Section A : GENERAL SURGERY

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 Chapter : 1 : General Aspects in Surgery

Topic 1a: Nutrition

Assessment of Nutrition:
• Midarm Circumference
• Triceps Skin Fold thickness
• Body Mass Index
• Albumin ( Best of all methods in Surgical Patients)

Malnutrition Universal Screening Tool:

THE MUST TOOL- Clinical assessment tool of malnutrition: Based on 3 Factors:

1. BMI: 2. Weight loss in 3-6 3. Acute disease effect

months
0- >20 Add a score of 2 if there is
1- 18.5- 20 0- <5% reduced intake >5 days
2- <18.5 1- 5-10%
2- >10%

Indications for artificial nutrition

• Any patient who has sustained > 7 days of inadequate intake
• Any patient who is anticipated to have no intake for > 7 days.

Types of nutrition
Enteral Nutrition Parenteral Nutrition
Nutrition given via GI tract Nutrition given via Veins
1. Sip feeding 1. Peripheral Parenteral
2. Tube feeding 2. Central Parenteral
• Nasogastric tube ( Ryles tube) 3. Peripherally Inserted Central Catheter
• Naso jejunal tube
• Feeding Gastrostomy ( PEG)
• Feeding Jejunostomy .

Nasogastric Feeding:
Ryles Tube:
Length of Ryles Tube:
• Length- 110-130 cm in adults
• NEX rule ( Nose, Ear to Xiphisternum) in Adults,
• NEMU rule ( Nose, Ear, Midpoint of Epigastrium to Umbilicus)

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 Figure: Ryles Tube

Ideal method to insert Ryles Tube:

• Sitting with Neck flexed
• Fowler’s Position

Once desired length mark has reached, confirm its position by:
▪ Auscultating with stethoscope in epigastric region by simultaneously pushing air in
an empty syringe through the external port of tube
▪ Look for reflux of gastric contents in the tube
▪ Aspiration of secretion and test with litmus paper for pH ( Most ideal method**)

Nasojejunal Tube ( Freka Tube)

• Inserted with help of Flouroscopy or with help of Endoscopy ( Invasive Procedure)
• Indications for NG to NJ tube:
- Duodenal Fistula
- Acute Pancreatitis Not tolerating NG tube.

Maximum Time we can use Nasal Tubes is for 4 weeks only

If you want to give > 4 weeks- Go for Surgical Tubes like PEG, FG, FJ

PEG tube ( 4-6 weeks nutrition)

Techniques :

Figure: PEG tube

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Feeding Jejunostomy/ Gastrostomy:
• Stamm Direct Stab Technique
• Witzel Tunneling Technique
• These methods are used for patients who need nutrition for long period more than >4
weeks.
• FJ is preferred in Coma Patients as FG will result in Aspiration

Complications of Enteral Nutrition:

1. Tube related Complications ( Most Common)- Malposition, Obstruction, Leakage,
Displacement
2. Osmotic Diarrhea
3. Electrolyte Imbalance
4. Refeeding Syndrome

Parenteral Nutrition:
Parenteral Nutrition types:
• Peripheral PN ( < 2 weeks)
• PICC ( Hickmann Lines)
• Central PN ( > 2 weeks)- IJV, SCV, FV are used

Best vein to give nutrition by central Vein:

• For Elective cases- Subclavian Vein
• For Trauma cases- IJV

TPN bag:
• Components of TPN:
- Dextran ( 60%)
- Fat ( 20%)
- Amino acids ( 20%)
- All essential nutrients, minerals and Vitamins
• Fat Free TPN- 75% Dextran+ 25%Amino acid ( Ratio 3:1)

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Insertion of central Vein Catheter:
• IJV- Between two heads of SCM
• SCV- USG guided Below Midclavicular point of Clavicle
• Tip must be in SVC and not in Atrium
• Advice X ray chest- To look for Pneumothorax and Look for Tip in SVC

Why Should you Shift Enteral to Parenteral Nutrition?

When GIT is not good When BP is not good

Lab Values to be monitored in patient on TPN long term:

• Weekly Twice- Blood Sugar and Electrolytes
• Weekly once- RFT and LFT
• Change the catheter only if there is catheter related sepsis. (Both Tip C/S and Blood C/S
are showing same organism)- Put a new catheter on opposite side.

Complications of TPN
Catheter related Metabolic Electrolyte Disturbances Overfeeding
Complications
Infection Azotemia Hyper / hypo natremia Hyperglycemia
( M/C complication)** Essential fatty Hyper/ hypo kalemia
acid deficiency Hypophosphatemia* Hepatic steatosis –
Injuries Fluid overload Hyper/ hypo Jaundice+
• Pneumothorax, Metabolic bone magnesemia Hypercapnia
Hydrothorax disease Hyper/ hypo calcemia Fluid retention
• Cardiac Liver dysfunction High/ low serum zinc
tamponade Excess fat:

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 Neutrophil High / low serum • Hypercholesterolemia
Central vein Thrombosis Dysfunction* copper • Hyper
Hyper chloremic triglyceridemia
Air embolism Glucose metabolic acidosis. • Lipoprotein X
imbalance formation
• Hypersensitivity.
Trace element
and vitamin Excess amino acid:
deficiency. • Metabolic acidosis
• Uremia
• Hypercalcemia

Refeeding Syndrome:
• Characterized by severe fluid and electrolyte shifts in malnourished patients undergoing
refeeding*
• It can occur with Enteral and Parenteral nutrition ( MC with TPN)
•

(Mnemonic- PCM*)
• Risk factors: Alcohol, Severe malnutrition, Anorexia, Prolonged fasting*
• Treatment: Avoid Overfeeding*
• Deliver calories slowly*
• Electrolyte imbalance needs to corrected*

Hepatic steatosis causing Jaundice:

• Stop TPN temporarily
• Restart with lipid Free TPN.

1st Sign of Sepsis- Elevated Blood Glucose**

Liver failure*- MC indication for Combined SB + Liver Transplant in Short Bowel Syndrome.
Other indication is Central vein thrombosis.

Image Based Questions:

Central vein catheter

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 PICC catheter ( Hickman Lines)

Topic 1b: Shock and Blood transfusion:

• MC cause of death in Surgical Patients- Shock*

Types of Shock (Based on the Image in App)

Features Hypovolemic Shock Distributive Shock
(Haemorrhagic Shock) ( Septic Shock)
Cardiac Output Decreased Increased
Peripheral vascular Increased Decreased
resistance ( Cold Peripheries) ( Warm Peripheries)
Oxygen Consumption Increased Decreased
Venous Resistance Low Low
Mixed Venous Oxygen MVOS < 50%** MVOS>70%**
Saturation ( MVOS)
Normal- 50-70%

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Monitoring of Shock:
Urine Output
• Best Clinical
parameter
• Best clinical method
to look for adequacy
of resuscitation
• Best to Look for tissue
perfusion
CVP Serum Lactate
• Best method to • Best Lab value to
calculate Amount of monitor Tissue
Fluid to be given perfusion
• Amount of Drug to be • Serum Lactate:
given • < 2 mmol/l- Good
resuscitation
• CVP is not accurate • >5 mmol/l- Bad
for cardiogenic shock resuscitation
and septic shock and • Best method to look
hence we use PCWP for Muscle and GIT
for those 2 shocks. perfusion

Haemorrhagic Shock:
• 4 classes of haemorrhagic shock: Class 1,2,3,4 based on amount of Blood Lost.
• Class 1 ( < 750 ml), Class 2 ( 750-1500 ml), Class 3 ( 1500-2000 ml) and Class 4 (
>2000 ml)
• Pulse rate, Respiratory rate increases and Pulse pressure decreases from Class 2 Shock
• BP falls from Class 3 shock

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Management of Haemorrhagic Shock:
• Crash 2 Trial: Bp < 90 mmHg, PR >110/minute- Injection Tranexamic acid * given
immediately.
• 2 Green Venflons ( 18 Gauge is used)
• 1 Litre Crystalloid is used.
• O negative blood without cross matching ( For post reproductive females and males- O
positive can be given**)
• Balanced resuscitation: 1:1:1 unit of PRBC: Platelets: Plasma
• Permissible Hypotension: BP should not be raised too much or must not be too low. It
should be in such a way Brain also receives adequate blood and at the same time the
coagulated vessels must not reopen and rebleed.

Cannulas:
Colour codes of Cannulas:

• In dehydration and Diarrhea to infuse maximum Fluids the ideal cannula is GREY- 16G. (
From the Table note- 200 ml/ minute using Grey*** and 85 ml/ minute using Green)
• In Trauma we use short and wide bore 2 Cannulas of atleast 18 Gauge – 2 in numbers as
per ATLS guidelines*

Damage control surgery (Abbreviated Laparotomy)

The surgery is restricted to two goals only
• Stop any active bleed
• Control any contamination.

The aim is to resuscitate the patient and plan for definite surgeries after the patient becomes
stable.

Deadly triad**
Following a trauma, protracted surgery in physiologically unstable patient,the three factors that
carry high mortality are:

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Hence originated a phenomenon- DAMAGE CONTROL SURGERY.

