tachycardia - Hyperthermia - Hypertension - Alte
red mental status.
. Give benzodiazepines (Barbiturates are 2nd line
agents due to low therapeutic range).
. Watch for seizures & rhabdomyolysis.
. N.B.
. Post-operative oliguria & azotemia:
______________________________________
. Oliguria (< 400 cc) of urine output per day.
. Azotemia ( ++ BUN/Creatinine ratio > 20:1) = Ac
ute Pre-renal failure from HYPOVOLEMIA !
. Urinary catheter obstruction should be ruled out
1st.
. Next step is an IV FLUID CHALLENGE.
. N.B.
. Post-operative ileus:
________________________
. An ileus is a functional defect in the bowel mot
ility without physical obstruction.

. Following most abdominal surgeries.

. Nausea, vomiting, abdominal distension, failure
to pass flatus or stools.
. Hypoactive or absent bowel sounds.
. In contrast (Mechanical obstruction e.g. adehsio
ns cause "HYPERactive" bowel sounds).
. Causes of ileus:
-> ++ splanchnic nerve sympathetic tone following
violation of the peritoneum.
-> Local release of inflammatory mediators.
-> Postoperative narcotic (opiate) analgesics e.g
Morphine causes disordered peristalsis.
. N.B.
. Post-operative DVT:
______________________
. DVT occurs due to Virchow triad (Stasis - endoth
elial injury - Hypercoagulability).
. Major surgery is a significant risk factor.
. Pts sh'd be ttt with LMW HEPARIN acutely & warfa
rin for several months.
. Stable pts can be ttt with anticoagulation as ea
rly as 48 - 72 hours after surgery.
. N.B.
. Transfusion reactions:
_________________________
. occur acutely during or immediately following tr
ansfusion of blood products.
. They are immune mediated;
. preformed host antibody reacts with antigens on
transfused blood products,
. causing the release of inflammatory mediators &
complement activation.
. They may be HEMOLYTIC -> Severe reaction that ma
y cause death.
. or NON-HEMOLYTIC -> Dose dependent self limited
reaction with fever & rigors.
. N.B.
. CATHETER (CENTRAL LINE) ASSOCIATED INFECTIONS:
_________________________________________________

. Intra-venous catheters are one of the most commo

n causes of nosocomial infections.
. Femoral central venous catheters carry a higher
risk of bacteremia than subclavian cath
. IV catheter infections are mostly caused by cuta
neous organisms such as STAPHYLOCOCCI.
. Femoral catheters may also cause gram -ve bacter
emia.
. N.B. Post-operative ACUTE ADRENAL INSUFFECIENCY:
___________________________________________________
. Acute onset of nausea, vomiting, abdominal pain,
hypoglycemia & hypotension.
. follows a stressful event e.g. surgical procedur
e.
. Preoperative steroid use -> A steroid sependent
pt is a common scenario (H/O of lupus)!
. Exogenous steroids depress the pituitary-adrenal
axis.
. N.B.
. POST-OPERATIVE MEDIASTINITIS:
________________________________
. May follow a cardiac surgery due ti intra-operat
ive wound contamination.
. Complicates 5 % of sternotomies.
. 14 days postoperative.
. Fever, tachycardia, chest pain, leukocytosis.
. Sternal wound drainage drainage of purulent disc
harge.
. CXR -> WIDENED MEDIASTINUM.
. Tx -> Drainage, surgical debridement with immed
iate closure & prolonged antibiotic ttt.
. High mortality rate.
__________________________________________________
________________________________________
. PEDIATRIC SURGERY:

_____________________
_____________________
. CONDITIONS THAT NEED SURGERY AT BIRTH:
_________________________________________
_________________________________________
. Congenital anomalies constitute the conditions t
hat need surgery at birth.
. The most imp. step is to rule out other associat
ed congenital anomalies.
. VACTER -> Vertebral, Anal, Cardiac, Tracheal, Es
ophageal, Renal & Radial anomalies.
{1} ESOPHAGEAL ATRESIA:
________________________
. Excessive salivation is noted shortly after birt
h.
. Chocking spells are noticed when 1st feeding is
attempted.
. Confirm the diagnosis with an NG tube -> Coiled
in the upper chest on CXR.
. Tx -> Primary surgical repair.
. If surgery needs to be delayed for further worku
p,
. perform gastrotomy to protect the lungs from aci
d reflux.
{2} IMPERFORATED ANUS:
_______________________
. ABSENCE of flatus or stools.
. Look for a fistula near by (to vagina or perineu
m).
. If present, delay repair until further growth (b
ut before toilet training time).
. If not present, a colostomy needs to be done for
high rectal pouches.
{3} CONGENITAL DIAPHRAGMATIC HERNIA:
_____________________________________
. Dyspnea is noted at birth !
. Loops of bowel in left chest are seen on x-ray.
. The primary abnormality is the HYPOPLASTIC LUNG

with FETAL TYPE CIRCULATION.

. Tx -> Endotracheal intubation, low pressure vent
illation, sedation & NG suction.
. Delay repair 3-4 days to allow lung maturation.
{4} GASTROSCHISIS & OMPHALOCELE:
_________________________________
* GASTROSCHISIS:
_________________
. The umbilical cord is NORMAL.
. The defect is to the right of the cord where is
no protective membrane.
. The bowel looks angry & matted.
* OMPHALOCELE:
_______________
. The umbilical cord goes to the defect.
. The defect has a thin membrane (one can see nor
mal looking bowel & little liver slice).
. Tx -> Small defects -> Close small defects prima
rily.
. Tx -> large defects -> Silastic "silo" to protec
t the bowel.
. Manual replacement of the bowel daily until comp
lete closure (in about 1 week).
. Give parenteral nutrition (The bowel will not wo
rk in gastrochisis).
{5} EXSTROPHY OF THE URINARY BLADDER:
______________________________________
. This is an abdominal wall defect over te pubis.
. Refer to a specialized center offering surgical
repair in 1st 1-2 days of life.
. Do NOT delay surgery.
{6} INTESTINAL ATRESIA:
________________________
. Like annular pancreas, it presents with green vo
miting.
. But, instead of double-bubble sign, there are m

ultiple air-fluid levels in the abdomen.

. There is no need to suspect other congenital ano
malies,
. because this condition results from a vascular a
ccident in utero !
. SURGICAL CONDITIONS IN THE FIRST TWO MONTHS OF L
IFE:
___________________________________________________
____
___________________________________________________
____
{1} NECROTIZING ENTEROCOLITIS:
_______________________________
. This shows up as feeding intolerance in prematur
e infants when they are 1st fed.
. There is abdominal distension.
. Rapid drop in platelet count (A sign of sepsis i
n babies).
. Tx -> Stop all feeds.
. Tx -> Broad spectrum IV antibiotics.
. Tx -> IV fluids & nutrition.
. Tx -> Surgery if there are signs of necrosis or
perforation:
. (Abdominal wall erythema - Portal vein gas - Bow
el wall gas).
{2} MECONIUM ILEUS:
____________________
. Feeding intolerance & bilious vomiting.
. Family H/O of cystic fibrosis.
. Dx -> X-ray -> Multiple dilated loops of small b
owel.
. Dx -> X-ray -> Ground glass appearance in lower
abdomen.
. Gastrograffin enema is both diagnostic & therape
utic.
. Diagnostic -> Microcolon & inspissated pellets o
f meconium in the terminal ileum.
. Therapeutic -> Gastrograffin draws fluid in & di

ssolves the pellets.

{3} HYPERTROPHIC PYLORIC STENOSIS:
___________________________________
. Approximately at 3 weeks of age.
. NON-bilious projectile vomiting after each feedi
ng.
. Look for gastric peristaltic waves.
. Palpable "olive-size" mass in the RUQ.
. Dx -> Abd. U/$.
. Tx -> Correct dehydration & associated hypochlor
emic hypokalemic metabloic alkalosis.
. Follow this with Ramstedt pyloromyotomy.
{4} BILIARY ATRESIA:
_____________________
. 6 - 8 weeks old babies.
. Persistent progressively increasing jaundice Con
jugated bilirubin).
. Dx -> Conduct serologies & sweat chloride test t
o rule out other problems.
. Dx -> HIDA scan after 1 week of phenobarbital (A
powerful choleretic).
. If no bile reaches duodenum even e' phenobarbit
al stimulation: Do surgical exploration.
{5} HIRSCHSPRUNG's DISEASE = AGANGLIONIC MEGACOLON
:
___________________________________________________
_
. The most important clue is chronic constipation.
. A rectal exam may lead to explosive expulsion of
stool & flatus,
. followed by relief of abdominal distension.
. Dx -> Full thickness biopsy of rectal mucosa.
. SURGICAL CONDITIONS LATER IN INFANCY:
________________________________________
________________________________________
{1} INTUSSUSCEPTION:

_____________________
. 6 - 12 months old chubby, healthy-looking kids.
. Brief episodes of colicky abdominal pain that ma
kes them double up & squat !
. A vague mass on the right side of the abdomen.
. An empty right lower quadrant.
. CURRANT JELLY STOOLS.
. Dx -> Barium or air enema -> Both diagnostic & t
herapeutic.
. Tx -> Perform surgery if enema fails to achieve
reduction.
{2} MECKEL's DIVERTICULUM:
___________________________
. Lower GI bleeding in a child of pediatric age.
. Dx -> Radioisotope scan -> to look for gastric m
ucosa in the lower abdomen.
__________________________________________________
________________________________________
. ORTHOPEDICS:
_______________
_______________
. GENERAL RULES ABOUT #s:
__________________________
. When you suspect a #, order 2 views at 90 to one
another.
. Always iclude the joints above & below the #.
. CLOSED REDUCTION -> for #s that are not badly di
splaced or angulated.
. OPEN REDUCTION & INTERNAL FIXATION -> for severe
ly displaced or angulated #s.
. Open #s (The broken bone sticking out through a
wound) require cleaning in the OR,
. & reduction within 6 hours from time of injury.
. Always worry about gas gangrene in any deep pene
trating or dirty wounds.

