SURGERY TIKI TAKA

___________________
. TRAUMA:
__________
__________
(1) AIRWAY:
____________
. Establishing & securing the airway is always the 1st step in management.
. Altered mental status is the most common indication for intubation in a traum
a pt.
. As an unconscious pt can't maintain his airway.
. The preferred method of securing an airway -> OROTRACHEAL INTUBATION.
. Trauma with cervical spine injury -> FLEXIBLE BRONCHOSCPE.
. Extensive facial trauma & bleeding into airway -> CRICOTHYROIDOTOMY or TRACHE
OSTOMY.
. N.B.
. Pts with cervical spine injury should 1st have stabilization of the cervical
spine.
. Oro-tracheal intubation with rapid sequence intubation is the preferred way,
. to secure an airway in an apnein pt with a cervical spine injury.
. N.B.
. In burn victims, clinical indicators of thermal inhalation injury to the uppe
r airway,
. or smoke inhalation injury to the lungs include burns on face, singing of eye
brows,
. oropharyngeal inflammation & blistering, oropharyngeal 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 tamponade - Tension pneumothora
x):
________________________________________________________________________________
___
________________________________________________________________________________
___
-> HYPOVOLEMIC SHOCK:
______________________
. The most common type of shock.
. Pale, cold , shivering pt with diaphoresis, hypotension & tachycardia.
. Look for a source of bleeding.

. The pt may lose a large volume of blood in the abdomen or thigh following fem
ur #.
. N.B.
. When hemorrhage occurs, tachycardia & peripheral vasoconstriction are the 1st
changes.
. These responses act to maintain the blood pressure within normal limits.
. PULSE CHANGE IS THE FIRST INDICATOR FOR HYPOVOLEMIA.
-> Pericardial tamponade:
__________________________
. Cause distended neck veins & high central venous pressure.
. Enlarged heart on CXR (May be normal cardiac silhouette).
. Electrical alternans on EKG.
. Pulsus paradoxus on vital signs.
. Tx -> immediate pericardiocentesis tap or pericardial 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 & Hypotension despite aggressive fluid
resusc.
. CXR findings typically reveal a normal cardiac silhouette without tension pne
umothorax.
-> 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 or IV catheter into the pleura
l space.
. Chest tube placement.
. Never wait for a CXR for diagnosis.
. N.B.
. Don't be distracted by head trauma or dilated pupils in a hypotensive trauma
pt.
. Intracranial bleeds are never the cause of hypotensive shock.
. The 1st step in management is to identify & control the site of bleeding.
. N.B.
. Most causes of shock in the setting of trauma are 2ry to hypovolemia from blo
od loss.
. However, ++ CVP/PCWP or failure of hypotension to resolve after a bolus of IV
fluids,
. should suggest an alternative diagnosis.
. Myocardial contusion sh'd be suspected in pts with evidence of injury to ante
rior chest
. MI can be confirmed with +ve cardiac markers & EKG changes.
. Tension pneumothorax is excluded if there is no tracheal deviation.
. Hypovolemia is excluded if there is failure to respond to an IV fluid bolus.
.
.
.
.

N.B.
High energy blunt trauma to the chest commonly causes aortic injury.
In most cases of aortic rupture, death is the immediate result.
Widened mediatinum, large left sided hemothorax & mediastinal deviation to ri

ght side.
. Disruption of the normal aortic contour..
. Bilateral COLLAPSED neck veins.
. Cardiac contusion & rupture cause pericardial tamponade only.
. Muffled heart sounds - Hypotension - DISTENDED NECK VEINS.
. N.B. PULMONARY CONTUSION:
____________________________
. Represents pulmonary bruising of the lung.
. Common after high-speed car accidents.
. Clinical manifestations develop in the 1st 24 hours (Often within few minutes
).
. Tachypnea - Tachycardia - Hypoxia.
. P/E -> Chest wall bruising & -- breath sounds on the side of pulmonary contus
ion.
. 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 & BILATERAL involvement.
. Pulmonary contusion manifests in the 1st 24 hours.
. N.B. PNEUMOTHORAX:
. Primary spontaneous pneumothorax -> No preceiding event & No H/O of lung dise
ase.
. Secondary spontaneous pneumothorax -> Complication of underlying COPD.
. Tx -> Small ( < 2cm between lung & chest wall on CXR) -> Observation & oxygen
.
. Tx -> Large (Stable) -> Needle aspiration or chest tube.
. Tension pneumothorax:
________________________
. Life threatening; trapped air with mediastinal shift.
. Compromised cardiopulmonary function.
. Chest pain or dyspnea.
. -- Breath sounds / -- TVF / -- chest movement.
. Hyperresonance to percussion on the affected side.
. Tachycardia, hypotension.
. Tracheal deviation away from the affected side.
. Imaging -> Notable visceral pleural line.
. Imaging -> Air in hemithorax -> Contralateral mediastinal shift.
. Imaging -> Radiolucent costophrenic sulcus.
. Tx -> Urgent needle decompression then chest tube placement (Tube thoracostom
y).
. Tx -> IV lines & fluid resuscitation follow urgent needle decompression.
. N.B.
. ONLY TWO CAUSES OF DISTENDED NECK VEINS -> TENSION PNEUMOTHORAX & CARDIAC TAM
PONADE.
. 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 wal

l.
. The pt takes shallow breaths due to severe pain.
. The pt compensates for the hypoxemia by hyperventillation.
. Tachypnea & PARADOXICAL THORACIC WALL MOVEMENTS.
. Paradox is corrected with positive pressure mechanical ventillation.
. The isolated thoracic wall segment exhibits paradoxical motion,
. inward motion on inspiration & outward motion during expiration !
. Tx -> Pain control & supplemental oxygen are the most important steps.
. Positive pressure mechanical ventillation replaces the negative intrapleural
pressure.
. so the flail chest movement will be normal with the rest of the rib cage on i
nspiration
. N.B. HEMO-THORAX:
____________________
. After blunt chest trauma, hemorrhagic shock associated e'
. decreased breath sounds & dullness to percussion over one hemithorax.
. & contralateral tracheal deviation.
. COLLAPSED NECK VEINS.
. Most common cause is damage to intercostal or internal 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 NEVER the answer.
. The next priority is FLUID RESUSCITATION.
. Do several things at once in preparation for immediate 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 management (Also diagnostic).
. If the pt responds promptly, then he's propably no longer bleeding.
.
.
<
.

N.B.
Intraosseous cannulation in the proximal tibia is 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 a
bdomen,
. and lacerates solid organs most commonly the spleen & liver.
. Hypotension, tachycardia, facial lacerations & abdominal wall ecchymosis.
. Most reliable symptoms -> Abdominal pain, tendrness & peritoneal signs.
. Intraabdominal injury sh'd be suspected in pts with:
. abdominal wall ecchymosis,abdominal distension & hyperactive bowel sounds.
. 1st step after fluid resuscitation to determine if the pt needs exploratory l
aparotomy.
. All pts with BAT sh'd 1st be assessed for intraperitoneal free fluid or hemor

rhage.
. Best test is -> BEDSIDE ULTRASONOGRAPHY to detect free intraperitoneal fluid,
. in hepatorenal space, splenorenal recess & inferior portion of intraperitonea
l cavity.
. When combined with pericardial evaluation -> known as FAST.
. FAST exam -> (Focused assessment with sonography for trauma).
. It is the best to detect hemoperitoneum, pericardial effusion or intraperiton
eal fluid.
. If FAST exam is limited or equivocal -> A diagnostic peritoneal lavage (DPL)
is done.
. DPL is done to evaluate for hemoperitoneum.
. Pts with +ve findings on either FAST or DPL -> should undergo exploratory lap
arotomy.
. 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 pancreas.
. Pancreatic injuries may be MISSED by CT scan during 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 following blunt abdominal traum
a.
. Left upper quadrant abdominal pain.
. Abdominal wall contusion, Lt lower chest wall tendrness.
. Lt shoulder pain referred from splenic hemorrhage 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 accident 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 pass gastric secretions past obs
truction.
. Tx -> NASOGASTRIC SUCTION & PARENTERAL NUTRITION.
. Most hematomas will resolve spontaneously in 1-2 weeks.
. N.B.
. Any gun shot wound below the 4th intercostal space (level of the nipple) is:

. considered to involve the abdomen & requires an exploratory laparotomy in uns

table pts.
. N.B.
. All hemodynamically UN-STABLE pts with penetrating abdominal trauma,
. must undergo immediate exploratory laparotomy to diagnose & treat source of b
leeding
. as well as to diagnose & treat perforation of any abdominal viscus to prevent
sepsis.
. N.B.
. Abdominal CT used to detect intra-abdominal injury in hemodynamically stable
trauma pts
. In hemodynamically un-stable pts, a FAST U/$ should be the initial test.
. DPL Diagnostic peritoneal lavage is used in hemodynamically unstable pts if ve FAST.
. N.B.
. DIAPHRAGMATIC TRAUMA:
________________________
. Blunt abdominal trauma -> Mild respiratory distress & Abnormal CXR.
. Sudden ++ in intra-abdominal pressure -> Large radial tears in the diaphragm.
. Rupture is more common on LEFT side bec. the right side is protected by the l
iver.
. 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 cavity.
. Tx -> Surgical repair & exploration for other traumatic injuries.
. N.B.
. TRACHEO-BRONCHIAL RUPTURE:
_____________________________
. Due to rapid decceleration blunt chest trauma.
. 1st manage the ABCs.
. Dx -> CXR -> Persistent pneumothorax & pneumomediastinum despite chest tube p
lacement !
. Subcutaneous emphysema (Palpable crepitus below the skin).
. The RIGHT MAIN BRONCHUS is the most commonly injured.
. 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 trauma).
-> If FAST is +ve for blood & pt is still UNSTABLE AFTER A TRIAL OF FLUID RESUS
CITATION,
-> URGENT LAPAROTOMY with surgical repair is indicated.
. HEMODYNAMICALLY STABLE PATIENT:
__________________________________
-> CT scan abdomen with contrast (to detect the amount of bleeding & the site o

f injury).
-> The surgeon can then select either laparotomy or admission & observation.
. MANAGEMENT OF BLUNT ABDOMINAL TRAUMA
_______________________________________
. in HEMODYNAMICALLY UN-STABLE PT
__________________________________
|
FAST EXAMINATION
________________
|
____________________________________________
|
|
|
+ve
inconclusive
-ve
|
|
|
LAPAROTOMY <--POSITIVE--- DPL ----NEGATIVE---> Signs of
____________
_____
extra-abdominal
hemorrhage (Pelvic/lon
g bone #)
|
___YES_____________NO_____
|
|
STABILIZE

ST

ABILIZE
ANGIOGRAPHY & 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 allergy).
. H/O of spinal anesthesia or exposure to allergen (bee stings).
* TRAUMA TO LOCALIZED SITES:
_____________________________
. All penetrating wounds with damage to internal organs 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 the accident (Only in the operat
ing 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 lacerations.
. Surgery "Repair or craniotomy" is always done for ..
. COMMINUTED or DEPRESSED SKULL # even if the pt is 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 him over the next 24 hours.
. i.e. wake him up frequently & watch for changes in mentation.
. Give tetanus toxoid & prophylactic antibiotics to 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 specific management.
. Prophylactic antibiotics are NOT indicated !!
. Facial palsy may occur 2-3 days later due to neuroapraxia (Use Steroids).
* EPI-DURAL HEMATOMA:
______________________
. Side head trauma & rupture of middle meningeal artery in the foramen spinosum
.
. H/O of head trauma & SUDDEN LOSS OF CONSCIOUSNESS.
. Accumulation of blood in the potential space inbetween the cranium & dura mat
ter.
. Honeymoon period (The period when the pt immediately awakes & appears normal)
.
. Pt typically has ipsilateral pupil dilatation due to oculomotor nerve compres
sion.
. Then the pt quickly deteriorates, so .. It is important to manage quickly.
. Dx -> CT scan -> BICONVEX LENS shaped hematoma with or without midline deviat
ion.
. 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 temp
oral lobe.
. Fluid resuscitation ++ the rate at which the epidural hematoma expanded.
. Hypertension, bradycardia & respiratory depression (Cushing's reflex) = ++ IC
P.
. 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 against the tentorial edge:
____________________________________________________________________________
. Ipsilateral hemiparesis.
. Compression of the ipsilateral oculomotor nerve (CN 3) by the herniated uncus
:
________________________________________________________________________________
_
. Loss of parasympathetic innervation causes mydriasis.
. Loss of motor innervation causes ptosis & down-outwards gaze of the ipsilater

al pupil,
. due to un-opposed trochlear (CN 5) & abducent (CN 6).
. Compression of the ipsilateral posterior cerebral artery:
____________________________________________________________
. causes ischemia of the visual cortex -> Contralateral 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 between the dura & arachinoid mem
brane.
. Head trauma with FLUCTUATING CONSCIOUSNESS i.e.
. gradual headaches, memory loss, personality changes, dementia, cofusion & dro
wsiness.
. Dx -> CT scan -> "S"EMILUNAR, CRESCENT shaped hematoma e' or e'out midline de
viation.
. Tx -> CONSERVATIVE management with STEROIDS.
. Emergency craniotomy is done if there are lateralizing signs & midline displa
cement.
* 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 the junctions of the grey & whi
te 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 trauma.
. Improvement.
. Progressive drowsiness.
. ++ ICT is a medical emergency.
. GRADUAL DILATATION OF ONE PUPIL & DECREASING RESPONSIVENESS TO LIGHT is an im
p. sign.
. It indicates clot expansion on the ipsilateral hemisphere.
. Dx -> Head CT -> Midline shift or dilated ventricles.
. 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 with ++ ICT, you'' herniate the
brain !
. Tx -> Head elevation - Hyperventillation - Avoid fluid overload.
. Tx -> Mannitol & furosemide (use very cautiously as they can reduce cerbral p
erfusion).
. Tx -> sedation & hypothermia may lower oxygen demand.
. N.B. Lowering ICP is not the ultimate goal; preserving brain perfusion is.
. Systemic hypotension or excessive cerebral vasoconstriction may be counterpro

ductive.
. 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 injury:
. 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 t
hat,
. warrant immediate return to the hospital.
________________________________________________________________________________
__________
. ACUTE ABDOMEN:
_________________
_________________
. 4 main causes -> Perforation - Obstruction - Inflammation/Infection - Ischemi
a.
. 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 pancreatitis is 1st ruled out !
. N.B. Primary peritonitis is spontaneous inflammation with nephrosis in childr
en.
. or .. An adult with ascites & mild abdominal pain (even there is fever & leuk
ocytosis).
. 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 CXR).
-> Myocardial ischemia (Look for EKG changes).
-> Pulmonary embolism (Look for immobilized pt).
6. Ruptured ovarian cyst.
. N.B.
. Cholangitis is a GIT medical emergency & intervention 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 emergen
cy).
* 1 * PERFORATION:
___________________
___________________
(1) GASTRO-INTESTINAL PERFORATION:
__________________________________
. Acute abdominal pain that is sudden, severe, constant & generalized.
. Pain is excruciating with any movement (may be blunted in elderly pts).
. Most common causes of GIT perforations:
(a) Diverticulitis: Elderly pt with lower abdominal pain & fever.
(b) Perforated peptic ulcer: Epigastric pain waking up the pt at night.
(c) Chron's disease.
.
.
.
.
.

Dx
Tx
Tx
Tx
Tx

->
->
->
->
->

Supine & erect abdominal x-ray (free air under diaphragm).

Nothing by mouth (NPO) & IV fluid hydration.
IV antibiotics such as flagyl & gentamycin.
IV 2nd generation cephalosporins (Cefotetan or cefoxitin).
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 comfort position.
.
.
.
.
.

H/O
H/O
H/O
H/O
H/O

of
of
of
of
of

prior surgery (Think adhesions).

elderly pt with anemia, weight loss & melanotic stools (Think tumor).
recuurent lower abdominal pain (Think diverticulitis).
hernia (incarcerated hernia).
sudden abdominal pain in elderly pt (Think 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 perforation has been ruled out).
. Volvuls -> Perform procto-sigmoidoscop with rigid instrument.
-> Leave the rectal tube in place.
-> Perform sigmoid resection for recurrent cases.
. Abdominal hernia -> Perform elective repair for all abdominal hernias.

-> except umbilical hernia in pts < 2 ys.

-> except esophageal sliding hernia.
. All other obstructions -> Perform emergency surgery.
. N.B.
. In a pt with a hernia, immediate surgery is the answer if the case describes:
. fever, leukocytosis, constant pain & signs of peritoneal irritation (Strangul
ation).
. 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 ten
dernesss.
. The contents of the vomitus are typically bilious in proximal SBO.
. The contents of the vomitus are feculent with more distal obstructions.
. Hyperactive bowel sounds due to peristaltic rush.
. Dx -> Abd. x-ray -> DILATED BOWEL LOOPS with MULTIPLE AIR FLUID LEVELS.
. Tx -> Complete bowel rest - Decompression e' nasogastric tube.
. Tx -> Pain control - Fluid resuscitation.
. Tx -> If no improvement -> Surgical intervention to avoid strangulation.
. Strangulation signs (fever - tachycardia - leukocytosis - Metabolic acidosis)
.
. N.B.
. Immediate surgical intervention is indicated for pts with intestinal obstruct
ion who,
. develop clinical or hemodynamic instability, fail to improve after conservati
ve ttt,
. or develop syms of strangulation (fever-tachycardia-leukocytosis-Metabolic ac
idosis).
* 3 * INFLAMMATION:
____________________
____________________
. Causes (Acute diverticulitis - Acute pancreatitis - Acute appendicitis).
. Gradual onset of constant abdominal pain that slowly builds up over several h
ours.
. Initially ill defined pain that becomes localized to the site of inflammation
.
. Note that signs of peritoneal irritation are ABSENT 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 th
e 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 acute phase.