Phases of Damage Control Surgery:

• Phase -1: Initial Exploration
• Phase-2: Secondary Resuscitation
• Phase -3: Definitive operation

Phase -1 Phase -2 Phase- 3

Initial exploration Secondary Resuscitation Definitive treatment
• Control Active • Transfer to ICU • Planned re exploration and
haemorrhage and • Ventilatory support definite surgery*
Contamination* • Correct the deadly triad- • Done 48-72 hours after
• Midline incision- 4 Hypothermia, Acidosis, secondary phase*
quadrant packing done. Coagulopathy* • Complex reconstruction
• GIT perforations closed must be avoided*
with sutures or Staples* • Abdomen closure done in
• External drains kept for this phase only**
pancreatic/Bile duct
injuries
• Temporary closure of
abdomen using plastic
sheet known as OPSITE**
• We do Bagotta Bag
method.

Septic Shock:
• Defined as Sepsis+ Organ Dysfunction+ Hypotension
• SIRS is defined by:
Two or more of the following: (Mnemonic- Orthopaedics Love THR)
o L- Leucocyte Count ( >12000 or <4000)
o T- Temperature >38 or < 35
o H- Heart rate > 90 beats/ minute
o R- Respiratory rate > 20/ minute ( PaCo2 <32 mmHG)
• Quick Sequential Organ Failure Assessment Score ( qSOFA score)
(Mnemonic – Royal Challengers Bangalore will be in SOFA)
o R-
o C-
o B-
≥2 points indicates organ dysfunction. Score > 2 carries 10% mortality

Management of Septic Shock:

• Eradicate the septic Foci
• Antibiotics

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 • IV fluids- Crystalloids (no need of Blood transfusion)
• Vasopressor of Choice- Nor adrenaline**

Blood transfusion and Blood Products

Transfusion:
• The amount of blood withdrawn from donor- 450ml
• Maximum three times/year
• Storage of Blood- 45 days using Saline Adenine Glucose mannitol ( SAG- M)
• Old Storage Component- Citrate Phosphate Dextrose ( 3 weeks only)
• Each unit of blood is screened for- Hepatitis B, hepatitis C, HIV 1 and HIV 2 and syphilis
( Western countries – Creutzfeld Jacob Disease which is usually depleted by Leucocyte
Filters)

Blood Products:

Whole blood: Packed red cells:

• Rich in coagulation factors than
packed cells and more metabolically
active than stored blood.
• Available as 450 ml pack.
• Contains RBC, WBC, Plasma, Platelet
of which WBC and Platelet are non
functional**
• Used in massive bleeding, open heart
surgery etc..
Fresh frozen plasma:
• Rich in coagulation factors
• Stored at -40 to -60 degrees C. (2
year shelf life)*
• Rh D positive FFP can be given to Rh
D negative women
• Available in 200-250 ml Packets**
Platelets:
• Mostly used in Dengue fever cases*
• Platelets are stored on a special
agitator at 20-24 degrees c. ( Room
temperature)
• Half life only 5 days* as a Fresh
component.
• Useful in patients with
thrombocytopenia
• The cells are spun down and
concentrated.
• Each unit is 330 ml*
• Hematocrit= 50-70%
• Stored at 2-6 degrees C.
• I unit increases Hb by 1 gm/dl/
• Hematocrit by 3%**
• Lacks coagulation factors.
Cryoprecipitate:
• Supernatant precipitate of FFP and is
rich in factor VIII* and fibrinogen.
• Stored at -30 degree C with a 2 year
shelf life*
• Available in 15 ml**
Prothrombin complex concentrates: (PCC)
• Highly purified concentrates prepared
from pooled plasma.
• They contain factors II, IX, X. Factor
VII may be included or produced
separately.

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Practical Points:
• Cross matching is done in 45 minutes in blood bank
• Blood received must be transfused in 1- 4 hours
• Un crossmatched Blood used in Trauma is O negative ( males- O Positive)
• Un crossmatched Plasma used in Trauma is AB
• Autologous blood -For patients undergoing elective surgery they pre donate their blood
upto 3 weeks* before surgery for re transfusion during operation.
• Massive Blood Transfusion- Replacing whole body blood volume ( 10 units of Blood in
adults)
• 1st Sign in Un anaesthetised patients – Wrong matched blood shows Itching**
• 1st Sign in anesthetised patients- Wrong matched blood transfusion shows unusual
Bleeding from operative site –followed by fall in BP – Hematuria*

Complications of Massive transfusion:

• Coagulopathy
• Hypocalcemia* ( due to binding of ionized calcium by citrate used as anticoagulant)
• Hyperkalemia* ( due to RBC lysis)
• Hypomagnesemia
• Hypothermia
• Volume overload
• Dilutional thrombocytopenia
• Decreased oxygen delivery ( due to decrease in 2,3 DPG)
• Metabolic Alkalosis (even though the stored blood contains pH- 6.3, Because of massive
transfusion sodium citrate is metabolized in liver to sodium bicarbonate)
• Rare- Metabolic Acidosis*

Complications of regular blood transfusion:

• Febrile non Haemolytic Transfusion reaction* ( Most Common)- Due to WBC present –
Leucocyte reduction filters remove the WBC*
• Allergic reaction
• Infection:
o Bacterial infection ( as a result of faulty storage)
o Hepatitis- B, C, G
o HIV- 1,2
o HTLV- 1 and 2
o Malaria**
o West Nile virus, Parvo virus B-19, HHV-8, CMV
• Air embolism
• Thrombocytopenia
• Transfusion related acute lung injury – TRALI (usually MC from FFP)
• Fatal hemolysis
• GVHD

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 • HLA and RBC allo-sensitisation
• Patients who receive repeated transfusions over long periods may get iron overload. Each
transfused unit of RBCs contain approximately 250mg elemental iron**

Must Know Table:

Effects of storage of whole blood?
• Reduction in pH**
• Raise in Potassium concentration**
• Progressive reduction of red cell content of 2,3 di phosphoglycerate which results in
decrease in oxygen carrying capacity.
• Loss of platelet function in whole blood within 48 hours of donation
• Reduction of factor VIII to 10-20% of normal in 48 hours
• Coagulation factors VII and IX are stable in storage*

Blood component Temperature of storage Shelf life

Whole blood 35 days
Packed cells 42 days
Platelets 5 days
FFP 2 years
Cryoprecipitate 2 years

Perioperative blood transfusion: ( Bailey 27th Edition Update)

Haemoglobin level (gm/dl) Indication

< 6gm Benefit from transfusion

6-8 gm Transfusion unlikely to be beneficial in the absence of bleeding
or impending surgery
> 8gm No indication for transfusion

Images from APP:

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Leukocyte reduction Filter to remove WBC and this prevents Non Hemolytic Febrile Reaction*

Foley’s Catheter:
Materials Used:
- Latex rubber
- Silicon

Silicon Catheter Latex Rubber Catheter

• Resistant to Chemical • Increased risk of Infection
• Insensitive to temperature • Hypersensitivity
(Chemical and Thermal Stability) • Irritation of Bladder mucosa
• Silicon catheter less chances of • Must be changed once in a month
Encrustation and Calcification and
hence less changing of catheter needed
(3 months once)

Color codes for Foley and Size:

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 • MC used is Orange ( 16 Fr)
• Women: 12 – 14 Fr, Men 16 – 18Fr catheter is used,
• Three Way Foley’s Catheter is used for – Bladder irrigation , Commonly used after
Prostate Surgery- TURP.
• In case of Retention of Foley’s inside Bladder and Unable to remove the Foley’s catheter-
we rupture the Foley’s Bulb using USG guidance.
• 1 mm= 3 French in units ( or) 1 French= 0.33 mm
• The Size mentioned in Foley’s catheter is based on Outer Diameter of the Catheter**
• Balloon is inflated with Sterile water only. Saline and Air must not be used. Saline may
cause blockage with crystals.
• In case of retained Foley’s how to remove it ideal- USG guided Puncture of Balloon

Topic 1c- Sutures , Suturing techniques, Knots and Anastomosis

Sutures:
• 1st Used Suture- ANTS

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Non absorbable Natural materials:
Silk:
• Black color suture
• Mainly used for Skin Sutures
• Increased infection rate.

Nylon:
• Skin sutures

Steel Sutures:
• Bones and Ribs and Sternums

Non Absorbable Synthetic Suture materials:

Polypropylene:
• Blue color
• Monofilament materials (Advantage- Less infection . Disadvantage- Poor Knotting
property)
• Classical feature of Coiling back is known as MEMORY* ( Bad Knotting property)
• Prolene- 6-7 knots used.
• Applications of Prolene:

Poly tetra Floro Ethylene:

• Graft materials for Femoral artery, Popliteal artery
Dacron:
• Graft material for AORTA replacement

Absorbable Suture Materials

Natural Absorbable:
Catgut:
• Brown in color
• Plain – 10 days
• Chromic – 60-90 days
• Storage solution of Catgut- Isopropyl Alcohol**

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 • Applications:
o Subcutaneous
o Muscle approximations
o Plain catgut- Circumcision
• Highest enzymatic reaction* , hence Banned in UK
• Absorbed by Enzymatic degradation.