. 3 days later, the pt will be septic with gas cre

pitus.
. Tx -> Large doses of IV penicillin & hyperbaric
oxygen.
. Always perform cervical spine films in any pt wi
th facial injury.
. MANAGEMENT OF COMMON ADULT ORTHOPEDIC #s:
____________________________________________
____________________________________________
{1} CLAVICULAR #:
__________________
. # of the MIDDLE 1/3 -> Brace (Figure 8 sling), r
est & ice.
. # of the DISTAL 1/3 -> Open reduction & internal
fixation to prevent malunion.
. All pts sh'd've a creful neurovascular examinati
on to rule out injury to:
. the underlying brachial plexus & subclavian arte
ry.
. Hearing a loud bruit warrants an angiogram to ru
le out subclavian artery injury.
{2} COLLE's #:
_______________
. Closed reduction & casting.
. Elderly woman falling on an out-stretched hand.
. Painful wrist.
. Dinner fork deformity.
{3} DIRECT BLOW TO ULNE (MONTEGGIA #) or RADIUS (G
ALEAZZI #):
___________________________________________________
___________
. Combination of diaphyseal # & displaced dislocat
ion of the nearby joint.
. Open reduction & internal fixation is needed for
the diaphyseal reduction.
. Closed reduction for the displaced joint.

{4} SCAPHOID #:
________________
. Young adult with fall on an out-stretched hand.
. Persistent pain in the anatomical snuff box.
. Takes > 3 weeks to be seen on x-ray.
. If the initial x-ray is -ve, subsequent x-ray is
done in 7-10 days.
. Wrist x-ray -> Fine radiolucent lines in nondisp
laced scaphoid #.
. Tx -> Wrist immobilization for 6 - 10 weeks.
. Place thumb spica cast to help to prevent non-un
ion.
{5} HIP #:
___________
. Any elderly pt who sustains a fall.
. Look for externally rotated & shortened leg.
. Femoral neck # -> High risk of avascular necrosi
s - Tx: Femoral head replacement.
. Intertrochanteric # -> Open reduction & pinning.
. Femoral shaft # -> Intra-medullary rod fixation.
{6} TRIGGER FINGER:
____________________
. Woman who awakens at night with an acutely flexe
d finger,
. that snaps when forcibly extended.
{7} DE QUERVAIN TENOSYNOVITIS:
_______________________________
. Young mother carrying baby,
. with flexed wrist & extended thumb to stabilize
the baby's head.
. Steroid injection is the best therapy.
{8} DUPUYTREN CONTRACTURE:
___________________________
. Contracture of the palm & palmar fascial nodules
.

. Surgery is the only ttt.

{9} POSTERIOR HIP DISLOCATION:
_______________________________
. H/O of head-on car collision where the knees hit
the dashboard (Orthopedic emergency).
. Differentiate it from hip # by an internally rot
ated leg (The leg is also shortened).
. Emergency ruduction is needed to avoid avascular
necrosis.
{10} KNEE INJURIES:
____________________
(a) Medial & lateral collateral ligament injury:
__________________________________________________
. Caused by a direct blow to the opposite side of
the joint.
. Casting if isolated ligament injury.
. Surgical repair if multiple ligaments injured.
. Medial -> Due to abduction injury to knee - Dx > VALGUS stress test.
. Lateral -> Due to adduction injury to knee - Dx
-> VARUS stress test.
(b) Anterior & posterior cruciate ligament injury
:
___________________________________________________
_
. Swelling & pain.
. Anterior / posterior drawer sign.
. Young athletes need arthroscopic repair.
. Older pts need immobilization & rehabilitation.
. Anterior -> H/O of forceful hyperextension injur
y to knee.
. Effusion is seen rapidly following injury.
. Dx -> Lachman's test, ANTERIOR drawer test & piv
ot shift test.
. Posterior -> H/O of dashboard injury.

. Forceful posterior-directed force on the tibia w

ith knee flexed at 90 dgrees.
. Dx -> POSTERIOR drawe test, REVERSE pivot test &
posterior sag test.
(c) Meniscal injury:
______________________
. Twisting injuries with the foot flexed.
. Medial meniscus is more commonly injured than th
e lateral meniscus.
. POPPING SOUND followed by severe pain at time of
injury.
. Prolonged pain & swelling.
. Localized tendrness at the side of the knee.
. Catching & locking of knee koint on extension (B
UCKET HANDLE TEARS).
. Palpable or audible snap while extending the leg
from full flexion (McMurray's sign).
. Tx -> Arthroscopic repair.
{11} TIBIAL STRESS INJURY:
___________________________
. H/O of military or cadet marches.
. X-ray may be -ve initially.
. Tx -> Cast.
. Order the pt not to bear weight.
. Repeat x-ray in 2 weeks.
{12} ACHILLES TENDON RUPTURE:
______________________________
. Middle-aged man overdoes it at tennis or basketb
all match.
. Pt with H/O of fluoroquinolone use.
. Complaining of sudden "POPPING" & limping.
. Tx -> Casting in equinous position or surgical r
epair.
{13} ANTERIOR SHOULDER DISLOCATION:
____________________________________
. Most common form of shoulder dislocation.
. Direct blow or fall on out-stretched arm.
. Adducted arm & (EXTERNALLY) rotated forearm.

. Numbness over deltoid (Axillary nerve is stretch

ed).
. Easily seen on erect postero-anterior (PA) & lat
eral views.
{14} POSTERIOR SHOULDER DISLOCATION:
_____________________________________
. Pt with recent seizure or electrical burn.
. H/O of an eclampsic pt is common.
. Due to violent muscle contractions during a toni
c-clonic seizure.
. Flattening of the anterior shoulder & prominent
coracoid process.
. Axillary or scapular view x-ray.
. Adducted arm & (INTERNALLY) rotated forearm.
. Inability of external rotation.
. Tx -> Closed reduction.
{15} FEMORAL #:
________________
. Femoral shaft # is an orthopedic emergency.
. Can result in massive blood loss & high rate of
infection.
. Immediate surgery & cleaning within 6 hours is n
eeded.
. N.B.
. Hip #s are common in the elderly,
. 1st -> Stabilization & treatment for pain contro
l & DVT prophylaxis.
. Next -> Discover the etiology of the pt's fall w
ith appropriate investigations.
. Do EKG , CXR & cardiac enzymes !
. N.B.
. Acute shoulder pain after forceful abduction &
external rotation at glenohumeral joint,
. suggests an anterior shoulder dislocation -> AXI
LLARY NERVE INJURY.
{16} NURSEMAID ELBOW:
______________________

. common injury in pre-school children.

. SUBLAXATION of HEAD of RADIUS at ELBOW joint.
. Due to swinging a young child by the arms or pul
ling a child arm while in a hurry.
. The child will be calm but will cry on an attem
pt to flex the elbow or supinate forearm
. Dx -> Clinically (Radiographs are often normal).
. Tx -> GENTLE PASSIVE ELBOW FLEXION & FOREARM SUP
INATION.
. 1st -> Extend & distract the elbow.
. Next -> Supinate the forearm.
. Hyperflex the elbow with your thumb over he radi
al head to feel reduction.
. No post reduction films are needed.
. The child will resume the use of the previously
unused extremity without crying.
* COMPARTMENT $YNDROME:
________________________
. Most frequent in the forearm or lower leg.
. H/O of prolonged ischemia followed by reperfusio
n, crushing injuries or other traumas.
. Pain & tightness & tenderness to palpation at th
e affected area.
. EXCRUCIATING PAIN with PASSIVE EXTENSION.
. Pulses may be normal !!
. Tx -> 1st step is emergent fasciotomy.
. N.B. When a pt complains of pain at the site of
a cast,
. Always remove the cast & examine for compartment
$.
. N.B. ISCHEMIA REPERFUSION $YNDROME:
. A form of compartment $.
. Extremeties subjected to at least 4-6 hours of i
schemia,
. suffer from intracellular & interstitial edema
upon reperfusion (SOFT TISSUE SWELLING).
. When edema causes the pressure within a muscular
fascial compartment to rise > 30 mmHg

. compartment $ occurs leading to further ischemic

injury to the confined tissue.
. N.B.
. Escharotomy is indicated for circumferential ful
l thickness burns of an extremity,
. with an eschar causing significant edema & const
riction of the vascular supply.
. Pts sh'd be evaluated for clinical signs of adeq
uate perfusion after escharotomy.
. Fasciotomy sh'd be done if there is NO signs of
relef.
* NEURO-VASCULAR INJURIES:
___________________________
___________________________
. OBLIQUE DISTAL HUMERUS #:
____________________________
. Radial nerve injury.
. Inability to dorsiflex (extend) the wrist.
. Function regained after reduction.
. Surgery is indicated if paralysis persists after
reduction.
. POSTERIOR KNEE DISLOCATION:
______________________________
. Popliteal artery injury.
. Decreased distal pilses.
. Doppler studies or arteriogram.
. Prophylactic fasciotomy if reduction is delayed.