. Tx -> If there is no peritoneal signs -> Manage as outpatient with antibiotic

s.
. Localized peritoneal signs & abscess -> Admit pt - NPO - IV fluids - IV antib
iotics.
. Generalized peritonitis or perforation -> Emergency 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' abscess, perforation, obstruction o
r fistula.
. Fluid collection < 3cm -> IV antibiotics & observation.
. Fluid collection > 3cm -> CT guided percutaneous drainage.
. If no response within 5 days -> Surgery for drainage & 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.
. Dx -> Serum or urinary amylase or lipase (serum 12 - 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 pancreatitis:
-> Alcoholism.
-> Gall stones.
-> Medications (Didanosine, pentamidine, Flagyl, Tetracycline, Thiazides & Furo
semide).
-> Hypertriglyceridemia.
-> Trauma.
-> Post-ERCP.
. N.B. COMPLICATIONS:
-> Abscess:
. Often appears 10 days after onset with persistent fever & high WBC count.
. Surgical drainage is the ttt.
->
.
.
s.
.
.
ge.

Pseudocyst:
Appears 5 weeks after initial symptoms.
when a collection of pancreatic juice causes anorexia, pain & a palpable mas
If < 6 cm & present < 6 weeks -> OBSERVATION.
If > 6 cm or present > 6 weeks -> Percutaneous drainage or endoscopic draina

-> Chronic damage:

. causes diabetes & steatorrhea.
. Treat with insulin & pancreatic enzyme supplementation.
.
e.
.
.
.

N.B. The most common causes of acute pancreatitis are gallstones & alcohol us
Identifying the underlying cause can prevent recurrent pancreatitis.
ULTRASOUND is the preferred test to detect gall stones.
Stable pts sh'd undergo cholecystectomy for biliary pancreatitis prior to dis

charge.
(3) ACUTE APPENDICITIS:
________________________
. Begins with anorexia.
. Followed by vague peri-umbilical pain.
. several hours later, it becomes sharp, severe, constant & localized to RLQ of
abdomen.
. RIGHT LOWER QUADRANT PAIN.
. Tenderness, guarding & rebound tendrness are found on the right & below the u
mbilicus.
. Dx -> Fever, leukocytosis 10000 - 15000 with neutrophilia & immature forms.
. Dx -> Reactive thrombocytosis.
. Dx -> Abdominal U/$ or CT scan if clinically unclear.
. Tx -> IV antibiotics before appendectomy.
. Tx -> If appendix is perforated -> Continue IV until fever & WBC count normal
ize.
. N.B. APEENDICEAL PERFORATION complicated by PSOAS ABSCESS:
_____________________________________________________________
. Localized Rt lower quadrant findings > 5days after onset of appendicitis.
. perforation occurs with abscees formation.
. Psoas abscess -> Flexion of the hip against resistance (Psoas sign).
. Tx -> IV hydration - Antibiotics - Bowel rest - Interval appendectomy after 6
-8 weeks.
. N.B. APPENDICEAL PERFORATION complicated by PELVIC ABSCESS:
______________________________________________________________
. Rupture of appendix with pelvic abscess formation.
. Drainage of fluid into the dependent recto-vesical pouch.
. Tender, fluctuant mass palpable only e' the tip of finger = recto-vesical pou
ch abscess
. Fever, lukocytosis, painful defecation & diarrhea.
. Tx -> Abscess drainage.
. N.B. CHRONIC ULCERATIVE COLITIS (CUC):
_________________________________________
. CUC is managed medically.
. Elective surgery is done in the following conditions:
-> Disease is present > 20 ys "High incidence of malignant degeneration".
-> Multiple hospitalizations.
-> Pt needs chronic high dose steroids or immunosuppressants.
-> Toxic megacolon (Abd. pain - fever - leukocytosis - epigastric tendrness).
-> Massively distended transverse colon on X-rays with gas within the wall of t
he 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 signs.
. If ischemia is suspected, don't w8 for lab findings (acidosis or ++ lactate),
. Go straight to surgery or order angiography.
. If diagnosis is during SURGERY -> Perform embolectomy & revascularization or

resection.
. If diagnosis is during ANGIOGRAPHY -> Give vasodilators or thrombolysis.
. Acute embolic mesenteric ischemia may progress to bowel infarction.
. N.B. INTRA-ABDOMINAL ABSCESS:
________________________________
. H/O of previous operation, trauma or intra-abdominal infection/inflammation.
. Abscesses can occur anywhere in the abdomen or retroperitoneum.
. Dx -> CBC & contrast CT of abdomen or pelvis.
. Tx -> Drain an intraabdominal abscess (either surgically or percutaneously).
. Tx -> Give antibiotics to prevent spread of infection (Doesn't cure abscess).
.
.
.
.

Ex. PSOAS ABSCESS:

It is not an exclusive complication of appendicitis.
It may present alone (Absence of rebound tenderness of appendicitis !).
Presence of multiple furuncles on the inner thighs 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 aneurysm repair surgery.
. Due to inadequate colonic collateral arterial perfusion to the left & sigmoid
colon.
. Due to loss of the inferior mesenteric artery during aortic graft placement.
. Abdominal pain (Dull pain over ischemic bowel) & bloody diarrhea (Hematochezi
a).
. Fever & leukocytosis.
. Colonoscopy -> Discrete segment of cyanotic & ulcerated bowel.
. Prevention -> Checking sigmoid colon perfusion following 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 cholangiopancreatography (MRCP).
. Tx -> Perform Endoscopic retrograde cholangiopancreatography (ERCP).
. Tx -> Cholecystectomy sh'd follow ERCP.
. N.B. ERCP & EU$ are never the 1st step in diagnosis.
. N.B. ERCP is mostly a management step on exam.
* OBSTRUCTIVE JAUNDICE CAUSED BY TUMOR:
________________________________________
. Progressive symptoms in the preceeding weeks & weight loss.
. Adenocarcinoma at the head of pancreas.
. Adenocarcinoma at the ampulla of Vater.
. Cholangiocarcinoma arising in the common bile duct itself.
. Dx -> Abdominal U/$.

.
.
.
.
n.
.
.

Dx -> CT scan.
Dx -> For lesions on CT -> Obtain a tissue diagnosis via EU$.
Dx -> If no lesions on CT -> Order MRCP.
MRCP -> will show the ampullary or common bile duct tumors not seen on CT sca
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 signs.
. Dx -> U/$.
. Tx -> Elective cholecystectomy.
. N.B. Ingestion of a fatty meal causes the gall bladder to contract.
. so .. it presses the gall stones against the cystic duct opening,
. increasing the intra gall bladder pressure causing VISCUS DISTENSION & colick
y pain.
. Subsequent gall bladder relaxation alows the stone to fall back from the duc
t,
. causin the pain to resolve completely.
. Biliary colic pain may be referred to right shoulder.
. N.B. Pain of biliary colic is distinguished from that of acute cholecystitis
by:
. its intermittent nature & relation to meals as well as absence of fever.
(2) ACUTE CHOLECYSTITIS:
_________________________
. PERSISTENT occlusion of the CYSTIC DUCT.
. Caused by a stone.
. Constant pain.
. Fver, leukocytosis & peritoneal irritation in the RUQ.
. Dx -> U/$ (Gall stones - Thick walled gall bladder - Pericholecystic fluid).
. Tx -> NG suction - NPO - IV fluids - IV antibiotics.
. Tx -> Followed by elective cholecystectomy after 6 - 12 wks.
. Tx -> Emergency cholecystectomy is needed if there is:
. generalized peritonitis or ephysematous cholecystitis (i.e. perforation or ga
ngrene).
(3) ACUTE ASCENDING CHOLANGITIS:
_________________________________
. Obstruction of the COMMON BILE DUCT causes obstruction & 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 transhepatic cholangiogram) or sur