Polyglycolic Acid: ( Vicryl)- Workshop material in theatre

• Multifilament material ( Made up of Glycolic acid+ Lactic acid co polymers)- as it is
multifilament it has good knotting capacity but increased infection.
• Violet color
• Absorption period- 60 -90 days
• Absorbed by Hydrolysis
• Types of Vicryl:
o Barbed Vicryl- No knotting needed, Used in Facelift sutures, plastic surgery
o Vicryl plus- Antibiotic coated ( Trichlosan antibiotic)
o Vicryl Rapide- Absorbed in 10 days
o White Vicryl ( MONOCRYL) – Poly glycaprone ( Monofilament material)- Suture
of choice for Subcuticular sutures in Skin ( Cosmetic Skin Closure)
• Applications:
o Bowel Anastomosis ( 3’0 vicryl)
o Bile duct anastomosis (4’0 Vicryl)
o Muscle closure
o Subcutaneous closure
o Vicryl Meshes ( Inner side of Dual Mesh to prevent bowel Adhesions)
• Pancreatic duct- Vicryl must not be used ( use only prolene or PDS)

Poly Dioxanone:
• Longest absorption period- 180-240 days
• Used for Linea alba closures

Properties to be noted in suture materials:

Thickness size : Ascending Order: 12’0< 10’0< 8’0< 6’0< 4’0<3’0<2’O< 0 < 1 size sutures
• Aorta repairs- 3’0
• Femoral repairs- 4’0 or 5’0
• Ophthalmic surgeries- 6’0

Size is inversely proportional to tensile strength of sutures*

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Needles:

Shapes of Needles:
Round Body
Less traumatic to tissues
Used in Bowel
Disadvantage:
- Cannot be used on
hard tissues like skin
Cutting
More traumatic
Used in Tendon, Fascia, Skin
Mainly in places where we
need to penetrate easily
Disadvantage:
- Cannot be used on
soft tissues like bowel
Reverse Cutting
Combines the advantage
properties of both Round
body and Cutting like
- Less traumatic
- Easy to penetrate
Used in vascular sutures

Blades:

Skin Suture Techniques:

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X: 2X rule: Skin Sutures:
• The depth of wound is X- the suture is taken at X cm on each edges.
• The next suture must be 2X cm from the previous suture.

When to remove the skin sutures?

• Scalp- 6-8 days
• 3-5 days- Lids, Lips and face
• 8-10 days- Laparotomy, Thoracotomy, Ear lobe repair
• 10-14 days- Palms and soles, back

Bowel Anastomosis:
• Halstaed Mathieson Single layer – Extra mucosal suture- Best and MC done
• Kocher’s 2 layer full thickness technique
• Sero muscular suture over the previously done anastomosis- LAMBERT SUTURES**using
Silk or non absorbable material as a support to previous sutue.
• Cheatle Cut: Approximate Disproportionate bowel by end to end anastomosis*

Cheatle Cut

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Stapler Anastomosis:
Linear stapler Circular Stapler
( Transverse Linear Cutter -TLC) ( EEA- End to End anastomosis staplers)
Side to side anastomosis End to End anastomosis

Vascular anastomosis:

Carrel triangulation is used in Vascular anastomosis

Image Based Questions:

1. What are the instruments you need for skin suturing (Video @49.07)
• Needle Holder
• Toothed Forceps
• Straight Scissors

2. TA ( Thoraco Abdominal Stapler)-Image

Only anastomosis and no cutting by TA stapler

3. Stapler Pin Color:

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 • Green Stapler-4 mm open pin- 2 mm Cclosed stapled Height ( Mnemonic- Gastric-
Green)
• Blue stapler- 3.5 mm open - 1.5 mm Closed Stapled Height ( Mnemonic- Blue- Bowel)
• Vasculae stapler- 1 mm Closed Stapled height (Mnemonic- Vascular- Vellai( Tamil)color)

Small staple height prevents bleeding like vascular stapler (1mm )

If you use a smaller staple on a thicker bowel – anastomotic leak happens.

4. Langer’s lines- Cosmetically good looking lines on skin

5. Named Incisions in abdomen:

• Paramedian incisions- Less chances of hernia, but more painful and bleeding
• Transverse incision- for paediatric
• Right subcostal incision- Kocher’s incision for Gallbladder surgery
• Roof top incision- Chevron for Pancreatic surgery
• Lanz- Cosmetic incision for appendectomy
• Mc Arthur- Grid iron incision for appendectomy
• Muscle cutting incision in abdominal wall is Rutherford Morrison incision**
• Lanz, Mc Arthur, Pfannenstein all are muscle splitting incisions

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6. Knots:

Granny knot ( Slip Knot) Square knot ( Reef Knot)

Right over the left Right over the left
Right over the left Left over the right
Not secure knot Secure knot and it will not get loosened
It will slip and fix in deeper pelvis or cavities
It will slip
Remember mnemonic- “Grandma will slip”

RRM’s method to remember:

Sir, very difficult to understand- any simple way?
• Yes- crude method- see in the crossing area of suture in centre:
• Granny knot will have colours crossing opposite ( Example in 1 st image- Red is on
top in one and Blue is top on other)
• Square knot will have same colour on the top ( Example in 2nd image- Blue is on
top)
Just seeing the image you can say what knot it is by following my method.

Surgeons KNOT”- For added security- Two throw technique of knots done and is advisable
to prevent slippage.

Aberdeen Knot- is used when completing the continuous sutures. Free end is partially pulled
through the final loop before cutting.

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 Aberdeen knot

TOPIC 1d: OPERATION THEATRE AND PROTOCOLS

Surgical Safety List ( WHO UK Process)

• Sign in Check done before induction of anaesthesia*
• Time out Check done before Skin incision*
• Sign out Check done before patient leaves operating room**
• Please remember there is no column known as Time in**

Sign in Time Out Sign Out

• Name
• Identity
• Confirm the disease
• Site marked or not
• Written consent
• H/o Drug Allergy
• Associated diseases
• Discussion between • Look for gauze count,
Surgeon and instrument count
anesthetist. • Any instrument
• Anticipated time of problem is addressed
surgery and blood loss here.
• Prophylactic
antibiotics given or
not is noted.

• Best Method to prevent operating wrong limb- Surgeon and Anaesthetist examining each
other separately.

Universal precaution kit: ( personal Protective Equipment kit)

• Boots
• Goggles ( Face shield)
• Plastic Gowns
• Double gloves ( Inside wear bigger gloves and outside your size gloves)

Take high risk cases in 1st round

Avoid unnecessary personnel in OT

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Transfer only in Kidney Tray

Sequence of removal of PPE after surgery ( Recent AIIMS)- Mnemonic- GFGF

MC Finger injured during surgery- Non Dominant hand index finger*

• Hollow needles have more risk of injury than surgical needles.

Inside OT:
Scrubbing- Hand Washing:
Sequence of washing ( Recent Washing)- Watch the procedure demonstration
• 1st- Palmar surface
• 2nd- Back of hand
• 3rd – Interdigits
• 4th- Finger tips
• 5th – Thumb

Wash upto elbow- 1st Normal water, 2nd Povidone scrub solution and finally Sterile water. Finally
apply sterilium antibacterial solution.

Instruments used in Operation Theatre:

Allis Tissue Forceps:

• Allis forceps for holding the tissues firmly*

• Used during laparotomy to hold the skin margins.
• Used to hold skin flaps during excision of Lipoma, Sebaceous cyst.
• It is helpful in creating flaps during thyroid surgeries*

Lane’s Tissue forceps:

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 • Used to hold structures very tight.
• It is used to hold submandibular gland and Parotid gland during dissection
from adjacent structures.
• Helps in holding breast during mastectomy.
• Also helpful like a towel clip to hold the suction tubes, draping sheet.

Babcock’s Forceps:

• Used to hold tissues very softly.

• The ideal instrument to hold and grasp the bowel and appendix during surgery*
• Hold the margins of stomach or small intestine during anastomosis*

Instruments used in Skin Suturing:

• Needle Holder
• Toothed forceps
• Straight scissors
Curved Scissors not used to cut sutures, used only to cut tissues.

Curved artery forceps- To catch the bleeding vessels

Straight artery Forceps- To hold tissues

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Cheatle’s Forceps:

• It is used to pick instruments and Mopping pads/ gauzes from Bin in a sterile way.
• It is kept in a sterile Bottle Container.

Langenback retractor:

• Used to retract tissues during hernia surgery, Appendectomy etc,

• Available in various sizes.

Morris retractor:

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 • Used to retract the abdominal wall in a wide manner.
• It is the instrument of choice for retraction in left subcostal region because it avoids the
risk of splenic injury*
Czerny retractor:

• Serves the same purpose of a Langenback retractor, but has another limb with a double
hook with space in between.
• Sutures can be made in the tissues between the gap of hooks.