. BACK PAIN:
_____________
_____________
{1} DISC HERNIATION:
_____________________
. Sudden onset severe back pain after lifting heav

y object.
. Electric shock like pain shooting down the leg.
. Straight leg raising test gives excruciating pai
n.
. Mostly lumbar in origin L4, L5 & S1.
. Peak age 43-46 ys.
. Tx -> Anti-inflammatories & brief bed rest.
. Immediate surgical compression is needed if the
H/O suggests Cauda equina $.
. (Bowel/Bladder incontinence - flaccid anal sphin
cter - Saddle anesthesia).
. MRI -> Confirm both disc herniation & causa equi
na.
. Trial of anti-inflammatories is always the 1st s
tep in management.
{2} ANKYLOSING SPONDYLITIS:
____________________________
. Man in his 30s or early 40s.
. Chronic back pain.
. Morning stiffness improving with activity.
. X-ray -> Bamboo spine.
. Associated with HLA B-27 antigen (Screen for uve
itis & IBD).
. Tx -> Anti-inflammatory agents & physical therap
y.
{3} METASTATIC MALIGNANCY:
___________________________
. Elderly pt with progressive & constant back pain
.
. Worse at night & unrelieved by rest.
. H/O of weight loss.
. X-ray -> Lytic lesions or blastic lesions.
. Blastic metastatic lesions -> Prostate cancer &
breast cancer.
. Lytic metastatic lesions -> Lung, renal, breast,
thyroid & multiple myeloma.
. Hypercalcemia & ++ ALP.
. 1st -> Order plain radiographs (Especially impor
tant in multiple myeloma).
. Bone scan is most sensitive in early disease.

. MRI shows the greatest amount of details.

. MRI -> test of choice if there are any neurologi
c syms to rule out cord compression.
. Bone scan will not be helpful in purely lytic le
sions (Multiple Myeloma).
. Instead order plain radiographs or MRI.
* FOOT PAIN:
_____________
_____________
. PLANTAR FASCIITIS:
_____________________
. Older, overweight pts with sharp heel pain ever
y time their foot strikes to the ground.
. Pain is worse with walking & in the mornings.
. X-ray -> Bony spur matching the location of the
pain.
. Exquisite tenderness to palpation over the spur.
. Burning pain in nature.
. More common in runners with repeated microtrauma
,
. who develop local point tendrness on plantar asp
ect of foot.
. However, surgical resection of the bony spur is
not indicated !
. MORTON NEUROMA:
__________________
. Inflammation of the common digital nerve at the
3rd interspace.
. Between the 3rd & 4th toes.
. Mechanically induced neuropathic degeneration.
. Numbness & burning of the toes, aching & burning
in the distal forefoot.
. Pain radiates forward from the metatarsal heads
to the 3rd & 4th toes.
. PALPATION & SQUEEZING the metatarsal joints -> C
LICKING SENSATION (MULDER SIGN).
. Caused by wearing pointy-toed shoes.

. The neuroma is palpable with very tender spot th

ere.
. Management is analgesics & appropriate foot wear
.
. STRESS # = HAIR LINE #:
__________________________
. Sudden ++ in repeated tension or compression wit
hout adequate rest.
. Sharp localized pain over a bony surface that is
worse with palpation.
. The tibia is the most common bone in the body to
be affected by stress #s.
. Occur in the anterior part of the middle 1/3 of
the shin of tibia in jumping sport pts.
. Occur in the postero-medial part of the distal 1
/3 of the tibia in runners.
. X-ray are frequently normal during initial evalu
ation.
. Stress # of the meta-tarsals are common in athel
etes & military recruits.
. The 2nd metatarsal is the most commonly injured.
. Tx -> Rest, analgesia & a hrd soled shoe.
. TARSAL TUNNEL $YNDROME:
__________________________
. Compression of the tibial nerve as it passes thr
ough the ankle.
. Usually caused by a # of the bones around the an
kle.
. Burning, numbness & aching of the distal plantar
surface of foot or toes.
. Pain may radiate up to the calf.
__________________________________________________
________________________________________
* UROLOGY:
___________
___________

. VARICOCELE:
______________
. Tortuous dilatation of pampiniform plexus of ve
ins surrounding spermatic cord & testis.
. Results from incompetence of the valves of the t
esticular vein.
. Occurs most frequently on the left side, bec.
. Lt testicular vein enters Lt renal vein inferio
rly at right angle -> impaired drainage.
. Dull or dragging discomfort scrotal pain that be
comes worse on standing.
. Examination -> Bag of worms (Enlarge with Valsal
va maneuver).
. NEGATIVE TRANSILLUMINATION.
. HYDROCELE:
_____________
. Due to fluid accumulation in tunica vaginalis.
. POSITIVE TRANSILLUMINATION.
. TESTICULAR NEOPLASIA:
________________________
. Painless testicular mass with negative transillu
mination.
. SPERMATOCELE:
________________
. Cystic dilatations of the efferent ductules.
. Painless fluif-filled cysts containing sperms.
. Located on superior pole of testis in relation t
o epididymis.
. +ve transillumination.
. TESTICULAR TORSION:
______________________
. Severe, sudden onset testicular pain.
. NO fever - NO pyuria.
. The testis is swollen & exquisitely tender.
. High riding testicle with transverse lie.
. Dx -> U/$.
. Tx -> Immediate surgical intervention with bilat

eral orchipexy.
. ACUTE EPIDIDYMITIS:
______________________
. Acute scrotal pain (may be referred to abdomen).
. FEVER & urinary symptoms.
. Dx -> Urinalysis & urine cultures & discharge cu
lture if present.
. Tx -> Males < 35 ys -> Treat for gonorrhea & chl
amydia -> Ciprofloxacin & Doxycycline.
. Tx -> Older males -> Treat as UTI (E-coli) with
Levofloxacin.
. UROLOGIC OBSTRUCTIONS:
_________________________
. Combination of obstruction & infection is a urol
ogic emergency.
. It can lead to destruction of the kidney in few
hours.
. Tx -> Immediate decompression of the urinary tra
ct above the obstruction.
. Tx -> IV antibiotics are given to prevent infect
ion.
. Tx -> A ureteral stent or percutaneous nephrosto
my is the most important intervention.
. N.B.
. Urinary calculi present as flank or abdominal pa
in radiating to the groin.
. Nausea & vomiting is common.
. Unlikepts with an acute abdomen, pts with urinar
y stones are WRITHING in pain.
. Unable to sit still in exam room (No peritoneal
irritation so movements don't ++ pain).
. Dx -> A NON-contrast spiral CT of the abdomen &
pelvis is the most accurate test.
. Dx -> X-ray can miss radio-lucent urinary stones
(15 % of stones).
. N.B.
. Nephrolithiasis

. Flank pain & hematuria accompanied by nausea & v

omiting.
. Pts with Chron's disease or small bowel dis -> F
at malabsorption.
. Fat malabsorption -> predispose to hyperoxaluria
.
. Oxalate is obtained from diet & is a normal prod
uct of human metabolism.
. Symptomatic hyperoxaluria is the result of ++ ox
alate absorption in the gut.
. Under normal circumstances: Calcium binds oxala
te in the gut preventing its absorption.
. In pts with fat malabsorption, Ca is bound by fa
t leaving oxalate free & unbound.
. Failure to adequately absorb bile salts in cases
of fat malabsorption,
. leads to -- bile salt reabsorption in small inte
stine.
. Excess bile salts may damage colonic mucosa -> +
+ oxalate absorption.
. CONGENITAL UROLOGIC DISEASES:
________________________________
________________________________
{1} POSTERIOR URETHRAL VALVE:
______________________________
. The most common cause for a new born boy not to
urinate during the 1st day of life.
. Dx -> Voiding cystourethrogram.
. Tx -> Catheterize to empty the bladder.
{2} HYDROCELE:
_______________
. Fluid collection within the processus vaginalis
or tunica vaginalis.
. Peritoneal fluid accumulation -> hydrocele
. POSITIVE TRANSILLUMINATION.
. Tx -> REASSURANCE -> Will resolve spontaneously
by the age of 12 months.
. Tx -> If not resloved by 12 months -> Surgical r

emoval to avoid inguinal hernia.