gery.
. Tx -> Cholecystectomy must follow.
. N.B.
. A pregnancy test sh'd be performed in any woman of childbearing period age be
fore,
. ordering diagnostic tests such as x-rays or computed tomography scans.
. PRE-OPERATIVE & POST-OPERATIVE CARE:
______________________________________
______________________________________
* PRE-OPERATIVE ASSESSMENT:
____________________________
{1} CARDIAC RISK:
__________________
. Ejection fraction < 35 % -> Prohibits non-cardiac 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 catheterization for coronary revasculari
zation.
{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 present.
{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 (preferrably via gut) before su
rgery.
. N.B. DIABETIC COMA is an ABSOLUTE contraindication to surgery.
. 1st stabilize diabetes.
. Rehydrate & normalize acidosis prior to surgery.
. N.B.
. If a pt presents with an acute abdomen due to perforation of hollow abdominal
viscus,
. (Rebound tendrness & subdiaphragmatic free intraperitoneal 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 reve
rsed !
. Bec. if it isn't reversed, it will lead to intra & postoperative bleeding com
plications
. The most rapid mean of normalizing PT: restoration of vit K dependent clottin
g factors.
. through infusion of FRESH FROZEN PLASMA.
. POST-OPERATIVE COMPLICATIONS & MANAGEMENT:
____________________________________________
____________________________________________
{1} MALIGNANT HYPERTHERMIA (Exceeding 104 F):
______________________________________________
. Shortly after the onset of the anesthetic (Halothane or succinyl choline).
. Tx -> IV DANTROLENE, 100% oxygen, Acidosis correction & cooling blankets.
. Watch for development of myoglobinuria.
{2} BACTEREMIA (Exceeding 104 F):
__________________________________
. Within 30-45 mins of invasive procedures (UTI instrumentation).
. 3 successive blood cultures.
. Start empiric antibiotics.
{3} POST-OPERATIVE FEVER (101 - 103 F):
________________________________________
* ATELECTASIS (Day 1):
________________________
-> Lobar or segmental collapse of the lung -> -- lung volume.
-> Due to impaired cough & shallow breathing.
-> Due to accumulation of pharyngeal secretions.
-> Due to the tongue prolapsing posteriorly into the pharynx.
-> Due to airway tissue edema or residual anesthetic effects.
-> Causes significant ventillation - perfusion mis-match -> hypoxemia & ++ brea
thing work
-> Atelectasis is MOST SEVERE at the SECOND POSTOPERATIVE DAY NIGHT.
-> As a compensation for hypoxia -> Hyperventilation -> Respiratory alkalosis &
-- pCO2.
-> Ex -> pH 7.49, pO2 70 mmHg, pCO2 50 mmHg.
-> Prevention: Breathing exercises - Incentive spirometry - Forced expiratory t
echniques.
. N.B.
. Moving from supine to sitting position ++ the functional residual capacity FR
C 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 diagnostic.
-> 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 postoperative setting !
. Mortality rate is higher than for non surgery related 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 progressively more difficult to bag.
. BP steadily declines & CVP steadily rises.
. Insert needle to decompress & place chest tube later.
{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 no evidence of CHF.
. Tx -> PEEP = Positive end expiratory pressure.
{10} DELIRIUM TREMENS (Day 2-3):
_________________________________

. Tachycardia - Hyperthermia - Hypertension - Altered 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) = Acute Pre-renal failure from HYP
OVOLEMIA !
. 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 motility without physical obstru
ction.
. 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. adehsions 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 pe
ristalsis.
. N.B.
. Post-operative DVT:
______________________
. DVT occurs due to Virchow triad (Stasis - endothelial injury - Hypercoagulabi
lity).
. Major surgery is a significant risk factor.
. Pts sh'd be ttt with LMW HEPARIN acutely & warfarin for several months.
. Stable pts can be ttt with anticoagulation as early as 48 - 72 hours after su
rgery.
. N.B.
. Transfusion reactions:
_________________________
. occur acutely during or immediately following transfusion 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 may 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 common causes of nosocomial infect
ions.
. Femoral central venous catheters carry a higher risk of bacteremia than subcl
avian cath
. IV catheter infections are mostly caused by cutaneous organisms such as STAPH
YLOCOCCI.

. Femoral catheters may also cause gram -ve bacteremia.

. N.B. Post-operative ACUTE ADRENAL INSUFFECIENCY:
___________________________________________________
. Acute onset of nausea, vomiting, abdominal pain, hypoglycemia & hypotension.
. follows a stressful event e.g. surgical procedure.
. 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-operative wound contamination.
. Complicates 5 % of sternotomies.
. 14 days postoperative.
. Fever, tachycardia, chest pain, leukocytosis.
. Sternal wound drainage drainage of purulent discharge.
. CXR -> WIDENED MEDIASTINUM.
. Tx -> Drainage, surgical debridement with immediate closure & prolonged antib
iotic ttt.
. High mortality rate.
________________________________________________________________________________
__________
. PEDIATRIC SURGERY:
_____________________
_____________________
. CONDITIONS THAT NEED SURGERY AT BIRTH:
_________________________________________
_________________________________________
. Congenital anomalies constitute the conditions that need surgery at birth.
. The most imp. step is to rule out other associated congenital anomalies.
. VACTER -> Vertebral, Anal, Cardiac, Tracheal, Esophageal, Renal & Radial anom
alies.
{1} ESOPHAGEAL ATRESIA:
________________________
. Excessive salivation is noted shortly after birth.
. 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 workup,
. perform gastrotomy to protect the lungs from acid reflux.
{2} IMPERFORATED ANUS:
_______________________
. ABSENCE of flatus or stools.
. Look for a fistula near by (to vagina or perineum).
. If present, delay repair until further growth (but before toilet training tim
e).
. 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 ventillation, sedation & NG sucti
on.
. 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 normal looking bowel & little liv
er slice).
.
.
.
).
.

Tx -> Small defects -> Close small defects primarily.

Tx -> large defects -> Silastic "silo" to protect the bowel.
Manual replacement of the bowel daily until complete closure (in about 1 week
Give parenteral nutrition (The bowel will not work 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 lif
e.
. Do NOT delay surgery.
{6} INTESTINAL ATRESIA:
________________________
. Like annular pancreas, it presents with green vomiting.
. But, instead of double-bubble sign, there are multiple air-fluid levels in th
e abdomen.
. There is no need to suspect other congenital anomalies,
. because this condition results from a vascular accident in utero !
. SURGICAL CONDITIONS IN THE FIRST TWO MONTHS OF LIFE:
_______________________________________________________
_______________________________________________________
{1} NECROTIZING ENTEROCOLITIS:
_______________________________
. This shows up as feeding intolerance in premature infants when they are 1st f
ed.
. There is abdominal distension.
. Rapid drop in platelet count (A sign of sepsis in 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 - Bowel wall gas).
{2} MECONIUM ILEUS:
____________________

. Feeding intolerance & bilious vomiting.

. Family H/O of cystic fibrosis.
. Dx -> X-ray -> Multiple dilated loops of small bowel.
. Dx -> X-ray -> Ground glass appearance in lower abdomen.
. Gastrograffin enema is both diagnostic & therapeutic.
. Diagnostic -> Microcolon & inspissated pellets of meconium in the terminal il
eum.
. Therapeutic -> Gastrograffin draws fluid in & dissolves the pellets.
{3} HYPERTROPHIC PYLORIC STENOSIS:
___________________________________
. Approximately at 3 weeks of age.
. NON-bilious projectile vomiting after each feeding.
. Look for gastric peristaltic waves.
. Palpable "olive-size" mass in the RUQ.
. Dx -> Abd. U/$.
. Tx -> Correct dehydration & associated hypochloremic hypokalemic metabloic al
kalosis.
. Follow this with Ramstedt pyloromyotomy.
{4} BILIARY ATRESIA:
_____________________
. 6 - 8 weeks old babies.
. Persistent progressively increasing jaundice Conjugated bilirubin).
. Dx -> Conduct serologies & sweat chloride test to rule out other problems.
. Dx -> HIDA scan after 1 week of phenobarbital (A powerful choleretic).
. If no bile reaches duodenum even e' phenobarbital stimulation: Do surgical ex
ploration.
{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 makes 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 & therapeutic.
. 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 mucosa 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 displaced or angulated.
. OPEN REDUCTION & INTERNAL FIXATION -> for severely displaced or angulated #s.
. Open #s (The broken bone sticking out through a wound) require cleaning in th
e OR,
. & reduction within 6 hours from time of injury.
. Always worry about gas gangrene in any deep penetrating or dirty wounds.
. 3 days later, the pt will be septic with gas crepitus.
. Tx -> Large doses of IV penicillin & hyperbaric oxygen.
. Always perform cervical spine films in any pt with facial injury.
. MANAGEMENT OF COMMON ADULT ORTHOPEDIC #s:
____________________________________________
____________________________________________
{1} CLAVICULAR #:
__________________
. # of the MIDDLE 1/3 -> Brace (Figure 8 sling), rest & ice.
. # of the DISTAL 1/3 -> Open reduction & internal fixation to prevent malunion
.
. All pts sh'd've a creful neurovascular examination to rule out injury to:
. the underlying brachial plexus & subclavian artery.
. Hearing a loud bruit warrants an angiogram to rule out subclavian artery inju
ry.
{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 (GALEAZZI #):
______________________________________________________________
. Combination of diaphyseal # & displaced dislocation 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 nondisplaced scaphoid #.
. Tx -> Wrist immobilization for 6 - 10 weeks.
. Place thumb spica cast to help to prevent non-union.
{5} HIP #:
___________

. Any elderly pt who sustains a fall.