Deavers retractor

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 • Used to retract liver without any damage to liver parenchyma.
• Used during Cholecystectomy to retract liver.
• Used in places where a careful retraction without organ damage is needed.

Doyen’s retractor:
To retract the pelvis and bladder at pubic symphysis.

Thompson Self retaining Liver retractor:

• Thompson retractor has multiple arms which can be fixed to a rod which is attached to
the Operating table.
• Adjustable and Self retaining in nature.
Balfours Abdominal Self Retaining retractor:

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 • It’s used to retract the lateral abdominal walls.
• The third limb- used to retract the bladder downwards.

Joll’s self retaining Thyroid retractor:

• Used during thyroidectomy* to retract the platysma.

• It’s a self retaining retractor.

De Bakey Bull dog clamp:

• Used to clamp blood vessels without damaging the blood vessel.

• The clamp has opposite action compared to other forceps- When Pressed it opens and
When Clamp released it occludes the blood vessel**

De Bakey Satinsky Clamp:

• Used for vascular clamping during vascular repairs, injuries

• Used to hold the cut end of esophagus after Total gastrectomy.
• Used during shunt operations.

RRM’S SURGERY SIXER APP BASED WORKBOOK 29

Towel Clips:
• Towel clips are used to hold the sterile dressing after drap in position*
• Some surgeons use this to hold and retract the tongue outside for intra oral surgeries.

Blade Handles: ( Bard Parker Handles)

• 3 size to load – 11 size blade and 15 size blade
• 4 size to load – 22 Size blade

Colour of venflons:
• Grey- 16 G
• Green- 18 G
• Pink- 20 G
• Blue- 22 G
• Yellow- 24 G

Demonstration of Foley’s catheter, Staplers are elsewhere in the Chapter 1

Drains:
Romo vac Suction Drain:

RRM’S SURGERY SIXER APP BASED WORKBOOK 30

Energy devices in operation theatre:

1.Diathermy:
It is a machine which converts Electrical energy into heat energy.

Figure : Diathermy machine

• Yellow Button in the Pencil is for Cutting ( Continuous Wave forms)

• Blue Button in the Pencil is for Coagulation ( Intermittent Wave forms)
• Earth Plate prevents Electric Shock to patient.

Diathermy can be used for three purposes:

• Coagulation: the sealing of blood vessels.
• Cutting: used to divide tissues during bloodless surgery.
• Fulguration: the destructive coagulation of tissues with charring. It’s a blended current
which uses both the above forms of diathermy activity

Monopolar Diathermy:

RRM’S SURGERY SIXER APP BASED WORKBOOK 31

 • Monopolar diathermy – the electrical energy is passed via the diathermy probe and
returned to the machine via the patient earth plate as shown in image above.
• MC complication inside OT is diathermy burns**
• Pacemaker containing patients must be carefully watched during monopolar diathermy
and earth plate must be far away from pacemaker.
• Contraindications of Monopolar Diathermy:
o Finger tips
o Penis ( Circumcision)
o Thyroid and parotid surgery near nerves

Bipolar diathermy:

• Bipolar diathermy needs no earth plate.

• The current is passed between the limbs of diathermy probe.
• Safe in Surgeries near nerve and circumcision.
• Can be safely used in pacemakers.

Image Based Question:

Please note the Bipolar and Monopolar Probes

RRM’S SURGERY SIXER APP BASED WORKBOOK 32

Harmonic Scalpel:

• The harmonic scalpel is an instrument that uses ultrasound technology to cut tissues while
simultaneously sealing them utilises a hand-held ultrasound transducer and scalpel at
frequency of 20 000–50 000 Hz
• Protein denaturation caused by vibration** rather than heat

Ligasure:
• Machine which involves same technology of Monopolar but uses the collagen and elastin of
the patient himself to seal and divide.
• 7mm Vessels can be ligated and cut

Drains in Surgery:

Open Drains Closed Drains

• Include Corrugated Rubber or Plastic Consists of Tubes draining into a bag or Bottle
Drains

• Drain fluid collects in a pad or Stoma Abdominal Drains, ICD drains, Suction drains
bag are examples

• Increased risk of infection seen Infection risk is less

Corrugated Rubber Open Drain

RRM’S SURGERY SIXER APP BASED WORKBOOK 33

 Jackson Pratt Closed Drain

Intercostal Drain Tube

Mallecot’s Self retaining Catheter drain

Double Pig tail Stent ( Double J stent)- Ureter, Bile duct

Place of Drain For Purpose of Removal on

Thyroid surgery To identify bleeding 24 Hours

Breast surgery To remove Serous Discharge 5 Days

ICD drain To drain Collections Collection < 20 ml/Day

T Tube Drain To Drain Bile 10- 14th POD

RRM’S SURGERY SIXER APP BASED WORKBOOK 34

 Pelvic drain after Colorectal To identify the leakage 7th POD
anastomosis

Inside the OT:

• Airflow/ hour- 15 to 25/ hour
• Laminar Air flow OT- Air exchange every 2 minutes ( 100-300/ hour may happen)-
Ortho and CTVS OT must have Laminar flow
• Temperature- 18-25 Degrees

Position of Patients in Operation theatre:

Trendelenburg:
Reverse Trendelenburg:
Varicose Vein Surgery
• Thyroid Surgeries

Llyod Davis position Jack knife position

• Trendelenburg + Leg Split • Prone Position
• Laparoscopy procedures • Pilonidal sinus operated
• Positional Asphyxia may happen

Lithotomy Position
Sitting position:
• Gynaecology procedures
- Neurosurgery
• Injury to Common Peroneal nerve
- Air embolism can happen
can happen

RRM’S SURGERY SIXER APP BASED WORKBOOK 35

Laparoscopic Surgery:
• Insufflation of gas in peritoneal cavity and operating via small holes.
• Gases used : Carbon Dioxide( MC), Nitrogen, Air
• Carbon dioxide is rapidly absorbable and causes less post-operative pain and less incidence
of Fat embolism**
• CO2 is 200 times more diffusible and rapidly cleared from circulation*
• Intraperitoneal pressure maintained during surgery- 12-15 mmHg**
• Laparoscopy pneumo peritoneum is created by 2 methods: Open and Closed method

Open method Closed method

Using Hassan’s Cannula Using Verres needle
Risk of major vessel injury is less Risk of Bowel injury is less as it has safety
valve at tip.
Trocar penetrates- Skin, Superficial and
Deep fascia, Fascia Transversalis, parietal
peritoneum.

Complications of Laparoscopy:
• Primary cannula (1st Cannula Insertion)- Injury to Bowel, Blood Vessel, Stomach,
Bladder, Mesentry, Diaphragm, AORTA, IVC, Epigastric vessels are injury ( MC in
Secondary Cannula)
• Secondary cannulas (Under vision inserted)- Epigastric vessel injury MC

Gas embolism:
• Sudden drop in p0 2 immediately during induction of Pneumoperitoneum suggest Co2
gas entering the systemic circulation via the torn splenic vessels by Verres or Trocars.
• MC seen at the time of insufflation of gas by trocar or Verres.
• Less common when Co2 gas is used compared to air (as Co2 is more soluble)
• Initial rise of ETCo2 due to pulmonary excretion of absorbed Co2 is followed by a sudden
decrease due to fall in cardiac output**

RRM’S SURGERY SIXER APP BASED WORKBOOK 36

 RRM’s Extra Bite:
DURANT’S Position/ manuever:
• A position used in Air embolism in which the patient is immediately put in left lateral
decubitus with head low position( Trendelenburg) so that gas will remain in the apex of
ventricle and may be aspirated under Echo guidance.

Capacitance Coupling Injury:

• On sandwich of the insulator between two metal electrodes – A capacitor is created.
• This occurs when we pass a metal hook into a metal made Port. By electromagnetic
induction current is created and there is a damage to abdominal viscera.
• Patient Presents with delayed leak
• Plastic ports avoids this injury.

Delayed Complications:
• Unabsorbed gas can irritate the diaphragm and causes shoulder pain*. It is worst
at 24 hours after operation and settles in 2-3 days. Paracetamol is enough.

Other advanced Laparoscopic Surgery:

• SILS- Single Incision Laparoscopic Surgery ( Single Umbilical port with multiple
openings)- Increased incidence of hernia
• HALS- Hand Assisted Laparoscopic Surgery
• NOTES- Natural orifice Transluminal Endoscopic Surgery
• SPA- Single Port access ( Other name of SILS)

RRM’S SURGERY SIXER APP BASED WORKBOOK 37

Robotic Surgery:
• Davinci Robot*

• Docking- Inserting the limbs of Robot inside

• Major Advantages:
▪ Eliminates tremors of the surgeon
▪ Multidirectional movement- 7 degree freedom
▪ Tele robotic Surgery can be done

VATS: Video Assisted Thoracoscopic Surgery:

• No need of Co2 Gas to create space.
• Space is created by collapsing the lungs.