{3} HYPOSPADIUS:
_________________
. Urethral opening at the ventral side of the peni
s.
. Never to perform circumcision on this child.
. The prepuce will be needed for the plastic recon
struction.
. N.B. A child who has HEMATURIA from TRIVIAL TRAU
MA,
. has an undiagnosed congenital anomaly until prov
en otherwise.
.
.
en
.
.
.

N.B. A child who has URINARY TRACT INFECTION,

has an undiagnosed congenital anomaly until prov
otherwise.
e.g. vesico-ureteral reflux.
Dx -> Voiding cystourethrogram.
Tx -> Long term antibiotics.

{4} LOW IMPLANTATION OF A URETER:

__________________________________
. A girl who void appropriately but also found to
be constantly wet,
. due to urinating into vagina.
{5} URETERO-PELVIC JUNCTION (UPJ) OBSTRUCTION:
_______________________________________________
. Only symptomatic when diuresis occurs.
. A teenager who drinks large volumes of beer & de
velops colicky flank pain.
__________________________________________________
________________________________________
. VASCULAR SURGERY:
____________________
____________________

{1} SUBCLAVIAN STEAL $YNDROME:

_______________________________
. Due to an arteriosclerotic stenotic plaque at th
e origin of subclavian artery.
. This allows enough blood to reach the arm for no
rmal activity, but,
. Not enough to meet the ++ demands of an exercise
d arm,
. resulting in BLOOD BEING STOLEN FROM THE VERTEBR
AL ARTERY.
. Posterior neurological signs (Visual symptoms Equilibrium problems).
. Claudication in the arm during arm exercises.
. Don't confuse this condition with thoracic outle
t $!
. Thoracic outlet $ causes vascular symptoms only
with-OUT neurological signs.
. Dx -> Angiography.
. Tx -> Bypass surgery.
{2} AORTIC ANEURYSM:
_____________________
. Size & symptoms are key to management of "ABDOMI
NAL" aortic aneurysm:
-> Aneurysms < 5cm -> Observe with serial annual i
maging.
-> Aneurysms > 5cm -> Elective surgical repair.
. More urgent surgery is needed if:
-> A TENDER AAA will rupture within a day or two r
equiring urgent repair.
-> Excruciating back pain in a pt e' large AAA mea
ns that,
. the aneurysm is already leaking, necessitating
emergency surgery.
. N.B. The following contributes to the developmen
t of "THORACIC" aortic aneurysm:
-> Chronic hypertension.
-> Hyperlipidemia.

-> Smoking.
-> Marfan $.
-> Untreated tertiary $yphilis.
. N.B. The most imp. modifiable risk to prevent wo
rsening of existing aneurysms is:
-> UNCONTROLLED HYPERTENSION.
. N.B. Asymptomatic lesions -> BLOOD PRESSURE MANA
GEMENT is the most important.
. N.B. Symptomatic lesions (including active disse
ction) -> Surgical intervention.
. (Look for sudden onset tearing pain in the back)
.
{3} ARTERIOSCLEROTIC OCCLUSIVE DISEASE OF THE LOWE
R EXTREMETIES:
___________________________________________________
______________
. Pain in the legs on exercise that is relieved by
rest (intermittent claudication).
. If the claudication doesn't affect the pt's life
style -> No intervention is needed.
. The only management indicated is CESSATION OF SM
OKING & THE USE OF CILOSTAZOL.
. If the pain is more severe,
. Dx -> Doppler studies (Pressure gradient ABI < 0
.9).
. Dx -> Arterigram to identify stenosis.
. If there is DISABLING symptoms (Affect work or d
aily life activity),
. or there is impending ischemia to the extremity,
. Tx -> SURGERY (Angioplasty & stenting for stenot
ic segments).
. More extensive disease requires bypass grafts or
sequential stents.

. N.B. PAIN AT REST indicates END STAGE DISEASE (P

t complains of calf pain at night).
. N.B. VVVVVVVVVVVVVVVVV. imp.
. The 1st step in evaluating a pt with suspected p
eripheral artery disease (PAD) is:
. to obtain an ANKLE-BRACHIAL INDEX (ABI) to confi
rm the diagnosis.
. Aspirin & cilostazol are antiplatelet agents tha
t can be given after confirming PAD.
. They are not given upon clinical suspicion !
. Pts with significant symptoms & NORMAL ABI may h
ave MILD diesase at rest.
. They sh'd undergo EXERCISE TESTING with pre & po
st exercise ABI measurment to confirm.
. ABI (1.0 - 1.3) -> Normal.
. ABI < 0.9 -> > 50 % occlusion of a major vessel.
. ABI < 0.4 -> Limb ischemia.
. N.B. ISCHEMIA REPERFUSION $YNDROME:
. A form of compartment $.
. Extremeties subjected to at least 4-6 hours of i
schemia,
. suffer from intracellular & interstitial edema
upon reperfusion (SOFT TISSUE SWELLING).
. When edema causes the pressure within a muscular
fascial compartment to rise > 30 mmHg
. compartment $ occurs leading to further ischemic
injury to the confined tissue.
. N.B. COMPARTMENT $ 5 "P"s:
____________________________
. May be caused by direct trauma (Hemorrhage), pro
longed compression of an extremity.
. May be caused after revascularization of an acut
ely ischemic limb.
. Muscles of extremity are encased in fascial comp
artments preventing tissue expansion.

. The ++ pressure interferes with perfusion leadin

g to muscle necrosis.
. Pressure > 30 mmHg leads to cessation of blood f
low through capillaries.
. Tx -> EMERGENT FASCIOTOMY.
-> Pain
. Earlest symptom.
. ++ by passive stretch of the muscles in the af
fected compartment.
-> Paresthesia
. Burning or tingling sensation.
. occurs in the distribution of the affected per
ipheral nerve.
-> Pallor
. of the overlying skin
. result from tense swelling & compromised perfu
sion.
-> Pulselessness
. Late finding.
. Presence of a pulse on exam does NOT rule out
compartment $.
-> Paresis/Paralysis
. Late finding.
. resilt from nerve & muscle ischemia & necrosis
.
. N.B. ESCHAR !
. Eschar is a firm necrotic tissue formed on on ex
posed tissue following burn wounds.
. When eschar occurs circumferentially on an extre
mity,
. it restricts the outward expansion of the compar
tment as edema follows burn.
. Interstitial pressure increases -> compromise va
scular flow to the limb.
. Deep pain out of proportion to injury, pulseless

ness, paresthesia, cyanaosis & pallor.

. Tx -> Escharotomy.
. N.B. Compartment $ 2ry to SUPRA-CONDYLAR # of hu
merus:
. 2ry to fall on out-stretched hand.
. Due to ++ pressure in a limited space.
. Pain, pallor, pulselessness, paralysis & presthe
sia.
. Tx -> Immediate fasciotomy.
. N.B. VOLKMANN's ISCHEMIC CONTRACTURE:
. is the final sequel of compartment $ (The dead m
uscle is replaced by fibrous tissue).
{4} ARTERIAL EMBOLIZATION OF THE EXTREMETIES:
______________________________________________
. H/O of Af or recent MI.
. Sudden onset painful, pale, cold, pulseless, par
esthetic & paralytic lower extremity.
. Dx -> Doppler studies to locate the obstruction.
. Tx -> Thrombolytics (if early) & Embolectomy (if
later) with fasciotomy.
. N.B. LERICHE $YNDROME = AORTO-ILIAC OCCLUSION:
_________________________________________________
. Arterial occlusion at the bifurcation of the aor
ta in the common iliac arteries.
. Triad of bilateral hip, thigh & buttock claudic
ation, impotences &
. symmetric atrophy of the bilateral lower extreme
ties due to chronic ischemia.
. Absence of impotence excludes the condition.
. N.B. SPINAL CORD ISCHEMIA:
_____________________________
. Follows aortic vascular surgery due to anterior
spinal artery $.

. The spinal cord derives its blood supply from th

e:
. anterior spinal artery & 2 posterior spinal art
eries originating from vertebral artery.
. Presents with flaccid paralysis, bowel/bladder d
ysfunction, sexual dysfunction.
. Possible hypotension & loss of deep tendon refle
xes.
. Spasticity & hyperreflexia develop over days to
weeks.
. Vibratory & proprioceptive sensation is preserv
ed as posterior circulation is preserved
. Dx -> Emergent MRI.
. Tx -> Supportive care & lumbar drains to reduce
spinal pressure.
__________________________________________________
________________________________________
. MISCELLANEOUS TOPICS:
________________________
________________________
. GASTRIC OUTLET OBSTRUCTION:
______________________________
. Can be caused by many diseases causing mechanica
l obstruction e.g.
. Gastric malignancy - Peptic ulcer disease - Chr
ons dis - Strictures e' pyloric stenosis
. Strictures 2ry to ingestion of caustics.
. Characterized by early satiety, nausea, non-bili
ous vomiting & weight loss.
. P/E -> ABDOMINAL SUCCUSSION SPLASH, elicited by
placing the stethoscope,
. over the upper abdomen & rocking the pt back & f
orth at the hips,
. Retained gastric material > 3 hours after a mea
l will generate a splash sound,
. indicating the presence of a hollow viscus fille
d with both fluids & gas.