. Look for externally rotated & shortened leg.
. Femoral neck # -> High risk of avascular necrosis - Tx: Femoral head replacem
ent.
. Intertrochanteric # -> Open reduction & pinning.
. Femoral shaft # -> Intra-medullary rod fixation.
{6} TRIGGER FINGER:
____________________
. Woman who awakens at night with an acutely flexed 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 em
ergency).
. Differentiate it from hip # by an internally rotated leg (The leg is also sho
rtened).
. 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 injury to knee.
. Effusion is seen rapidly following injury.
. Dx -> Lachman's test, ANTERIOR drawer test & pivot shift test.
. Posterior -> H/O of dashboard injury.
. Forceful posterior-directed force on the tibia with 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 the 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 (BUCKET 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 basketball match.
. Pt with H/O of fluoroquinolone use.
. Complaining of sudden "POPPING" & limping.
. Tx -> Casting in equinous position or surgical repair.
{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 stretched).
. Easily seen on erect postero-anterior (PA) & lateral 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 tonic-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 needed.
.
.
.
.
s.
.

N.B.
Hip #s are common in the elderly,
1st -> Stabilization & treatment for pain control & DVT prophylaxis.
Next -> Discover the etiology of the pt's fall with appropriate investigation
Do EKG , CXR & cardiac enzymes !

. N.B.
. Acute shoulder pain after forceful abduction & external rotation at glenohume
ral joint,

. suggests an anterior shoulder dislocation -> AXILLARY 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 pulling a child arm while in a h
urry.
. The child will be calm but will cry on an attempt to flex the elbow or supina
te forearm
. Dx -> Clinically (Radiographs are often normal).
. Tx -> GENTLE PASSIVE ELBOW FLEXION & FOREARM SUPINATION.
. 1st -> Extend & distract the elbow.
. Next -> Supinate the forearm.
. Hyperflex the elbow with your thumb over he radial head to feel reduction.
. No post reduction films are needed.
. The child will resume the use of the previously unused extremity without cryi
ng.
* COMPARTMENT $YNDROME:
________________________
. Most frequent in the forearm or lower leg.
. H/O of prolonged ischemia followed by reperfusion, crushing injuries or other
traumas.
. Pain & tightness & tenderness to palpation at the 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 ischemia,
. 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 tissu
e.
. N.B.
. Escharotomy is indicated for circumferential full thickness burns of an extre
mity,
. with an eschar causing significant edema & constriction of the vascular suppl
y.
. Pts sh'd be evaluated for clinical signs of adequate perfusion after escharot
omy.
. 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 heavy object.
. Electric shock like pain shooting down the leg.
. Straight leg raising test gives excruciating pain.
. 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 sphincter - Saddle anesthesia).
. MRI -> Confirm both disc herniation & causa equina.
. Trial of anti-inflammatories is always the 1st step 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 uveitis & IBD).
. Tx -> Anti-inflammatory agents & physical therapy.
{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 important 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 neurologic syms to rule out cord compr
ession.
. Bone scan will not be helpful in purely lytic lesions (Multiple Myeloma).
. Instead order plain radiographs or MRI.
* FOOT PAIN:
_____________
_____________
. PLANTAR FASCIITIS:

_____________________
. Older, overweight pts with sharp heel pain every time their foot strikes to t
he 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 aspect 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 -> CLICKING SENSATION (MULDER SIG
N).
. Caused by wearing pointy-toed shoes.
. The neuroma is palpable with very tender spot there.
. Management is analgesics & appropriate foot wear.
. STRESS # = HAIR LINE #:
__________________________
. Sudden ++ in repeated tension or compression without 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 evaluation.
. Stress # of the meta-tarsals are common in atheletes & 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 through the ankle.
. Usually caused by a # of the bones around the ankle.
. 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 veins surrounding spermatic cord
& testis.
. Results from incompetence of the valves of the testicular vein.
. Occurs most frequently on the left side, bec.
. Lt testicular vein enters Lt renal vein inferiorly at right angle -> impaired
drainage.

. Dull or dragging discomfort scrotal pain that becomes worse on standing.

. Examination -> Bag of worms (Enlarge with Valsalva maneuver).
. NEGATIVE TRANSILLUMINATION.
. HYDROCELE:
_____________
. Due to fluid accumulation in tunica vaginalis.
. POSITIVE TRANSILLUMINATION.
. TESTICULAR NEOPLASIA:
________________________
. Painless testicular mass with negative transillumination.
. SPERMATOCELE:
________________
. Cystic dilatations of the efferent ductules.
. Painless fluif-filled cysts containing sperms.
. Located on superior pole of testis in relation to 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 bilateral orchipexy.
. ACUTE EPIDIDYMITIS:
______________________
. Acute scrotal pain (may be referred to abdomen).
. FEVER & urinary symptoms.
. Dx -> Urinalysis & urine cultures & discharge culture if present.
. Tx -> Males < 35 ys -> Treat for gonorrhea & chlamydia -> Ciprofloxacin & Dox
ycycline.
. Tx -> Older males -> Treat as UTI (E-coli) with Levofloxacin.
. UROLOGIC OBSTRUCTIONS:
_________________________
. Combination of obstruction & infection is a urologic emergency.
. It can lead to destruction of the kidney in few hours.
. Tx -> Immediate decompression of the urinary tract above the obstruction.
. Tx -> IV antibiotics are given to prevent infection.
. Tx -> A ureteral stent or percutaneous nephrostomy is the most important inte
rvention.
.
.
.
.

N.B.
Urinary calculi present as flank or abdominal pain radiating to the groin.
Nausea & vomiting is common.
Unlikepts with an acute abdomen, pts with urinary 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 t
est.
. Dx -> X-ray can miss radio-lucent urinary stones (15 % of stones).
. N.B.
. Nephrolithiasis

. Flank pain & hematuria accompanied by nausea & vomiting.

. Pts with Chron's disease or small bowel dis -> Fat malabsorption.
. Fat malabsorption -> predispose to hyperoxaluria.
. Oxalate is obtained from diet & is a normal product of human metabolism.
. Symptomatic hyperoxaluria is the result of ++ oxalate absorption in the gut.
. Under normal circumstances: Calcium binds oxalate in the gut preventing its a
bsorption.
. In pts with fat malabsorption, Ca is bound by fat leaving oxalate free & unbo
und.
. Failure to adequately absorb bile salts in cases of fat malabsorption,
. leads to -- bile salt reabsorption in small intestine.
. 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 removal to avoid inguinal hern
ia.
{3} HYPOSPADIUS:
_________________
. Urethral opening at the ventral side of the penis.
. Never to perform circumcision on this child.
. The prepuce will be needed for the plastic reconstruction.
. N.B. A child who has HEMATURIA from TRIVIAL TRAUMA,
. has an undiagnosed congenital anomaly until proven otherwise.
.
.
.
.
.

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

has an undiagnosed congenital anomaly until proven 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 & develops colicky flank pain.
________________________________________________________________________________

__________
. VASCULAR SURGERY:
____________________
____________________
{1} SUBCLAVIAN STEAL $YNDROME:
_______________________________
. Due to an arteriosclerotic stenotic plaque at the origin of subclavian artery
.
. This allows enough blood to reach the arm for normal activity, but,
. Not enough to meet the ++ demands of an exercised arm,
. resulting in BLOOD BEING STOLEN FROM THE VERTEBRAL ARTERY.
. Posterior neurological signs (Visual symptoms - Equilibrium problems).
. Claudication in the arm during arm exercises.
. Don't confuse this condition with thoracic outlet $!
. 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 "ABDOMINAL" aortic aneurysm:
-> Aneurysms < 5cm -> Observe with serial annual imaging.
-> Aneurysms > 5cm -> Elective surgical repair.
. More urgent surgery is needed if:
-> A TENDER AAA will rupture within a day or two requiring urgent repair.
-> Excruciating back pain in a pt e' large AAA means that,
. the aneurysm is already leaking, necessitating emergency surgery.
. N.B. The following contributes to the development of "THORACIC" aortic aneury
sm:
-> Chronic hypertension.
-> Hyperlipidemia.
-> Smoking.
-> Marfan $.
-> Untreated tertiary $yphilis.
. N.B. The most imp. modifiable risk to prevent worsening of existing aneurysms
is:
-> UNCONTROLLED HYPERTENSION.
. N.B. Asymptomatic lesions -> BLOOD PRESSURE MANAGEMENT is the most important.
. N.B. Symptomatic lesions (including active dissection) -> Surgical interventi
on.
. (Look for sudden onset tearing pain in the back).
{3} ARTERIOSCLEROTIC OCCLUSIVE DISEASE OF THE LOWER EXTREMETIES:
_________________________________________________________________
. Pain in the legs on exercise that is relieved by rest (intermittent claudicat
ion).
. If the claudication doesn't affect the pt's life style -> No intervention is
needed.
. The only management indicated is CESSATION OF SMOKING & 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 daily life activity),

or there is impending ischemia to the extremity,
Tx -> SURGERY (Angioplasty & stenting for stenotic segments).
More extensive disease requires bypass grafts or sequential stents.