Other instruments:
Desjardin Stone removal Forceps:
• To remove CBD stone

Vim’s Silverman Biopsy Needle:

• Liver Biopsy needle

RRM’S SURGERY SIXER APP BASED WORKBOOK 38

Payr’s Soft Occlusion clamp of Bowel
• To clamp the bowel and prevent the spillage of the content

Topic 1e: Surgical Site Infections:

Type of Surgery Examples of Surgeries Infection rate with Infection rate

Prophylaxis without
prophylaxis
Clean Surgery: • Heart, Brain, Joint, Transplant 1%
(No viscus opened) surgeries
• Herniorrhaphy*
• Swelling excision
Clean Contaminated • Wound of Bowel, Biliary and 5-10%
Surgery: Pancreatic Surgery
(Viscus Opened, • Uncomplicated appendicitis*
Minimal Spillage) • Gastro Jejunostomy
Contaminated • Appendiceal abscess 10-20%
surgery: • Perirectal abscess drainage
• Infected laceration
• Diverticulitis

RRM’S SURGERY SIXER APP BASED WORKBOOK 39

 Dirty Surgery • Worst wound Upto 40%
• Acute cholecystitis with spillage of
pus from gall bladder.
• Traumatic wound
• Bowel obstruction with
enterotomy and spillage of
content.

Surgical Site infection is defined as :

• Wound Infection in < 30 days of Surgery
• Wound Infection in < 1 year of Implant cases
• Most common SSI pathogens are all gram-positive cocci—Staphylococcus
epidermidis**, S. aureus, and Enterococcus **
• For infra inguinal incisions and intra cavitary surgery, gram-negative bacilli such as
Escherichia coli and Klebsiella are potential pathogens.

Grading Systems for SSI:

Southampton Wound grading System: ( Mnemonic- EISPA)
Grade Appearance
0 Normal healing
1 Erythema
2 Inflammation
3 Serosanguinous discharge
Major Complications
4 Pus
5 Anatomical separation

ASEPSIS Scoring system

Criterion Points
A Additional treatment 0
• Antibiotics for Wound Infection 10
• Drainage of Pus under Local anesthesia 5
• Debridement of Wound under GA 10
S Serous Discharge Daily 0-5
E Erythema Daily 0-5
P Purulent Discharge Daily 0-10
S Separation of deep tissues Daily 0-10
I Isolation of bacteria from Wound 10
S Stay as inpatient prolonged over 14 days 5
(Author’s Excuse: Sorry for mentioning in video “this is not asked so far”- probably the
examiners noted it and asked it immediately in NEET PG 2020)

Causes of Post operative fever:

RRM’S SURGERY SIXER APP BASED WORKBOOK 40

 Day Cause ( Mnemonic- ABCDE)
1

2-3

4-5

7 onwards

Incentive spirometer for Breathing Exercises

Pneumatic Compression Device to prevent DVT

Factors preventing wound healing:

• Hypoalbuminemia
• Obesity, Weight loss
• Diabetes
• Hypercholesterolemia
• Renal failure
• Cancer, AIDS, Chemotherapy, radiotherapy
• Jaundice

RRM’S SURGERY SIXER APP BASED WORKBOOK 41

 • Old age
• Poor surgical techniques

How to prevent SSI?

• 1 hour before surgery Prophylactic antibiotics ( before incision)
• Shaving not advised now ( If needed skin clippers or epilators used to remove the hair just
before shifting to OT)
• Avoid hyperglycemia during surgery ( Blood sugar < 200 mg/dl)
• Avoid Hypothermia
• Avoid contamination ( Sterile precautions)
• Avoid Hypoxia Intraop and post op also for 4 hours.
• Avoid Hypotension
• Surgery Extending > 4 hours ( Every 4 hours one more dose is given)- Prophylactic
antibiotics not given beyond 24 hours.

Burst abdomen closures:

• Tight abdominal closure ( not advised nowadays- may result in Abdominal Compartment
syndrome )
• Latest- Vacuum Assisted Closure Device ( Negative Suction of -120 mmHg of Excess fluid
is absorbed)

RRM’S SURGERY SIXER APP BASED WORKBOOK 42

 Chapter 2: Trauma

Topic 2a- Introduction

Triage:
In cases of Mass Casualty, categorising the patients to be transferred to Hospital according to the
severity of injury is known as Triage.

Triage a french word means “to sort”

Four colour codes are given
• Red- first priority is a critical patient (Eg: Tension Pneumothorax, Pericardial
Tamponade)
• Yellow- urgent is second priority (Eg: Major Bone Fractures, Open Pneumothorax)
• Green is minor and third priority (Eg: Tibial Fractures, Wrist bone fractures)
• Black is dead or about to die patients.

• Multiple Casualty: Enough resources available to manage the patients

• Mass Casualty: Enough resources are not available to manage the patients coming to
casualty

Primary survey : cABCDE

• c-
• A-
• B-
• C-
• D-
• E-

C: Exsanguinating External Haemorrhage:

• Stop major vessel bleeding by pressure or Tourniquet first before ensuring airway

RRM’S SURGERY SIXER APP BASED WORKBOOK 43

Airway with Cervical spine Control:
• Intubation when GCS< 8
• Put a Hard Cervical Collar and make the patient lie on a Hard Board
• Airway Manoeuvres to prevent Tongue Falling backward:
- Jaw Thrust
- Chin Lift
- Guedel Airway
- Definitive Airway: Oropharyngeal ,Nasopharyngeal airway insertion, Tracheostomy
intubation.

Orotracheal intubation Nasotracheal Intubation

• MC done method
• Contraindicated in Maxillo-facial
injuries( more than one time we must
not do)
• Contraindicated in
- Base of Skull Fractures
- Cribriform Plate fractures
- CSF Rhinorrhea+
- Maxillo facial fractures

• Maxillo facial injuries- Tracheostomy Intubation advised*

Tracheostomy:
Emergency Needle tracheostomy Elective Tracheostomy
• Done at 2/3rd Tracheal rings

LEMON Assessment:
• L- Look Externally
• E- Evaluate 3-3-2 Rule ( 3 Fingers enter mouth, 3 Finger distance between hyoid bone
to chin, 2 finger distance between Thyroid notch to floor of mouth)
• M- Malampatti classification ( Class 4- Only Hard Palate is seen; difficult to intubate)
• O- Look for obstruction
• N- Neck Spine Tenderness

Breathing and ventilation

• Oxygen must be offered to all trauma patients via reservoir mask in high flow.
• Ventilation must be assessed by seeing chest walls, lungs

RRM’S SURGERY SIXER APP BASED WORKBOOK 44

 • Tension pneumothorax, flail chest, massive haemothorax and open pneumothorax are all
clinical diagnosis and not radiological diagnosis and need immediate treatment.

Circulation
• Rapid thready pulse is more reliable and warning sign than BP**
• It represents the Blood lost:
“ One on Floor and four more”
- Closed fist size Clot on floor ( 350 ml), Pad fully soaked ( 500ml)
- Abdominal Cavity
- Chest
- Pelvic
- Long Bones

Management of circulation:
• Two large bore, short, peripheral IV catheters. ( Green 16 G 2 Cannulas )
• Other options are Cut down into Saphenous veins or IJV
• Children < 6 years- Intraosseous transfusion
• 1 litre of 7.5% Hypertonic Saline
• Permissive Hypotension: Target Systemic pressure 70-90 mmHg; It must not go very
high to prevent rebleeding and must not go very low to prevent cerebral hypoxia.
• CRASH-2 Trial:

Disability and Exposure:

• Expose the patient fully and examine
• Log Roll is done in this heading ( Discussed separately)

Secondary Survey:
• Gold Standard Investigation: WBCT ( Whole Body CT Scan) from head to pelvis with IV
contrast for severely injured Adult Blunt trauma patient**
• One WBCT = 76 X ray Chest
• Provisional hot report issued in minutes for WBCT and definitive report obtained after
30-60 minutes,

Log Roll:
• Not done now as there is a delay in WBCT.
• Done by 4 people
• Primarily meant for Spine Examination
• Part of Primary Survey

RRM’S SURGERY SIXER APP BASED WORKBOOK 45

 • Along with Spin examination we can also do Anal Wink Reflex and PR examination.
• During PR- Vermooten sign to look for Floating Prostate in Membranous urethra injury
(contraindicated now)
• Log roll is absolutely -Contraindicated in Pelvic Fracture patients**

In secondary survey:
Remember Mnemonic AMPLE:
• Allergy H/o
• M- Medical H/o
• P- Pregnancy H/o/ Present Illness
• L- Last meal
• E- Explain the mechanism of injury

Xray Cervical Spine is taken in secondary survey:

• AP and Lateral View taken
• Based on NEXUS Criteria and Canadian C Spine Rule

Scoring Systems:
RTS score TRISS Score MESS Score
TRISS includes • M- Main energy that caused
• R- RTS injury
• I- Injury Severity score • E-Extremity Ischemia
• S- Seen Age • S- Seen Age
• S- Specific Mechanism • S- Shock
(Blunt or Penetrating)

ABBREVIATED INJURY SCALE:

• Has a Seven Digit Code and represented as 123456.7
1 Anatomic Body Region
2 Type of anatomic structure
3/4 Specific anatomic structure
5/6 Level of injury
Post dot 7 Grade of injury