. In a pt with a H/O of acid ingestion, pyloric st

ricture is the most likely cause.
. H/O of a recent acid ingestion is a risk factor
of developing pyloric stricture.
. Acid ingestion causes fibrosis 6-12 weeks after
the resolution of acute injury.
. Dx -> Upper endoscopy.
. Tx -> Surgery.
. TOTAL BODY BURN & SYSTEMIC INFLAMMATORY RESPONSE
$:
___________________________________________________
___
. Systemic inflammation & tissue injury.
. Burn -> Dysregulated host response,
. Massive uncontrolled release of proinflammatory
substances -> extensive tissue damage.
. This is known as systemic inflammatory response
$yndrome:
-> Temperature -> > 38.5 c (101.3 F) or < 35 c (95
F) !!!!!
-> Pulse -> > 90/min.
-> Respirations -> > 20/min.
-> WBC > 12000 or < 4000 or > 10 % bands !!!!
. SIR$ can follow pancreatitis, autoimmiune dis, v
asculitis & burns.
. Sepsis (SIRS e' a known infection) is considere
d severe when there is end organ failure
. Oliguria - Hypotension (SBP < 90mmHg) - Thromboc
ytopenia (PLT < 80000).
. Metabolic acidosis - Hypoxemia.
. Hyperglycemia occur due to insulin resistance.
. Muscle wasting & protein loss & Hyperthermia.
. Sepsis with septic shock may occur in the 1st we
ek post-burn.
. Main causes of sepsis are pneumonia & wound infe
ctions (Staph aureus & Pseudomonas).

. Criteria indicating sepsis -> Leukocytosis - Thr

ombocytopenia - Mild hypothermia < 36.
. Tachypnea & tachycardia due to associated pneumo
nia.
. Worsening hyperglycemia due to worsening insulin
resistance.
. Bottom line:
. In pts with severe significant total body surfac
e areas burns,
. The major cause of morbidity & mortality is HYPO
VOLEMIC SHOCK.
. In case of adequate initial fluid resuscitation,
. Bacterial infection (Bronchopneumonia or burn w
ound infection) -> Sepsis & septic shock
. INTRA-PERITONEAL RUPTURE OF THE BLADDER:
___________________________________________
. Intra-abdominal pathology causing shoulder pain
= Subdiaphragmatic peritonitis.
. Among the possible blunt traumatic bladder injur
ies,
. Only an INTRA-PERITONEAL RUPTURE OF THE (BLADDER
DOME) -> CHEMICAL PERITONITIS.
. The dome of the bladder is the only region cover
ed by peritoneum.
. Pain could be transferred to the ipsilateral sho
ulder because,
. Phrenic nerve originates from C3 to C5 spinal n
erves mediating sensation for shoulders.
. INTRA-ABDOMINAL MALIGNANCY (CANCER PANCREAS):
________________________________________________
. Day time fatigue, anorexia, significant weight l
oss.
. Visceral type abdominal pain interfering with sl
eep.
. Constant eigastric pain radiating to the back, w

eight loss & jaundice.

. Migratory thrombophlebitis is a classic associat
ion.
. N.B.
. A peptic duodenal ulcer causes periodic epigastr
ic pain relieved by meals.
. PILO-NIDAL SINUS:
____________________
. Acute pain & swelling of the midline sacro-coccy
geal skin & subcutaneous tissues.
. Due to infection of a dermal sinus tract origina
ting over the coccyx.
. RIB #:
_________
. Pain relief is the prime objective in management
of rib #.
. As it allow proper ventillation & prevent atelec
tasis & pneumonia.
. TETANUS PROPHYLAXIS:
_______________________
_______________________
. Un-immunized, uncertain or < 3 tetanus toxoid do
ses:
___________________________________________________
____
. Minor clean wound -> Tetanus toxoid only.
. Severe or dirty wound -> Tetanus toxoid & tetanu
s immunoglobulins.
. > 3 tetanus toxoid doses:
____________________________
. Minor & clean wound -> None.
. Severe or dirty wound -> Tetanus toxoid if lates
t boster given > 5 years ago.

. N.B. Tetanus-diphtheria toxoid sh'd be given to

individuals with severe or dirty wounds
. who received a booster > 5ys ago
. & those with minor clean wounds who received a b
ooster dose > 10 ys ago.
. N.B. Tetanus immune globulin sh'd be given to an
y individual with severe dirty wound
. & unclear or incomplete immunization history.
. CO CARBON MONOXIDE POISONING:
________________________________
. H/O of smoke inhalation.
. CO is a tasteless, colorless & odorless gas.
. It has affinity 200 times more than O2 for hemog
lobin.
. Confusion, wheezes, headache, nausea, dyspnea, m
alaise, altered mentation, dizziness.
. If severe -> Seizure, coma, syncope, heart failu
re & arrhythmias.
. Bright cherry lips can be seen but not specific.
. Dx -> ++ Carboxyhemoglobin level > 3 % in non-sm
okers & > 15 % in smokers.
. Tx -> 100 % OXYGEN NON-BREATHER FACE MASK.
__________________________________________________
________________________________________
. BREAST PROBLEMS:
__________________
__________________
. 1 . INTRA-DUCTAL PAPILLOMA:
______________________________
. Benign breast disease.
. Most common in peri-menopausal women.
. Intermittent BLOODY discharge from one nipple.
. Most intraductal papillomas are situated beneath

the areola.
. Difficult to palpate on physical examination due
to their small sizes (< 2 mm).
. Soft in consistency.
. U/$ will be normal because it can detect masses
only greater than 1 cm in diameter.
. 2 . FIBRO-CYSTIC DISEASE:
____________________________
. Very common in pre-menopausal women.
. Bilateral breast pain.
. Associated with cystic changes of the breast.
. Benign condition.
. Symptoms vary cyclically with the menstrual cycl
e.
. P/E -> Lumpiness of the breast.
. 3 . FIBRO-ADENOMA:
_____________________
. Solitary breast lesion.
. Painless, firm, mobile breast lump.
. Average size about 2 cm.
. Women ages 15 - 25 ys.
. Benign condition.
. Do NOT change with menstrual cycle.
. 4 . DUCTAL CARCINOMA IN-SITU:
________________________________
. Post-menopausal women.
. Incidental finding on mammography.
. Nipple discharge & breast mass are the most comm
on complaints.
. It is a HISTOLOGICAL diagnosis.
. 5 . INFLAMMATORY BREAST CARCINOMA:
_____________________________________
. Brawny edematous cutaneous plaque.
. "P'eau d'orange" orange peel appearance overlyin
g a breast mass.
. It is an aggressive tumor.
. 1/4 of the pts have metastatic disease at the ti
me of presentation.

. Most pts present with axillary lymphadenopathy.

. Spontaneous nipple discharge is a sign of breast
cancer.
. Nipple discharge in a non-lactating woman sh'd a
lways raise suspicion for cancer,
. spontaneous, unilateral, localized to single duc
t, bloody discharge in pt > 40 ys old.
. Mass association is an imp. sign of malignancy.
. Clinicalyy, you can't differentiate it from an i
nflammatory process (breast abscess).
. A BIOPSY FOR HISTOLOGY IS THE MAIN STAY OF DIAGN
OSIS !
. PALPABLE BREAST MASS EVALUATION:
___________________________________
PALPABLE BREAST
MASS
_________________
_____
|
______________________
__________
|
|
< 30 ys
> 30 ys
|
|
ULTRASONOGRAM ONLY
MAMMOGRAM & ULTRASONOGRAM
|
|
____________________
|
|
|
|
SIMPLE CYST
SOLID MASS
USPICIOUS FOR MALIGNANCY
|
|
|

NEEDLE ASPIRATION
CORE BIOPSY

CORE BIOPSY

. N.B.
. BREAST FAT NECROSIS
. shows clinical signs & radiographic findings sim
ilar to breast cancer !
. Syms include (Skin or nipple retraction - Calcif
ication on mammography).
. Biopsy of the mass -> FAT GLOBULES & FOAMY HISTI
OCYTES.
. No ttt is indicated (Self limiting condition).
__________________________________________________
________________________________________
. SPINAL CORD INJURIES:
________________________
________________________
. ANTERIOR CORD $YNDROME:
__________________________
. Burst # of the vertebra -> Occlusion of vertebra
l artery.
. Total loss of the motor function below the level
of the lesion.
. Loss of pain & temperature on both sides below t
he lesion.
. NORMAL proprioception.
. NEGATIVE Straight leg raising test.
. Dx -> MRI.
. CENTRAL CORD $YNDROME:
_________________________
. Hyperextension injury in elderly pts with degene
rative diseases of the cervical spine.
. Selective damage to the central portion of the s
pinal cord.
. specially the corticospinal & decussating fibers
of the lateral spinothalamic tracts.
. Burning pain & paralysis in the UPPER extremetie
s e' relative SPARING of lower limbs.