. N.B. PAIN AT REST indicates END STAGE DISEASE (Pt complains of calf pain at n
ight).
. N.B. VVVVVVVVVVVVVVVVV. imp.
. The 1st step in evaluating a pt with suspected peripheral artery disease (PAD
) is:
. to obtain an ANKLE-BRACHIAL INDEX (ABI) to confirm the diagnosis.
. Aspirin & cilostazol are antiplatelet agents that can be given after confirmi
ng PAD.
. They are not given upon clinical suspicion !
. Pts with significant symptoms & NORMAL ABI may have MILD diesase at rest.
. They sh'd undergo EXERCISE TESTING with pre & post 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 ischemia,
. 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 tissu
e.
. N.B. COMPARTMENT $ 5 "P"s:
____________________________
. May be caused by direct trauma (Hemorrhage), prolonged compression of an extr
emity.
. May be caused after revascularization of an acutely ischemic limb.
. Muscles of extremity are encased in fascial compartments preventing tissue ex
pansion.
. The ++ pressure interferes with perfusion leading to muscle necrosis.
. Pressure > 30 mmHg leads to cessation of blood flow through capillaries.
. Tx -> EMERGENT FASCIOTOMY.
-> Pain
. Earlest symptom.
. ++ by passive stretch of the muscles in the affected compartment.
-> Paresthesia
. Burning or tingling sensation.
. occurs in the distribution of the affected peripheral nerve.

-> Pallor
. of the overlying skin
. result from tense swelling & compromised perfusion.
-> 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 exposed tissue following burn w
ounds.
. When eschar occurs circumferentially on an extremity,
. it restricts the outward expansion of the compartment as edema follows burn.
. Interstitial pressure increases -> compromise vascular flow to the limb.
. Deep pain out of proportion to injury, pulselessness, paresthesia, cyanaosis
& pallor.
. Tx -> Escharotomy.
.
.
.
.
.

N.B. Compartment $ 2ry to SUPRA-CONDYLAR # of humerus:

2ry to fall on out-stretched hand.
Due to ++ pressure in a limited space.
Pain, pallor, pulselessness, paralysis & presthesia.
Tx -> Immediate fasciotomy.

. N.B. VOLKMANN's ISCHEMIC CONTRACTURE:

. is the final sequel of compartment $ (The dead muscle is replaced by fibrous
tissue).
{4} ARTERIAL EMBOLIZATION OF THE EXTREMETIES:
______________________________________________
. H/O of Af or recent MI.
. Sudden onset painful, pale, cold, pulseless, paresthetic & paralytic lower ex
tremity.
. 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 aorta in the common iliac arteri
es.
. Triad of bilateral hip, thigh & buttock claudication, impotences &
. symmetric atrophy of the bilateral lower extremeties 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 the:
. anterior spinal artery & 2 posterior spinal arteries originating from vertebr
al artery.
. Presents with flaccid paralysis, bowel/bladder dysfunction, sexual dysfunctio
n.

. Possible hypotension & loss of deep tendon reflexes.

. Spasticity & hyperreflexia develop over days to weeks.
. Vibratory & proprioceptive sensation is preserved 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 mechanical obstruction e.g.
. Gastric malignancy - Peptic ulcer disease - Chrons dis - Strictures e' pylori
c stenosis
. Strictures 2ry to ingestion of caustics.
. Characterized by early satiety, nausea, non-bilious vomiting & weight loss.
.
.
.
d,
.

P/E -> ABDOMINAL SUCCUSSION SPLASH, elicited by placing the stethoscope,

over the upper abdomen & rocking the pt back & forth at the hips,
Retained gastric material > 3 hours after a meal will generate a splash soun
indicating the presence of a hollow viscus filled with both fluids & gas.

. In a pt with a H/O of acid ingestion, pyloric stricture is the most likely ca

use.
. H/O of a recent acid ingestion is a risk factor of developing pyloric strictu
re.
. Acid ingestion causes fibrosis 6-12 weeks after the resolution of acute injur
y.
. 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 tissu
e 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 !!!!

.
.
an
.
.
.
.
.

SIR$ can follow pancreatitis, autoimmiune dis, vasculitis & burns.

Sepsis (SIRS e' a known infection) is considered severe when there is end org
failure
Oliguria - Hypotension (SBP < 90mmHg) - Thrombocytopenia (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 week post-burn.

. Main causes of sepsis are pneumonia & wound infections (Staph aureus & Pseudo
monas).
. Criteria indicating sepsis -> Leukocytosis - Thrombocytopenia - Mild hypother
mia < 36.
. Tachypnea & tachycardia due to associated pneumonia.
. Worsening hyperglycemia due to worsening insulin resistance.
. Bottom line:
. In pts with severe significant total body surface areas burns,
. The major cause of morbidity & mortality is HYPOVOLEMIC SHOCK.
. In case of adequate initial fluid resuscitation,
. Bacterial infection (Bronchopneumonia or burn wound infection) -> Sepsis & se
ptic shock
. INTRA-PERITONEAL RUPTURE OF THE BLADDER:
___________________________________________
. Intra-abdominal pathology causing shoulder pain = Subdiaphragmatic peritoniti
s.
. Among the possible blunt traumatic bladder injuries,
. Only an INTRA-PERITONEAL RUPTURE OF THE (BLADDER DOME) -> CHEMICAL PERITONITI
S.
. The dome of the bladder is the only region covered by peritoneum.
. Pain could be transferred to the ipsilateral shoulder because,
. Phrenic nerve originates from C3 to C5 spinal nerves mediating sensation for
shoulders.
. INTRA-ABDOMINAL MALIGNANCY (CANCER PANCREAS):
________________________________________________
. Day time fatigue, anorexia, significant weight loss.
. Visceral type abdominal pain interfering with sleep.
. Constant eigastric pain radiating to the back, weight loss & jaundice.
. Migratory thrombophlebitis is a classic association.
. N.B.
. A peptic duodenal ulcer causes periodic epigastric pain relieved by meals.
. PILO-NIDAL SINUS:
____________________
. Acute pain & swelling of the midline sacro-coccygeal skin & subcutaneous tiss
ues.
. Due to infection of a dermal sinus tract originating over the coccyx.
. RIB #:
_________
. Pain relief is the prime objective in management of rib #.
. As it allow proper ventillation & prevent atelectasis & pneumonia.
. TETANUS PROPHYLAXIS:
_______________________
_______________________
. Un-immunized, uncertain or < 3 tetanus toxoid doses:
_______________________________________________________

. Minor clean wound -> Tetanus toxoid only.

. Severe or dirty wound -> Tetanus toxoid & tetanus immunoglobulins.
. > 3 tetanus toxoid doses:
____________________________
. Minor & clean wound -> None.
. Severe or dirty wound -> Tetanus toxoid if latest boster given > 5 years ago.
. N.B. Tetanus-diphtheria toxoid sh'd be given to individuals with severe or di
rty wounds
. who received a booster > 5ys ago
. & those with minor clean wounds who received a booster dose > 10 ys ago.
. N.B. Tetanus immune globulin sh'd be given to any individual with severe dirt
y 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 hemoglobin.
. Confusion, wheezes, headache, nausea, dyspnea, malaise, altered mentation, di
zziness.
. If severe -> Seizure, coma, syncope, heart failure & arrhythmias.
. Bright cherry lips can be seen but not specific.
. Dx -> ++ Carboxyhemoglobin level > 3 % in non-smokers & > 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 dia
meter.
. 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 cycle.
. 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 common complaints.
. It is a HISTOLOGICAL diagnosis.
. 5 . INFLAMMATORY BREAST CARCINOMA:
_____________________________________
. Brawny edematous cutaneous plaque.
. "P'eau d'orange" orange peel appearance overlying a breast mass.
. It is an aggressive tumor.
. 1/4 of the pts have metastatic disease at the time 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 always raise suspicion for can
cer,
. spontaneous, unilateral, localized to single duct, bloody discharge in pt > 4
0 ys old.
. Mass association is an imp. sign of malignancy.
. Clinicalyy, you can't differentiate it from an inflammatory process (breast a
bscess).
. A BIOPSY FOR HISTOLOGY IS THE MAIN STAY OF DIAGNOSIS !
. PALPABLE BREAST MASS EVALUATION:
___________________________________
PALPABLE BREAST MASS
______________________
|
________________________________
|
< 30 ys
|
ULTRASONOGRAM ONLY
|
____________________
|
SIMPLE CYST
|
NEEDLE ASPIRATION

|
SOLID MASS
|
CORE BIOPSY

|
> 30 ys
|
MAMMOGRAM & ULTRASONOGRAM
|
|
|
SUSPICIOUS FOR MALIGNANCY
|
CORE BIOPSY

. N.B.
. BREAST FAT NECROSIS
. shows clinical signs & radiographic findings similar to breast cancer !
. Syms include (Skin or nipple retraction - Calcification on mammography).
. Biopsy of the mass -> FAT GLOBULES & FOAMY HISTIOCYTES.
. No ttt is indicated (Self limiting condition).
________________________________________________________________________________
__________

. SPINAL CORD INJURIES:

________________________
________________________
. ANTERIOR CORD $YNDROME:
__________________________
. Burst # of the vertebra -> Occlusion of vertebral artery.
. Total loss of the motor function below the level of the lesion.
. Loss of pain & temperature on both sides below the lesion.
. NORMAL proprioception.
. NEGATIVE Straight leg raising test.
. Dx -> MRI.
. CENTRAL CORD $YNDROME:
_________________________
. Hyperextension injury in elderly pts with degenerative diseases of the cervic
al spine.
. Selective damage to the central portion of the spinal cord.
. specially the corticospinal & decussating fibers of the lateral spinothalamic
tracts.
. Burning pain & paralysis in the UPPER extremeties e' relative SPARING of lowe
r limbs.
. POSTERIOR CORD $YNDROME:
___________________________
. Bilateral loss of vibratory & proprioceptive sensation.
. BROWN SEQUARD $YNDROME:
__________________________
. Acute hemisection of the spinal cord.
. Ipsilateral motor & proprioception loss below the level of the lesion.
. Contralateral pain loss below the level of the lesion.
. 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 cord due to CSF retention.
. Impaired strenght & pain/temperature sensation in upper extremeties.
. Preservation of dorsal column function (Light touch - vibration - position se
nse).
. CAPE LIKE DISTRIBUTION.
________________________________________________________________________________
__________
. # Mid-shaft humerus -> Radial nerve injury -> Wrist drop.