RRM’S SURGERY SIXER APP BASED WORKBOOK 46

 • Pre dot Code for Body region (1st digit) is as follows
1
2
3
4
5
6
7
8
9

Damage control surgery (Abbreviated Laparotomy)

Indications for DCS:
Deadly triad**
• Hypothermia
• Acidosis
• Coagulopathy
Others:
• Serum Lactate > 5mmol/L
• ISS >36
• Systolic BP < 70 mmHg
• Transfusion > 15 units of Blood

Early Trauma Care ( ETC)- Definitive management in Trauma Patient:

- Within 36 hours ETC if there is none of the above features seen

Serum Lactate- Significance:

• <2 mmol/l- ETC
• 2-5 mmol/l- Management in ICU
• > 5mmol/l- DCS

Phases of Damage Control Surgery:

• Phase -1: Initial Exploration
• Phase-2: Secondary Resuscitation
• Phase -3: Definitive operation

Phase -1 Phase -2 Phase- 3

Initial exploration Secondary Resuscitation
• In Emergency OT • Transfer to ICU
• Control Active • Ventilatory support
haemorrhage and • Correct the deadly triad-
Contamination* Hypothermia, Acidosis,
Coagulopathy*
Definitive treatment
• Planned re exploration and
definite surgery*
• Done 48-72 hours after
secondary phase*

RRM’S SURGERY SIXER APP BASED WORKBOOK 47

 • Midline incision- 4 • Complex reconstruction
quadrant packing done. must be avoided*
• GIT perforations closed
with sutures or Staples or
as Stomas
• Temporary closure of
abdomen using plastic
sheet known as OPSITE**
• This technique of closure is
known as
“ VACPAC or OPSITE
SANDWICH”

Stages of Damage Control Surgery as Per Bailey and Love

Stage Procedure
I
II
III
IV
V

Topic 2: Head Injury, Face injury and neck injury

Values in Neurosurgery:
• Cerebral Blood flow= 55ml/minute
• Ischemia happens if < 20 ml/minute
• Maintain Cerebral perfusion pressure (CPP)– Normal= 75-105 mmHg to prevent
Ischemia
• CPP= MAP(90-110)- ICP ( 5-15)= 75-105 mmHg

Munro Kellie Doctrine:

• Skull is closed Compartment containing 3 Components in a Constant manner.
- Brain
- CSF
- Blood
• If one component is compressed or increased the other component will compensate.
• Hence you can realise- if there is a hematoma on one side of the brain it will do the
following: ( see the image below)
- Midline shift ( 1)
- Cingulate Gyrus herniation (2)
- Herniation of Uncus of Temporal lobe (3)
- Brain stem herniation ( 4)

RRM’S SURGERY SIXER APP BASED WORKBOOK 48

 - Cerebellum herniation ( 5)

Features of herniation:
• Uncus of temporal Lobe Herniation- Ipsilateral Fixed dilated pupil happen due to
Oculomotor nerve compression
• Cerebellum herniation- Cushing Triad- Hypertension, Brady cardia and respiratory
Irregularities.

How to prevent brain herniation?

• By reducing the CSF pressure inside: by reducing ICP:
• Head up position 15-30 degree
• Injections to reduce ICP: Mannitol( osmotic diuretics), Diuretics if BP is fine.
• Sedate them- Inj Barbiturates (Don’t give Diazepam as it can cause respiratory
depression)
• Seizure prophylaxis- Sodium Valproate
• Open Skull fractures- prophylactic antibiotics
• Don’t give Steroids in Trauma** ( Can be used in Malignancy in Brain causing Increased
ICP)
• Lumbar puncture is contraindicated.
• External ventricular drainage is used to remove the CSF**
• Nasal Oxygen

Neuro intensive care unit values:

• ICP < 20 mmHg
• CPP > 60-70mmHg
• MAP> 90 mmHg
• PaO2- 80-100 mmHg (10 -12 Kpa)
• PaCO2- 35- 45 mmHg (4-6 Kpa)

Glassgow Coma Scale:

RRM’S SURGERY SIXER APP BASED WORKBOOK 49

 Eye opening: Verbal Motor
• Spontaneous – 4 • Normal Oriented- 5 • Obeys commands- 6
• To loud voice- 3 • Confused- 4 • Localizes to pain- 5
• To pain stimuli- 2 • Inappropriate words- 3 • Withdrawal flexion- 4
• Do not open- 1 • Sounds only- 2 • Abnormal flexion- 3
• No sounds- 1 (decorticate)
• Extension- 2 (Decerebrate)
• No motor response-1

Mnemonic:
• Verbal- One Confused Word Sounds Nowhere* (54321)
• Motor- Obey Localities With Flexion and Extension Now. ( 654321)

Essential points in GCS

• Motor component – most predictive of future neurologic outcome
• Maximum Score= 15
• Minimum Score ( Dead Patient)=3
• Intubated Patient= Mentioned as VNT ( Not Testable)= Score -0
• Intubate when score is < 8
• At admission when score is <13 take CT scan
• Score represents the best performance elicited, Example: Flexion response to pain in left limb and
localising pain in right limb- take into consideration the best which is in right limb- M5**

Classification of Head injury based on GCS:

• Minor: GCS 15 with no LOC
• Mild: GCS 14 or 15 with LOC
• Moderate: GCS 9-13
• Severe: GCS 3-8

Salient points:
1. Hutchinson Pupil: Ipsilateral Fixed and Dilated Pupil due to Oculomotor nerve stretching. Hence
Blind Burrhole without CT scan is done in Side of Hutchinson pupil in olden Days.

2. Kernohan Notch Phenomenon: usually there will be contralateral hemiplegia if one side
hematoma is seen. But in this phenomenon, Huge hematoma will cause brain pushed to opposite
side and compresses Pyramidal tract on Same side itself.

3. Base of Skull fractures:

• Raccoon/ Panda eyes- bilateral peri orbital hematoma ( Anterior Cranial Fossa fractures)
• Battle’s sign- bruising over mastoid. Middle cranial fossa Fracture

RRM’S SURGERY SIXER APP BASED WORKBOOK 50

• CSF otorrhea- Middle Cranial Fossa Fractue
• CSF rhinnorrhea – Anterior Cranial fossa fractures
• Haemotympanum or bleeding from ear.

Battle sign*

• Anterior cranial fossa fractures- NG tube and Nasotracheal intubation are contraindicated.
• CSF rhinorrhea testing:
- Put the CSF in a tissue paper
- Blood will occupy the centre and CSF will occupy the periphery.
- Beta -2 Transferrin will be elevated in fluid

• Posterior Cranial Fossa fractures:

- Visual disturbance
- VERNET Syndrome: 9-11 nerve paralysis due to Jugular foramen Compression
and fracture.

Indications of NCCT Brain- NICE Guidelines:

(National institute for health and clinical excellence)

Indications of CT in 1 hour:
1. GCS < 13 at any point*
2. GCS < 15 at 2 hours
3. Focal neurological deficit
4. Suspected open, depressed or base of skull fracture
5. Post trauma Seizure
6. Vomiting > one episode.

Indications of CT within 8 hours:

1. Age >65
2. Coagulopathy (on warfarin, aspirin or Rivaroxaban)
3. Dangerous mechanism of injury
4. Retrograde amnesia ( > 30 minutes)

RRM’S SURGERY SIXER APP BASED WORKBOOK 51

EDH SDH SAH

Biconvex Appearance Concavo-Convex appearance MC type of haemorrhage-

Intracerebral haemorrhage
due to hypertension in
PUTAMEN.
The picture shown above is
Subarachnoid haemorrhage
with Blood in Subarachnoid
Cisterns
• M/c in young male • Accumulates in • MC cause of SAH
patients space between dura nowadays is Trauma
• Always associated and arachnoid • Other cause is Sudden
with skull fracture • Associated with rupture of Berry
• Injured vessel- middle Bridging vein Aneurysm
meningeal artery** disruption and brain
• M/c site of injury is laceration*
temporal bone at • Associated with
pterion (most thinnest primary brain injury
part of skull) which • Presents with
overlies the middle impaired
meningeal artery consciousness from
• The hematoma is the impact time
located between bone itself.
and Durameter. • Acute SDH- follows
• Lucid Interval is seen trauma
• Chronic SDH- people
on Anticoagulants*

Treatment: Treatment:

RRM’S SURGERY SIXER APP BASED WORKBOOK 52

 Burr hole is TOC Acute SDH- Decompressive
Mortality- 5% craniectomy and evacuation
Chronic SDH- Burr Hole

Mortality- 40%

Other injuries:
Diffuse Axonal injury:
• High Acceleration and deceleration injury
• No surgery done
• Wait and watch
• IOC- MRI

Skull fractures:
• Depressed Fracture- No need to worry
• Displaced Fracture ( open fracture)- Surgery needed.