. POSTERIOR CORD $YNDROME:

___________________________
. Bilateral loss of vibratory & proprioceptive sen
sation.
. BROWN SEQUARD $YNDROME:
__________________________
. Acute hemisection of the spinal cord.
. Ipsilateral motor & proprioception loss below th
e level of the lesion.
. Contralateral pain loss below the level of the l
esion.
. ACUTE DISK PROPLAPSE:
________________________
. Severe radicular pain.
. +ve Straight leg raising test.
. CAUDA EQUINA $YNDROME:
_________________________
. Paraplegia.
. Variable sensory loss.
. Urinary & fecal incontinence.
. SYRINGOMYELIA:
_________________
. May follow spine cord trauma.
. Whiplash is often the incinting injury.
. Symptoms develop months to years later.
. Enlargement of the central canal of the spinal c
ord due to CSF retention.
. Impaired strenght & pain/temperature sensation i
n upper extremeties.
. Preservation of dorsal column function (Light to
uch - vibration - position sense).
. CAPE LIKE DISTRIBUTION.
__________________________________________________
________________________________________
. # Mid-shaft humerus -> Radial nerve injury -> Wr

ist drop.
. # Supracondylar humerus -> Brachial artery -> p
ain, pallor, pulselessness, paresthesia.
. # Humerus -> Ulnar nerve -> Claw hand.
. ROTATOR CUFF TEAR:
_____________________
. Rotator cuff is formed by tendons of:
. (supraspinatous, infraspinatous, teres minor & s
ubscapularis muscles).
. The supraspinatous is most commonly injured,
. due to repeated bouts of ischemia near its inser
tion on the humerus,
. induced by its compression between the humerus &
the acromion.
. Common cause of tear is fall on out-stretched ha
nd.
. Severe shoulder pain & edema following the traum
a.
. Inability to abduct the arm at 90 degrees.
. When the pt's arm is abducted passively to great
er than 90 degrees,
. And the pt is asked to lower the arm slowly; the
pt's arm drops suddenly !
. N.B.
. D.D. for rotator cuff tear is "RUPTURE OF TENDON
OF LONG HEAD OF BICEPS";
. POSITIVE POPEYE SIGN (The biceps muscle belly be
comes prominent in the mid upper arm.
. PAGET'S DISEASE OF BONE = OSTEITIS DEFORMANS:
________________________________________________
. Disordered bone remodelling.
. ++ Osteoclast activity -> ++ bone resorption.
. Accelereated osteoblastic activity to rebuild th
e degraded bone.
. WOVEN BONE formation (Various stages of bone thr
oughout the body).
. The woven bone is larger than normal bone & more

liable to bowing & #.

. Most common presenting symptom is secondary arth
ritis of hip or knee.
. ++ ALKALINE PHOSPHATASE.
. NORMAL serum phosphorous & calcium levels.
. Enlargement of skull bones -> Bossing, ++ head s
ize (Old hats no longer fits!).
. Headaches & cranial nerve palsies.
. Hearing loss is due to damage of the cochlear ne
rve,
. due to enlargement of the temporal bone & entrap
ment at the internal auditory meatus.
. VARICES:
___________
. NON-BLEEDING VARICES are managed with BB "Prpora
nolol".
. After 1st episode of bleeding -> Sclerotherapy,
endoscopic band ligation & surgery.
. If not responsive to medical or endoscopic inte
rvention -> Porto-systemic shunt (TIPS).
. RESPIRATORY QUOTE (RQ):
__________________________
. RQ is the ratio bet. CO2 produced to O2 consumed
.
. Used to make assessmentsof metabolism taking pla
ce in the body.
. In mechanically ventillated pt, the RQ is 1.05.
. The ratio depends upon the major fuel being oxid
ized for ATP production.
. An RQ close to 1 indicates that CARBOHYDRATE is
the major nutrient being oxidized.
. The RQ for protein & lipid as sole energy source
s are 0.8 & 0.7 respectively.
. Massive atelectasis could affect ABG, but once a
new steady state is achieved,
. the RQ value w'd still depend only upon the natu
re & proportions of metabolics used.

. TROCHANTERIC BURSITIS:
_________________________
. Unilateral hip pain in a MIDDLE-AGED adult.
. Inflammation of the bursa around the insertion o
f gluteus medius greater trochanter.
. Excessive frictional forces 2ry to overuse or tr
auma are common causes.
. Hip pain when pressure is applied (When sleeping
) & external rotation or abduction.
. FEMORAL HEAD AVASCULAR NECROSIS = LEGG CALVE' PE
RTHES DISEASE:
___________________________________________________
______________
. Boys between 4 & 10 ys with peak incidence bet.
5 & 7 us.
. Hip, groin or knee pain + Antalgic pain.
. Dx -> X-ray -> Flattened & fragmented femoral he
ad.
. Alternating regions of lucency & density = Refle
cts of necrotic tissue by new bone.
. Tx -> Conservatively with observation & bracing.
. Tx -> Surgery in cases where femoral head isn't
well contained within the acetabulum.
. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE):
____________________________________________
. Obese male child with pain during LATE CHILDHOOD
or EARLY ADOLESCENCE.
. Metaphysis & femur slip relative to the epiphysi
s at the epiphyseal plate.
. The capital femoral epiphysis remains structural
ly intact within the acetabulum.
. Loss of abduction & internal rotation of the hip
.
. Loss of external rotation of the thigh while the
hip is flexed.
. Dx -> FROG-LEG LATERAL X-RAY VIEW (Diagnostic).
. Tx -> SURGICAL PINNING to avoid avascular necros

is.
. TRENDELENBURG SIGN:
______________________
. Drooping of the contralateral pelvis when the pt
stands on one foot.
. Associated with TRENDELENBURG gait (Waddling) ca
used by the trunk rocking,
. to compensate for the pelvic drooping !
. Caused by weakness or paralysis of the gletues m
edius & minimus muscles,
. due to superior gluteal nerve trauma or inflamma
tion or entrappment.
. The pt presents with unilateral intermittent kne
e pain.
. Physical activity e.g. stair clumbing exacerbate
s the pain.
. Hip tenderness is common.
. SQUAMOUS CELL CARCINOMA:
___________________________
. Suspected in all non-healing wounds.
. SCC may arise within chronicallu wounded, scarre
d or inflammaed skin.
. SCC arising within burn wounds is known as MARJO
LIN ULCER.
. SCC arise in skin overlying a focus of osteomyle
itis, radiotherapy or venous ulcers.
. SCC arising within chronic wounds exhibit aggres
sive behavior.
. Early diagnosis is the key to prevent metastatic
spread
. A biopsy sh'd be obtained in all chronic wounds
failing to heal to rule out malignancy.
. BASAL CELL CARCINOMA:
________________________
. Presents on chronically sun-exposed skin.
. Lesions are PEARLY TELANGIECTATIC papules with a
central RODENT ulceration.

. BILATERAL LOWER LIMB EDEMA & STASIS DERMATITIS:

__________________________________________________
. Both are due to lower extremity venous valvular
incompetence.
. resulting in pooling of venous blood & ++ pressu
re in post-capillary venules.
. ++ pressure = VENOUS HYPERTENSION.
. ++ pressure -> Damages capillaries -> Loss of fl
uid, plasma ptns & RBCs into tissue.
. Erythrocytes extravasation -> Hemosiderin deposi
tion & bluish discoloration.
. May be complicated by venous ulcers.
. It involves the medial leg below the knee & abov
e the medial malleolus.
. Xerosis is the most common early finding.
. Lipodermatosclerosis & venous ulcerations are la
te findings.
. RETRO-PERITONEAL HEMORRHAGE:
_______________________________
. An iatrogenic complication after cardiac cathete
rization.
. After cannulation of the femoral artery to acces
s the cardiac vessels.
. A hematoma is formed at the upper thigh -> Exten
ds into the retro-peritoneal space.
. Significant belleding with hypotension & tachyca
rdia.
. Ipsilateral flank/back pain.
. Dx -> CT scan of ABDOMEN & PELVIS with-OUT contr
ast.
. Tx -> Supportive -> Blood transfusion - IV fluid
s - Bed rest.
. Tx -> Immediate surgical decompression if there
are neurological deficits.
. PNEUMO-PERITONEUM:
_____________________
. AIR UNDER DIAPHRAGM = Intra-peritoneal air.

. Best seen bet. the liver & the diaphragm.