. # Supracondylar humerus -> Brachial artery -> pain, pallor, pulselessness, pa

resthesia.
. # Humerus -> Ulnar nerve -> Claw hand.
. ROTATOR CUFF TEAR:
_____________________
. Rotator cuff is formed by tendons of:
. (supraspinatous, infraspinatous, teres minor & subscapularis muscles).
. The supraspinatous is most commonly injured,
. due to repeated bouts of ischemia near its insertion on the humerus,
. induced by its compression between the humerus & the acromion.
. Common cause of tear is fall on out-stretched hand.
. Severe shoulder pain & edema following the trauma.
. Inability to abduct the arm at 90 degrees.
. When the pt's arm is abducted passively to greater 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 becomes prominent in the mid up
per arm.
. PAGET'S DISEASE OF BONE = OSTEITIS DEFORMANS:
________________________________________________
. Disordered bone remodelling.
. ++ Osteoclast activity -> ++ bone resorption.
. Accelereated osteoblastic activity to rebuild the degraded bone.
. WOVEN BONE formation (Various stages of bone throughout the body).
. The woven bone is larger than normal bone & more liable to bowing & #.
. Most common presenting symptom is secondary arthritis of hip or knee.
. ++ ALKALINE PHOSPHATASE.
. NORMAL serum phosphorous & calcium levels.
. Enlargement of skull bones -> Bossing, ++ head size (Old hats no longer fits!
).
. Headaches & cranial nerve palsies.
. Hearing loss is due to damage of the cochlear nerve,
. due to enlargement of the temporal bone & entrapment at the internal auditory
meatus.
. VARICES:
___________
. NON-BLEEDING VARICES are managed with BB "Prporanolol".
. After 1st episode of bleeding -> Sclerotherapy, endoscopic band ligation & su
rgery.
. If not responsive to medical or endoscopic intervention -> Porto-systemic shu
nt (TIPS).
. RESPIRATORY QUOTE (RQ):
__________________________
. RQ is the ratio bet. CO2 produced to O2 consumed.
. Used to make assessmentsof metabolism taking place in the body.
. In mechanically ventillated pt, the RQ is 1.05.
. The ratio depends upon the major fuel being oxidized for ATP production.
. An RQ close to 1 indicates that CARBOHYDRATE is the major nutrient being oxid
ized.
. The RQ for protein & lipid as sole energy sources 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 nature & proportions of metabolic
s used.
. TROCHANTERIC BURSITIS:
_________________________
. Unilateral hip pain in a MIDDLE-AGED adult.
. Inflammation of the bursa around the insertion of gluteus medius greater troc
hanter.
. Excessive frictional forces 2ry to overuse or trauma are common causes.
. Hip pain when pressure is applied (When sleeping) & external rotation or abdu
ction.
. FEMORAL HEAD AVASCULAR NECROSIS = LEGG CALVE' PERTHES 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 head.
. Alternating regions of lucency & density = Reflects of necrotic tissue by new
bone.
. Tx -> Conservatively with observation & bracing.
. Tx -> Surgery in cases where femoral head isn't well contained within the ace
tabulum.
. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE):
____________________________________________
. Obese male child with pain during LATE CHILDHOOD or EARLY ADOLESCENCE.
. Metaphysis & femur slip relative to the epiphysis at the epiphyseal plate.
. The capital femoral epiphysis remains structurally intact within the acetabul
um.
. 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 necrosis.
. TRENDELENBURG SIGN:
______________________
. Drooping of the contralateral pelvis when the pt stands on one foot.
. Associated with TRENDELENBURG gait (Waddling) caused by the trunk rocking,
. to compensate for the pelvic drooping !
. Caused by weakness or paralysis of the gletues medius & minimus muscles,
. due to superior gluteal nerve trauma or inflammation or entrappment.
. The pt presents with unilateral intermittent knee pain.
. Physical activity e.g. stair clumbing exacerbates the pain.
. Hip tenderness is common.
. SQUAMOUS CELL CARCINOMA:
___________________________
. Suspected in all non-healing wounds.
. SCC may arise within chronicallu wounded, scarred or inflammaed skin.
. SCC arising within burn wounds is known as MARJOLIN ULCER.
. SCC arise in skin overlying a focus of osteomyleitis, radiotherapy or venous
ulcers.
. SCC arising within chronic wounds exhibit aggressive 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 m

alignancy.
. 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 & ++ pressure in post-capillary venules.
. ++ pressure = VENOUS HYPERTENSION.
. ++ pressure -> Damages capillaries -> Loss of fluid, plasma ptns & RBCs into
tissue.
. Erythrocytes extravasation -> Hemosiderin deposition & bluish discoloration.
. May be complicated by venous ulcers.
. It involves the medial leg below the knee & above the medial malleolus.
. Xerosis is the most common early finding.
. Lipodermatosclerosis & venous ulcerations are late findings.
. RETRO-PERITONEAL HEMORRHAGE:
_______________________________
. An iatrogenic complication after cardiac catheterization.
. After cannulation of the femoral artery to access the cardiac vessels.
. A hematoma is formed at the upper thigh -> Extends into the retro-peritoneal
space.
. Significant belleding with hypotension & tachycardia.
. Ipsilateral flank/back pain.
. Dx -> CT scan of ABDOMEN & PELVIS with-OUT contrast.
. Tx -> Supportive -> Blood transfusion - IV fluids - 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 PEPTIC ULCER.
. PERFORATED PEPTIC ULCER (H/O of epigastric pain & discomfort with eating).
. Tx -> SURGICAL CONSULATATION IMMEDIATELY for EXPLORATORY LAPAROTOMY.
. CHILD ABUSE:
_______________
. Patterned scalds & burns = forceful immersion of hot object e.g. cigarette or
hot iron.
. Incoherent or impropable explanation of the injuries.
. Delay in seeking care after injury.
. #s of long bones or ribs, #s in various stages of healing.
. Suspicious bruises include those on thighs, abdomen, cheeks & genitalia.
. Subdural hematoma & retinal hemorrhages in very young infants.
. Inaapropriate affect of the care giver.
.
al
.
.

Physician should perform a thorough physical exam. & full radiographic skelet
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-MOISTENED GAUZE,
. SEALED IN A PLASTIC BAG,
. PLACED ON ICE,
. brought to the emergency department with the patient.
. CAUSES OF HEMOPTYSIS:
________________________
. Pulmonary -> Bronchitis - Pulmonary embolism - Bronchiectasis - Lung cancer.
. Cardiac -> Mitral stenosis - Acute pulmonary edema.
. Infectious -> Tuberculosis - Lung abscess.
. Hematologic -> Caogulopathy.
. Vascular -> Arteriovenous malformation.
. Systemic diseases -> Wegener's granulomatosis - Goodpasture's $ - SLE - Vascu
litis.
. HEMOPTYSIS MANAGEMENT
________________________
|
. H/O & P/E to rule out other causes (Oropharynx & GIT)
________________________________________________________
|
_______________________________
|
|
. MILD/MODERATE
. MASSIVE (>600 ml/24hs)
________________
_________________________
|
|
. CXR, CBC, COAGULATION STUDIES
. SECURE AIRWAY, BREATHING & CIRCULA
TION
. 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 flooding with blood.
. Establishing an adequate patent airway is the most imp. initial step.
. The pt should be placed with the bleeding lung un the dependent lateral posit
ion,
. to avoid blood collection in the airways of the opposite lung.
. Bronchoscopy is the best to localize the bleeding 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 spread of infection.