AIS -2 Face injury:

Mc injury – Nasal bone Fracture*
Maxillofacial Fractures- Le fort Injuries:
Type 1: Fracture line at Hard Type 2: Pyramidal shaped Type 3: Cranio facial
Palate dislocation
-CSF rhinorrhea+

Mandible fractures: ( Sequence Based Question)

• Order of fracture in mandible- MC @ Neck of condyle> Angle of mandible > Canine
Tooth> middle of mandible.

Zygomatic Fractures
Orbit Fractures: Order of Injury is Floor> Medial wall> Lateral wall > Roof ( Sequence Based
Question).
Trapping of muscle happens in orbit fracture- Inferior rectus gets trapped in children Most
commonly.

RRM’S SURGERY SIXER APP BASED WORKBOOK 53

IOC- CECT Facial Bones
TOC- ORIF ( open Reduction Internal fixation)

AIS 3: Neck Injury:

• It forms the highest mortality rate of all body regions with penetrating wounds are the
most common mechanism for this injury.
ZONES EXTENT REMARKS
Zone I From thoracic inlet to cricoid cartilage Large vascular structures, Trachea and
esophagus
Zone II Between Cricoid cartilage to angle of
mandible

Zone III Between angle of mandible and base of Difficult to access surgically
skull

Blunt cerebrovascular injury in Neck ( DENVER’S Grading):

Grade I Luminal irregularity with <25% narrowing
Grade II Dissection of hematoma with >25% luminal narrowing
Grade III Pseudoaneursym
Grade IV Occlusion
Grade V Transection with extravasation

• Grade 5: Needs Immediate Surgery

• Grade 1- 4: Anti thrombotic drugs ( Antiplatelets )

RRM’S SURGERY SIXER APP BASED WORKBOOK 54

 Topic 2C; Thoracic Trauma
AIS -4- Thoracic Injuries
Dangerous Dozen Injuries:
Immediately life threatening Potentially life threatening
• Aortic injury
• Trachea and Bronchus injury
• Myocardial contusion
• Diaphragm Rupture
• Esophageal Injuries
• Pulmonary contusion

• MC injury in Thorax- Rib Fracture

• MC cause of Death in a Blunt Thoracic Injury- Tracheobronchial injury
• MC cause of Death in a Penetrating injury- Haemothorax

Intercostal Tube Placement: ( ICD Placement)

• Pass the ICD in upper border of the Rib ( in lower border intercostal vessels and nerve
are present)
• Triangle of Safety – Anteriorly by Lateral border of Pectoralis Major, Posteriorly by
Mid axillary line and Inferiorly by an imaginary horizontal line drawn at level of nipple
to meet mid axillary line .

Triangle of Safety

• Best space is 5th ICS in Midaxillary Line.

• 28Fr, 32 Fr tubes are used. Ensure all holes are inside the chest*
• Underwater drainage device providing 20 cm H2O suction.***

How to say ICD is functioning well?

• Moving of the Air liquid column in ICD tube in correspondence with respiration.

If the column is not moving: Implies:

• ICD is not in position
• ICD is blocked

RRM’S SURGERY SIXER APP BASED WORKBOOK 55

 • ICD is Displaced and hole lying outside
• Lung Has fully expanded

Other essential MCQs:

• ICD tube is removed when the fluid coming is less than 50 ml/day ( Some books 20
ml/day) or when lung is fully expanded.
• Remove the Tube in Full Inspiration.
• -5 to -20cm H2O Suction
• In hemothorax if there is excessive bleeding even if we clamp the tube is not useful ( it
doesn’t give tamponade effect)

Indications of thoracotomy in Thoracic Injury:

• Hemothorax more than 1500 ml( Blunt trauma)
• Hemothorax more than 1000 ml (Penetrating trauma)
• Hourly collection in ICD of > 200 ml/hour for 3 hours
• And all the Dangerous dozen Injuries ( Except pulmonary contusion, Flail Chest)

Pericardial Tamponade:
• MC mechanism – Penetrating trauma**
• Collection of Blood inside the pericardial cavity.
• Blood in pericardial cavity will compress the heart.
• Beck’s Triad: Raised JVP, Low BP and Muffled Heart sounds*
• X ray shows- Air Bag Appearance
• Differential Diagnosis: Tension Pneumothorax (Tachypnea with Absent Breath Sounds
seen)
• IOC – eFAST diagnosis ; Immediately under ECHO guidance at an angle of 45 degree you
must do Needle Pericardiocentesis*
• MC complication of Needle Insertion- Arrythmias*
• Definite Treatment- Thoracotomy and repair of Myocardial leak.

Tension Pneumothorax:
• Mechanisms- Penetrating trauma, Blunt Trauma with rib injuring, Central vein insertion.
• Collection of Air between the parenchyma and Pleura.
• Pleura is intact and hence during every breath air enters the pleural cavity and compress
the lung which is already compressed.
• This results in mediastinal shift, Absent Breath sounds**, low BP and raised JVP. ( DD:
Pericardial Tamponade)
• C/F- Tachypnea and Dyspnea
• Life saving Procedure – Midclavicular line along 2nd ICS – Put a Wide bore needle-
Emergency Thoracocentesis ( Latest ATLS manual- 5th ICS in Midaxillary Line in adults
and same old 2nd ICS in children)

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 • Definite procedure- ICD insertion.

Open Pneumothorax ( Simple)

• Both Lung and Pleura is injured.
• Chest wall is intact.
• Air will enter out of pleural cavity and air will go back to lungs and no tension.
• Not so dangerous and can be managed by putting an ICD tube*

Open Pneumothorax ( Sucking Chest Wound)

• Opening is seen in Lung ( Large defect >3cm) , Pleura and chest wall also.
• Air is entering from Atmosphere to lungs ( No proper Oxygenation)- Sucking the air.
• Immediate treatment- Three Way Flap valve type closure
• Definite Treatment- ICD insertion

Three way flap closure* in Sucking chest wound

Haemothorax:
• MC vessel injured- Intercostal artery
• MC vessel injured in massive hemothorax- Internal Mammary artery bleeding or Internal
thoracic vessels.
• 1st line treatment- ICD
• Immediately thoracotomy needed for >1500ml ( Blunt), >1000ml ( penetrating) and
>200ml/hour X 3 hours .

Rib fracture:
• 1st Rib fracture- Rare, but suspect Brachial plexus or Subclavian artery injury or apex of
lung injury.
• 10-12 ribs fractures- Think of Spleen or liver injuries
• CPR done- 4-6th Rib fractured*
• Management- Analgesics and No need of stripping or surgery needed for Simple fractures

Sternal Fracture:
• Very rare
• Suspect underneath Myocardial injury*

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Flail chest:
• It’s a clinical diagnosis and not radiological diagnosis ( OLD CONCEPT)
• Three or more ribs fractured in two or more places**
• Even one rib fractured at Costochondral junction can cause Flail chest.
• Here a segment of chest wall does not have continuity with rest of thoracic cage.
Clinical features:
• On inspiration paradoxical movement of chest occurs. (segment moves inside on
inspiration and on expiration that flail segment will move outside)
• Due to pain there is hypoxia.
• Underlying pulmonary contusion is the most important prognostic factor*
Investigation of Choice:
• CT Scan with 3D reconstruction* to display vascular structures is the GOLD STANDARD
IOC . It also shows the underlying lung parenchymal injury
Management:
• Traditionally the treatment is mechanical ventilation.
• But current treatment is only oxygen administration, adequate analgesia and
physiotherapy.
• Mechanical ventilation is reserved for cases who develop respiratory failure, Pao2 <60%
and RR >18/minute- Intermittent positive Pressure ventilation(IPPV)
• Surgery and internal fixation of ribs are in use again

Paradoxical respiration in Flail chest.

Diaphragm Injury:
• Mc mechanism is penetrating trauma ( Below 5th ICS)- Wound will be bigger in
Diaphragm.
• Blunt Trauma – by rib causing perforation or Compression injury- MC on left side > right
side.
• Clinical feature: Most remain silent, if wound is big enough, the bowel , stomach and
abdominal viscera enters the chest.

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 • Ryles tube will enter the chest
• Don’t give bag and mask ventilation, immediately do IPPV.
• BERGVIST TRIAD: Fracture Rib+ Fracture Spine or Pelvis+ Diaphragm Rupture*
• MC organ to herniate – Stomach> Colon
Management:
• Most diagnostic investigation- VATS or Laparoscopy*- having added advantage of doing
repair simultaneously*
• Chest X ray and CECT are all used to diagnose*
• Surgery is advised for all cases whatever may be the size of tear**
• All injuries can be treated by Abdominal approach* and not via chest**
• Diaphragm repaired using 1’ size Polypropylene.

Aortic injury:
• Injury is seen distal to ligamentum arteriosum- tear or disruption happens
• False aneurysm can happen and blood can track along the false passage.
• Disproportionate BP between Upper limbs or between upper and lower limb is diagnostic .
• X ray chest: Widened mediastinum
• Unstable Chest IOC- Trans esophageal Echo
• Stable IOC- CT Scan
• Management- Keep BP less than 120 mmHg – By using Short acting Esmolol
• Endovascular Stenting or DACRON grafting for Aortic replacement.