. Caused by PERFORATED VISCUS e.g. PERFORATED PEPT
IC ULCER.
. PERFORATED PEPTIC ULCER (H/O of epigastric pain
& discomfort with eating).
. Tx -> SURGICAL CONSULATATION IMMEDIATELY for EXP
LORATORY LAPAROTOMY.
. CHILD ABUSE:
_______________
. Patterned scalds & burns = forceful immersion o
f hot object e.g. cigarette or hot iron.
. Incoherent or impropable explanation of the inju
ries.
. Delay in seeking care after injury.
. #s of long bones or ribs, #s in various stages o
f healing.
. Suspicious bruises include those on thighs, abdo
men, cheeks & genitalia.
. Subdural hematoma & retinal hemorrhages in very
young infants.
. Inaapropriate affect of the care giver.
. Physician should perform a thorough physical ex
am. & full radiographic skeletal survey.
. Report the case to child protective services.
. Admit the pt to ensure their safety.
. The child should never be sent home.
. The caregiver should never be confronted.
. Physicians are mandatory reporters.
. AMPUTATION INJURY:
_____________________
. Amputated parts sh'd be wrapped in SALINE-MOISTE
NED GAUZE,
. SEALED IN A PLASTIC BAG,
. PLACED ON ICE,
. brought to the emergency department with the pat
ient.

. CAUSES OF HEMOPTYSIS:
________________________
. Pulmonary -> Bronchitis - Pulmonary embolism - B
ronchiectasis - Lung cancer.
. Cardiac -> Mitral stenosis - Acute pulmonary ede
ma.
. Infectious -> Tuberculosis - Lung abscess.
. Hematologic -> Caogulopathy.
. Vascular -> Arteriovenous malformation.
. Systemic diseases -> Wegener's granulomatosis Goodpasture's $ - SLE - Vasculitis.
. HEMOPTYSIS MANAGEM
ENT
____________________
____
|
. H/O & P/E to rule out other ca
uses (Oropharynx & GIT)
________________________________
________________________
|
_______________________
________
|
|
. MILD/MODERATE
.
MASSIVE (>600 ml/24hs)
________________
_
________________________
|
|
. CXR, CBC, COAGULATION STUDIES
. SECUR
E AIRWAY, BREATHING & CIRCULATION
. RENAL FUNCTIONS & URINALYSIS
|
. RHEUMATOLOGY WORK UP
. IF BLEEDING
|

|
<----------------STOPS--------------------CONTINUES
|
|
. CT SCAN + BRONCHOSCOPY
|
|
|
. treat the cause;persistent bleeding
|
treated via bronchoscopic interventions <-----------------------embolization or resection.
. N.B.
. Massive hemoptysis = > 600 ml/24 hs.
. Greatest danger is asphyxiation due to airway fl
ooding with blood.
. Establishing an adequate patent airway is the mo
st imp. initial step.
. The pt should be placed with the bleeding lung u
n the dependent lateral position,
. to avoid blood collection in the airways of the
opposite lung.
. Bronchoscopy is the best to localize the bleedin
g site, provide suction.
. Bronchoscopy is both diagnostic & therapeutic.
. Pt from endemic area - Night fever - weight loss
- Upper lobe involvement = T.B.
. Respiratory isolation is mandatory to prevent sp
read of infection.

. FAT EMBOLISM:
________________
. Common in pt with polytrauma with multiple #s of
long bones.
. Severe respiratory distress, petichial rash, sub

conjunctival hemorrhage.
. Tachycardia, tachypnea & fever.
. May occur after 12-72 hs after trauma.
. CNS dysfunction -> Confusion - Agitation - Stupo
r - Seizures - Coma.
. Dx -> Fat droplets in urine.
. Dx -> Intra-arterial fat globules on fundoscopy.
. Dx -> CXR -> Diffuse bilateral pulmonary infiltr
ates.
. Tx -> Respiratory support.
. NECROTIZING SURGICAL INFECTION:
__________________________________
. Intense pain in wound.
. Fever, hypotension & tachycardia.
. Decreased sensitivity at the edge of the wound.
. Cloudy gray discharge.
. Tense edema out-side the involved skin.
. Subcutaneous gas with crepitus.
. More common in diabetics.
. Caused by mixed gram +ve & gram -ve flora.
. Tx -> Early surgical exploration & debridement o
f the necrotic tissues.
. Adjunctive ttt -> Antibiotics, adequate hydratio
n & tight glycemic control.
. MASTITIS ASSOCIATED WITH BREAST FEEDING:
___________________________________________
. Due to transmission of bacterial organism from t
he infant's nasopharynx,
. to a fissure on the mother's nipple or areola.
. Most commonly Staph. aureus.
. Tx -> Analgesics, antibiotics (Dicloxacillin-Cep
halosporin) & CONTINUE BREAST FEEDING.
. Continued nursing from the affected breast -> - the progression of mastitis to abscess
. Incision & drainage only if there is abscess for
mation !
. Mammogram is not useful in mastitis !

. Mammogram is not useful before age of 50 due to

dense breast tissue.
. Suppression of breast milk is NOT recommended.
. HYPOVOLEMIC SHOCK & POSITIVE PRESSURE MECHANICAL
VENTILLATION:
___________________________________________________
______________
. +ve pressure mechanical ventillation -> ++ intra
thoracic pressure -> -- VR to heart.
. -- VR -> -- Ventricular preload.
. In pts with hypovolemic shock, this effect may c
ause circulatory collapse !
. if the pt's intravascular volume isn't replaced
before mechanical ventillation begins.
. URETHRAL INJURY & PELVIC #:
______________________________
. POSTERIOR urethral injury is associated with pel
vic #s.
. Blood at urethral meatus.
. High riding prostate.
. Scrotal hematoma.
. Inability to void despite sensing an urge to voi
d.
. Palpable distended bladder.
.
to
.
.
.
.
.

ANTERIOR urethral injury is due to blunt trauma

perineum (Straddle injury).
May be caused by instrumentation to urethra.
Perineal tenderness & hematoma.
NORMAL PROSTATE.
Bleeding from urethra.
NORMAL URINATION.

. DUMPING $YNDROME:
____________________
. Common post-gastrectomy complication.
. Due to rapid emptying of gastric contents into t

he duodenum & small intestine.

. Post-prandial abd. cramps - weakness - lighthead
edness - diaphoresis.
. Symptoms diminish over time.
. Symptoms result from fluid shift from intravascu
lar space to small intestine.
. Stimulation of intestinal vasoactive peptides ->
Stimulation of autonomic reflexes.
. Dietary changes are helpful to control symptoms.
. In resistant cases, octreotide sh'd be tried.
. Reconstructive surgery is reserved for intractab
le cases.
. HEMATOCHEZIA:
________________
. Bright red blood in stool.
. Due to lower GI bleeding (distal to ligament of
Treitz).
. May occur in very brisk upper GI bleeding.
. Most common causes of lower GI bleeding in pts
>50 ys-> DIVERTICULOSIS - ANGIODYSPLASIA
. Nasogastric tube placement with bile not blood =
No active upper GI bleeding.
. Upper endoscopy sh'd be done next not to miss du
odenal bleeding.
. In cases of hematochezia due to diverticulosis,
. The initial step is COLONOSCOPY.
. If -ve -> Radio-nuclide (Technetium 99 Labelled
eryhthrocyte scintigraphy tagged RBCs).
. It is less invasive & more sensitive than angiog
raphy.
. It localizes the source of bleeding so that,
. the region can be further evaluated by colonosco
py or angiography.
. CENTRAL VENOUS CATHETERIZATION:
__________________________________
. A CXR sh'd be done to confirm proper placement &

absence of complications.
. e.g. subclavian artery injury, pneumothorax, hem
othorax, thrombosis & air embolism.
. To avoid myocardial perforation the catheter tip
sh'd be located proximal to either:
. the cardiac silhouette or the angle between the
trachea & right main stem bronchus.
. The catheter sh'd lie in the superior vena cava.

. DIABETIC FOOT ULCERS:

________________________
. Result from neuropathy, microvascular insuffecie
ncy & immunosuppression.
. They occur on the plantar surface of the foot un
der points of greatest pressure,
. such as under the head of the 1st metatarsal bon
e.
. SOLITARY PULMONARY NODULE EVALUATION:
________________________________________
SOLITARY PULMONARY NODU
LE EVALUATION
________________________
______________
|
CHEST CT WITH
CONTRAST
______________
__________
|
____________________
______
|
|
Benign features
diate or suspicious for malignancy
_________________
___________________________________

Interme
________

|
|
SERIAL CT SCANS TO MONITOR
ER INVESTIGATION WITH BIOPSY or PET scan

FURTH

. VENOUS VALVULAR INCOMPETENCE:

________________________________
. is the most common cause of lower extremity edem
a.
. It classically worsens thoroughout the day & res
olves overnight when pt is recumbent.
. NASAL SEPTAL PERFORATION:
____________________________
. Any pt develops a whistling noise during respira
tion following rhinoplasty.
. One suspect nasal septal perforation due to Sept
al hematoma.
. TRAUMATIC SPINAL CORD INJURIES:
__________________________________
. Should be 1st hemodynamically stabilized.
. Proper airway management.
. Urinary catheterization placement is imp. to ass
ess for urine retention !
. It is important to prevent bladder distension &
damage.
. A retrograde urethrogram sh'd be the 1st step in
management of urethral injury,
. Foley catheterization is contraindicated as it w
ill worsen the condition.
. ACUTE BACTERIAL PAROTITIS:
_____________________________
. Fever, leukocytosis & parotid inflammation.
. Dehydrated post-operative pts & elderly are most

prone to develop infection.