. FAT EMBOLISM:
________________
. Common in pt with polytrauma with multiple #s of long bones.
. Severe respiratory distress, petichial rash, subconjunctival hemorrhage.
. Tachycardia, tachypnea & fever.
. May occur after 12-72 hs after trauma.
. CNS dysfunction -> Confusion - Agitation - Stupor - Seizures - Coma.
. Dx -> Fat droplets in urine.
. Dx -> Intra-arterial fat globules on fundoscopy.
. Dx -> CXR -> Diffuse bilateral pulmonary infiltrates.
. 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 of the necrotic tissues.
. Adjunctive ttt -> Antibiotics, adequate hydration & tight glycemic control.
. MASTITIS ASSOCIATED WITH BREAST FEEDING:
___________________________________________
. Due to transmission of bacterial organism from the infant's nasopharynx,
. to a fissure on the mother's nipple or areola.
. Most commonly Staph. aureus.
. Tx -> Analgesics, antibiotics (Dicloxacillin-Cephalosporin) & CONTINUE BREAST
FEEDING.
. Continued nursing from the affected breast -> -- the progression of mastitis
to abscess
. Incision & drainage only if there is abscess formation !
. 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 -> ++ intrathoracic pressure -> -- VR to
heart.
. -- VR -> -- Ventricular preload.
. In pts with hypovolemic shock, this effect may cause circulatory collapse !
. if the pt's intravascular volume isn't replaced before mechanical ventillatio
n begins.
. URETHRAL INJURY & PELVIC #:
______________________________
. POSTERIOR urethral injury is associated with pelvic #s.

.
.
.
.
.

Blood at urethral meatus.

High riding prostate.
Scrotal hematoma.
Inability to void despite sensing an urge to void.
Palpable distended bladder.

. ANTERIOR urethral injury is due to blunt trauma to 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 the duodenum & small intestine
.
. Post-prandial abd. cramps - weakness - lightheadedness - diaphoresis.
. Symptoms diminish over time.
. Symptoms result from fluid shift from intravascular space to small intestine.
. Stimulation of intestinal vasoactive peptides -> Stimulation of autonomic ref
lexes.
. Dietary changes are helpful to control symptoms.
. In resistant cases, octreotide sh'd be tried.
. Reconstructive surgery is reserved for intractable 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 - ANGI
ODYSPLASIA
. Nasogastric tube placement with bile not blood = No active upper GI bleeding.
. Upper endoscopy sh'd be done next not to miss duodenal bleeding.
. In cases of hematochezia due to diverticulosis,
. The initial step is COLONOSCOPY.
. If -ve -> Radio-nuclide (Technetium 99 Labelled eryhthrocyte scintigraphy tag
ged RBCs).
. It is less invasive & more sensitive than angiography.
. It localizes the source of bleeding so that,
. the region can be further evaluated by colonoscopy or angiography.
. CENTRAL VENOUS CATHETERIZATION:
__________________________________
. A CXR sh'd be done to confirm proper placement & absence of complications.
. e.g. subclavian artery injury, pneumothorax, hemothorax, thrombosis & air emb
olism.
. 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 bro
nchus.
. The catheter sh'd lie in the superior vena cava.

. DIABETIC FOOT ULCERS:

________________________
. Result from neuropathy, microvascular insuffeciency & immunosuppression.
. They occur on the plantar surface of the foot under points of greatest pressu
re,
. such as under the head of the 1st metatarsal bone.
. SOLITARY PULMONARY NODULE EVALUATION:
________________________________________
SOLITARY PULMONARY NODULE EVALUATION
______________________________________
|
CHEST CT WITH CONTRAST
________________________
|
__________________________
|
|
Benign features
Intermediate or suspicious for malig
nancy
_________________

_____________________________________

______
|
|
SERIAL CT SCANS TO MONITOR FURTHER INVESTIGATION WITH BIOPSY o
r PET scan

. VENOUS VALVULAR INCOMPETENCE:

________________________________
. is the most common cause of lower extremity edema.
. It classically worsens thoroughout the day & resolves overnight when pt is re
cumbent.
. NASAL SEPTAL PERFORATION:
____________________________
. Any pt develops a whistling noise during respiration following rhinoplasty.
. One suspect nasal septal perforation due to Septal hematoma.
. TRAUMATIC SPINAL CORD INJURIES:
__________________________________
. Should be 1st hemodynamically stabilized.
. Proper airway management.
. Urinary catheterization placement is imp. to assess for urine retention !
. It is important to prevent bladder distension & damage.
. A retrograde urethrogram sh'd be the 1st step in management of urethral injur
y,
. Foley catheterization is contraindicated as it will 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 purulent saliva expressed from paro
tid duct.
. Most common infectious agent is STAPHYLOCOCCUS AUREUS.
. Tx -> Adequate fluid hydration & oral hygiene can prevent this condition.
. N.B. Spirometry prevents post-operative respiratory complications not parotit
is.
. DIVERTICULOSIS:
__________________
. is the most common cause of a lower gastro-intestinal hemorrhage in an elderl
y.
. Bright red bleeding from the rectum is usually caused by a lower GI hemorrhag
e.
. Colonic diverticula are formed due to high intra-luminal pressure,
. which causes the mucosa to herniate through the bowel wall penetrating its va
sculature.
. They don't include all layers of the bowel (False divertuculae).
. Chronic constipation is due to low fiber diet.
. Most common predisposing factor to diverticulosis.
. Diverticulae erode the bowel vasculature leading to profuse bleeding per rect
um.
. Most common site is sigmoid colon.
. Dx -> CT Abdomen.
. N.B.
. Diverticulosis -> Non-inflammed diverticula -> Painless bleeding.
. Diverticulitis -> Abdominal pain & infectious syms 2ry to obstruction of dive
rticula.
. It is uncommon to see bleeding with diverticulitis !
. 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 pain.
. 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 occur.
. Subcutaneous emphysema may be seen.
. Dx -> CT or CONTRAST ESOPHAGOGRAPHY e' GASTROGRAFIN (Water soluble) confirms
diagnosis.
. CXR -> Pneumo-mediastinum & pleural effusion.
. Pleural fluid analysis -> EXUDATIVE, LOW pH, VERY HIGH AMYLASE > 2500 IU.
. Tx -> Surgery for thoracic perforations.

. Conservative measures e.g. antibiotics for cervical perforation.

.
.
.
.

IATROGENIC esophageal perforation:

CXR -> Pleural effusion, pneumomediastinum & pneumothorax.
Dx -> Water soluble contrast esophagogram.
Avoid endoscopy not to worsen the condition !

. MECHANISMS OF LOWERING INTRA-CRANIAL TENSION:

________________________________________________
. HEAD ELEVATION -> ++ venous outflow from the head.
. SEDATION -> -- metabolic demand & control of HTN.
. IV MANNITOL -> Extraction of free water out of brain tissue -> Osmotic diures
is.
. HYPERVENTILLATION -> CO2 washout -> Cerebral VASOCONSTRICTION.
. POST-SPLENECTOMY VACCINES:
_____________________________
. Following splenectomy, pts are at ++ risk for sepsis 2ry to encapsulated orga
nisms
. Capsulated organisms (S. pneumoniae - N. meningitidis - H. influenzae).
. Vaccination against these organisms sh'd be administered.
. 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 parotid gland -> facial palsy.
. Facial palsy -> Facial droop.
. INJURY -> CULPRIT INJURED NERVE:
___________________________________
. HOARSENESS -> RECURRENT LARYNGEAL BRANCES OF VAGUS NERVE (Thyroid/Parathyroid
surgery).
. TIC DOULOUREUX (TRIGEMINAL NEURALGIA) -> TRIGEMINAL 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 structures (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 urethral injury.
. Tx -> Surgical exploration to evacuate hematoma & mend the torn tunica albugi
nea.
. 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 origin.
. Higher frequency in people of Mediterranean or far eastern descent.
. Most NPC are metastatic at the time of diagnosis.
. Recurrent otitis media (Due to eustachian tube obstruction by tumor).
. Recurrent epistaxis or nasal obstruction.
. Associated with positive serology for EPSTEIN BARR VIRUS (EBV).
. It is associated with smoking & chronic nitrosamine 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 reaction after abdominal surgery
.
. Due to disruption of normal neurologic & motor control of the gastrointestina
l tract.
. Failure to pass stool or flatus, abdominal distension, nausea & vomiting.
. Distended abdomen with tympany.
. Decreased or absent bowel sounds.
. Abdominal x-ray -> Air-fluid levels & distended gas-filled loops of small & l
arge int.
. Tx -> Conservative with bowel rest & supportive care.
. LUDWIG's ANGINA:
___________________
. Infection of the submandibular & sublingual glands.
. Source of infection -> Infected tooth (2nd or 3rd 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 the growth becomes symptomatic.
. i.e. interfering with speech or eating.
. NEURO-ANATOMY:
_________________
_________________
. FEMORAL NERVE:
_________________
. Motor to anterior compartment of thigh (Quadriceps femoris - Sartorius - Pect
ineus).

. Responsible of knee extension & hip flexion.

. Sensory to the anterior thigh & medial leg via saphenous branch.
. TIBIAL NERVE:
________________
. Motor to posterior compartment of thigh, posterior compartment of leg & plant
ar foot ms
. Responsible of knee flexion & digits & plantar flexion of foot.
. Sensory to the leg (except the medial side) & plantar 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 foot.
. 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 Mohamed

_________________________