. Painful swelling of the parotid gland aggravated
by chewing.
. Tender, swollen & erythematous gland with purule
nt saliva expressed from parotid duct.
. Most common infectious agent is STAPHYLOCOCCUS A
UREUS.
. Tx -> Adequate fluid hydration & oral hygiene ca
n prevent this condition.
. N.B. Spirometry prevents post-operative respirat
ory complications not parotitis.
. DIVERTICULOSIS:
__________________
. is the most common cause of a lower gastro-intes
tinal hemorrhage in an elderly.
. Bright red bleeding from the rectum is usually c
aused by a lower GI hemorrhage.
. Colonic diverticula are formed due to high intra
-luminal pressure,
. which causes the mucosa to herniate through the
bowel wall penetrating its vasculature.
. They don't include all layers of the bowel (Fals
e divertuculae).
. Chronic constipation is due to low fiber diet.
. Most common predisposing factor to diverticulosi
s.
. Diverticulae erode the bowel vasculature leading
to profuse bleeding per rectum.
. Most common site is sigmoid colon.
. Dx -> CT Abdomen.
. N.B.
. Diverticulosis -> Non-inflammed diverticula -> P
ainless bleeding.
. Diverticulitis -> Abdominal pain & infectious sy
ms 2ry to obstruction of diverticula.
. It is uncommon to see bleeding with diverticulit
is !

. GASTRO-ESOPHAGEAL MURAL INJURY CHARACTERISTICS:

_________________________________________________
_________________________________________________
(A) MALLORY WEISS $YNDROME:
____________________________
. Upper gastro-intestinal MUCOSAL TEAR.
. Caused by forceful retching (++ pressure).
. Submucosal arterial or venule plexus bleeding.
. Vomiting, retching, hematemesis & epigastric pai
n.
. Dx -> EGD confirms diagnosis.
. Most tears heal spontaneously.
. Endoscopic therapy for continous bleeding.
(B) BOERHAAVE $YNDROME:
________________________
. Esophageal TANS-MURAL tear.
. Caused by forceful retching (++ pressure).
. ESOPHAGEAL AIR/FLUID LEAKAGE into nearby areas e
.g. pleura.
. Vomiting, retching, chest & upper abdominal pain
.
. Odynophagia, fever, dyspnea & septic shock may o
ccur.
. Subcutaneous emphysema may be seen.
. Dx -> CT or CONTRAST ESOPHAGOGRAPHY e' GASTROGR
AFIN (Water soluble) confirms diagnosis.
. CXR -> Pneumo-mediastinum & pleural effusion.
. Pleural fluid analysis -> EXUDATIVE, LOW pH, VER
Y HIGH AMYLASE > 2500 IU.
. Tx -> Surgery for thoracic perforations.
. Conservative measures e.g. antibiotics for cervi
cal perforation.
. IATROGENIC esophageal perforation:
. CXR -> Pleural effusion, pneumomediastinum & pne
umothorax.
. Dx -> Water soluble contrast esophagogram.
. Avoid endoscopy not to worsen the condition !

. MECHANISMS OF LOWERING INTRA-CRANIAL TENSION:

________________________________________________
. HEAD ELEVATION -> ++ venous outflow from the hea
d.
. SEDATION -> -- metabolic demand & control of HTN
.
. IV MANNITOL -> Extraction of free water out of b
rain tissue -> Osmotic diuresis.
. HYPERVENTILLATION -> CO2 washout -> Cerebral VAS
OCONSTRICTION.
. POST-SPLENECTOMY VACCINES:
_____________________________
. Following splenectomy, pts are at ++ risk for se
psis 2ry to encapsulated organisms
. Capsulated organisms (S. pneumoniae - N. meningi
tidis - H. influenzae).
. Vaccination against these organisms sh'd be admi
nistered.
. Pneumococcal vaccine boosters are required every
5 years.
. PAROTID NEOPLASM:
____________________
. The two lobes of the parotid gland are separated
by the facial nerve.
. Parotid surgery involve the deep lobe of the par
otid gland -> facial palsy.
. Facial palsy -> Facial droop.
. INJURY -> CULPRIT INJURED NERVE:
___________________________________
. HOARSENESS -> RECURRENT LARYNGEAL BRANCES OF VA
GUS NERVE (Thyroid/Parathyroid surgery).
. TIC DOULOUREUX (TRIGEMINAL NEURALGIA) -> TRIGEMI
NAL NERVE.
. TONGUE PALSY -> HYPOGLOSSAL NERVE (Submandibular
gland surgery).

. WINGED SCAPULA -> LONG THORACIC NERVE (Axillary

lymphadenectomy surgery).
. PERIPHERAL ARTERY ANEURYSM:
______________________________
. Pulsatile mass that can compress adjacent struct
ures (nerves - veins).
. May lead to thrombosis & ischemia.
. Most common are popliteal & femoral aneurysms.
. Associated with peripheral artery aneurysm.
. PENILE #:
____________
. Crush injury of an erect penis.
. Common during intercourse with female on top of
male.
. Dx -> Emergent urethrogram to assess for urethra
l injury.
. Tx -> Surgical exploration to evacuate hematoma
& mend the torn tunica albuginea.
. URIC ACID STONES:
____________________
. Ureteral colic -> Vagal reaction -> ILEUS.
. Urinalysis -> Needle shaped crystals = uric acid
stones.
. Dx -> CT abdomen or IV pyelography.
. Tx -> Stones < 0.6 cm -> Pass spontaneously with
hydration & analgesia.
. Tx -> Stones > 0.6 cm -> Surgical removal.
. NASOPHARYNGEAL CARCINOMA (NPC):
__________________________________
. Undifferentiated carcinoma of squamous cell orig
in.
. Higher frequency in people of Mediterranean or f
ar eastern descent.
. Most NPC are metastatic at the time of diagnosis

.
. Recurrent otitis media (Due to eustachian tube o
bstruction by tumor).
. Recurrent epistaxis or nasal obstruction.
. Associated with positive serology for EPSTEIN BA
RR VIRUS (EBV).
. It is associated with smoking & chronic nitrosam
ine consumption (Salted fish diet).
. PARALYTIC ILEUS:
___________________
. Abdominal pain after a traumatic injury.
. Associated with vertebral # or retro-peritoneal
hemorrhage.
. Ileus is caused by an exagerrated intestinal rea
ction after abdominal surgery.
. Due to disruption of normal neurologic & motor c
ontrol of the gastrointestinal tract.
. Failure to pass stool or flatus, abdominal diste
nsion, nausea & vomiting.
. Distended abdomen with tympany.
. Decreased or absent bowel sounds.
. Abdominal x-ray -> Air-fluid levels & distended
gas-filled loops of small & large int.
. Tx -> Conservative with bowel rest & supportive
care.
. LUDWIG's ANGINA:
___________________
. Infection of the submandibular & sublingual glan
ds.
. Source of infection -> Infected tooth (2nd or 3r
d mandibular molar).
. Most common cause of death -> Asphyxia.
. TORUS PALATINUS:
___________________
. CONGENITAL !
. Young individual.

. Fleshy immobile mass on the midline hard palate.

. No medical or surgical ttt is required unless th
e growth becomes symptomatic.
. i.e. interfering with speech or eating.
. NEURO-ANATOMY:
_________________
_________________
. FEMORAL NERVE:
_________________
. Motor to anterior compartment of thigh (Quadrice
ps femoris - Sartorius - Pectineus).
. Responsible of knee extension & hip flexion.
. Sensory to the anterior thigh & medial leg via s
aphenous branch.
. TIBIAL NERVE:
________________
. Motor to posterior compartment of thigh, poster
ior compartment of leg & plantar foot ms
. Responsible of knee flexion & digits & plantar f
lexion of foot.
. Sensory to the leg (except the medial side) & pl
antar foot.
. OBTURATOR NERVE:
___________________
. Motor to medial compartment of thigh.
. Responsible of thigh adduction.
. Sensory to the medial thigh.
. COMMON PERONEAL NERVE = FIBULAR NERVE:
_________________________________________
. Give rise to superficial & deep peroneal nerves.
. Motor to anterior & lateral leg.
. Sensory to antero-lateral leg & dorsum of the fo
ot.

. GLASGOW COMA SCALE:

______________________
______________________
. EYE OPENING:
_______________
4 -> Spontaneous.
3 -> To verbal command.
2 -> To pain.
1 -> None.
. VERBAL RESPONSE:
___________________
5 -> Oriented.
4 -> Disoriented/confused.
3 -> Inappropriate words.
2 -> Incomprehensible sounds.
1 -> None.
. MOTOR RESPONSE:
__________________
6 -> Obeys.
5 -> Localizes.
4 -> Withdraws.
3 -> Flexion posturing (Decorticate).
2 -> Extension posturing (Decerebrate).
1 -> None.

Dr. Wael Tawfic Mo

hamed
__________________
_______