Tracheo Bronchial injuries:

• Massive air leak will be seen
• Inflate the unaffected bronchus and shift to OT for Thoracotomy and repair*.

Topic 2d- Abdominal Injuries

Diagnostic Peritoneal Lavage:

• Insert a cannula below the umbilicus.
• About 1000 ml of warmed ringer lactate is instilled into the abdomen and is then
drained out.
• DPL has sensitivity about 97- 98% .
• DPL is especially useful in the hypotensive, unstable patient with multiple injuries as a
means of excluding intraabdominal bleeding.

Result: Positive

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Disadvantages:
• Invasive
• Non-Repetitive
• So many false positive cases ( Non Therapeutic laparotomies happened)

Focussed Assessment with Sonography for Trauma ( FAST)

• Latest e-FAST is done at 6 regions, previously done by 4 FAST
• Done by Casualty doctors or Trauma surgeons trained for FAST.
Traditional four views
• Sub Xiphoid Transverse view – assess pericardial fluid
• Right Upper quadrant Longitudinal view – Collection in Morrison pouch or any liver/renal
injuries
• Left Upper quadrant Longitudinal view – Collection in perisplenic region or any splenic
injuries
• Suprapubic Longitudinal and transverse view – Collection in pelvis; assess bladder and
POD
• Added up now 2 extra areas- right and left thoracic views to rule out pneumothorax
(Stratosphere sign) or hemothorax.

Advantages of e-FAST:
• Repetitive
• Non Invasive
• Bedside investigation
• Short time study

Disadvantages:
• Detects Blood more than 100 ml only** ( Bailey value)
• Not detects bowel injury
• Not useful for penetrating injury ( NEET PG 2020)
• Unreliable for RP collections
• Operator Dependent.

IOC for Unstable patients- eFAST

IOC for Stable Patients- CECT abdomen

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Sequence Order Question:
Blunt trauma Penetrating Trauma Gun shot Seat belt injuries
1. Spleen 1. Liver 1. Small bowel 1. MC is mesenteric
2. Liver 2. Stomach 2. Colon tear
3. Small Intestine 3. Small bowel 2. in GIT- DJ
4. Diaphragm flexure in injured
5. Colon
• Urban Bomb Blast- Ear drum > Lungs
• Underwater Bomb Blast- GIT ( MC in terminal Ileum )

Blunt Trauma Protocol:

Mechanism of injuries to each GI organ:

Stomach:
• MC mechanism- Penetrating trauma
• In Blunt Trauma- Greater curve at antrum is MC injured
• Penetrating Trauma- Don’t miss the posterior tear if present.
• Treatment- Surgery and repair of the rent

Small bowel Injury:

• MC mechanism- Blunt trauma> Penetrating Trauma
• Urgent Surgery is needed.

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 • Stable- Primary Repair
• Unstable cases- Clip and Drop technique**( Damage Control Surgery)- Proximal Bowel as
Stoma and keep the distal bowel in abdominal cavity itself by stapling.

Colon Injury:
• MC mechanism – Penetrating trauma> Blunt trauma
• Stable- Primary repair
• Unstable- Clip and Drop method

Rectal Injury:
• MC mechanism- Penetrating trauma > Blunt trauma
• Unstable and high contamination- Hartmann’s operation (Proximal colostomy and distal
closure)

Duodenal injury: ( Pancreatico Duodenal Injury)

• MC mechanism- Blunt trauma; MC site- Neck
• Penetrating Trauma: MC site= Equal in all sites
• IOC- CECT Abdomen
• DPL may show elevation of Amylase if duct disruption seen*
• Serum Amylase may be elevated in 50% cases.
• Stable Cases:
o Distal Pancreatic injury- Distal Pancreatectomy+ Splenectomy
o Duodenum normal with only Pancreatic head injury- Duodenum preserving
pancreatic head resection (BEGER Procedure)
o Combined Duodeno Pancreatic injuries- Trauma Whipple’s ( Pancreas head and
duodenum removed and no reconstruction done now- will be done later)
• Unstable cases of Duodeno Pancreatic injuries: Damage Control Surgery
• Triple Tube Ostomy is done – Decompressive Gastrostomy(A), Decompressive
duodenostomy (B) and Feeding Jejunostomy (C) is done after repair of 2 nd part
injury.

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Solid organ injury-AAST Grading:

Management of Solid Organ injury:

Liver Injury
• Stable patients- 90% are managed by Non operative management ( NOM)
• Unstable Liver injury patient: 4P’s

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 • Pringle- Inflow occlusion manuever at Epiploic foramen- maximum done for 45 minutes.
If pringle done and bleeding stops means it is from PV or HA. If bleeding does not stop it
is from Hepatic vein**
• MC mechanism of Liver trauma- Penetrating Trauma > Blunt trauma**
• Even in penetrating trauma of Liver- Stable patients manage by Non operative
management.
• After 48 hours – while removing the pack- Hepatic artery can be ligated but Portal vein
needs to be repaired**

Spleen Injury:
• Stable patients- NOM
• Unstable patients- Grade 1,2,3- Splenorrhaphy
• Unstable Patients- Grade 4 and 5- Splenectomy
• NOM patients before discharge must undergo CECT abdomen to look for “SPLENIC
TUMOR BLUSH”- False aneurysm developed in Traumatic injury- Such cases need coil
embolization and this condition is known as failure of NOM**

Renal Injury:
• MC mechanism- Blunt trauma
• Omnious sign- Hematuria* ( hematuria is absent in 40% cases)
• CECT abdomen with oral contrast/ IV contrast- IOC
• 90% patients are managed by NOM.
• 10% patients need surgery.
• IVP is advised in NOM patients- to look for enhancement of both kidney.
• If one kidney is not visualised in an IVP- Treatment is exploration of renal hilum as there
can be hematoma in the renal hilar area compressing renal artery or renal artery injury.
If kidney is viable- Repair the renal artery.

Grades of renal laceration ( AIIMS November 2019- Sequence order question)

• Grade 1- Subcapsular Non Expanding Perirenal hematoma
• Grade 2- Laceration <1cm, Non Expanding Perirenal hematoma confined to
retroperitoneum and Gerota fascia
• Grade 3- Laceration > 1cm, No urine extravasation
• Grade 4- Laceration with Urine Extravasation, Injury to Main renal artery and Vein

Grade V:
• Shattered kidney.
• Avulsion of renal hilum: Devascularisation of a kidney due to hilar injury.
• Uretero pelvic avulsions**
• Complete laceration or thrombus of the main renal artery or vein.

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Protocol for Penetrating injury:

Mesentric tear:

More dangerous is Transverse tear as this can result in small bowel gangrene and short bowel
syndrome.

Retroperitoneal hematoma:
In retroperitoneum 4 zones are explained and based on the hematoma in each zone management
differs.
ZONES CONTENTS MANAGEMENT
ZONE I Central vascular structures such as aorta Needs exploration
and IVC

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 ZONE II Kidneys and adrenal glands Observed
ZONE III Retroperitoneum associated with pelvic External pelvic compression and
vasculature fixation
ZONE IV Retro hepatic IVC and Hematoma behind Observation
portal Vein

Figure: Zones of retroperitoneal hematoma

• Mattox Manuever- Left side medial visceral rotation to reach aorta

• Cattel- Braasch Maneuver- Right side medial visceral rotation to reach IVC

Fullen zone classification of SMA injuries

• Zone I – located posterior to pancreas – exposed by Mattox maneuver
• Zone II – from pancreatic edge to middle colic branch, approached via lesser sac
• Zone III & IV – distal SMA injuries – approached directly within mesentery

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 Topic 2e- BURNS ( AIS-9)

MC cause of death in burns:

• At spot (Immediate death)- Asphyxia > Neurogenic shock
• 1-3 days (Early death)- Hypovolemic Shock
• Late death: Septic Shock
• MC cause of death in burns overall- Septic shock

If percentage of burns is more than 15% (Adults), 10%(Children) can develop hypovolemic shock.

Admission criteria for burns Patients:

• >20% partial thickness in > 10 years
• > 10% Partial thickness in < 10 years
• >5% Full thickness
• Eyes, face, genitalia, fingers burns
• Chemical and electrical burns admit
• Psychiatric/ No body to take care the patient

Pathophysiology of Burns:

• Zone of coagulation- Irreversible damage

• Zone of stasis- Can progress or regress
• Zone of Hyperemia- reversible zone ** - Vessels are vasodilated here.

Percentage of burns calculation:

Rule of nine ( Alexander Wallace rule)
• Each upper limb- 9% TBSA
• Each lower leg- 18% TBSA
• Anterior or Posterior Trunk- 18% TBSA
• Head and neck- 9% TBSA
• Perineum – 1% TBSA

Palm rule- Patient’s palm= 1%

Lund and Browder chart:

RRM’S SURGERY SIXER APP BASED WORKBOOK 67

 • Most accurate method for calculating the Burns percentage**
• Best method to calculate burns in children.

Berkow formula:
• Tabular column used to calculate the Burns Percentage.
• Just remember 0-1 year: head=19% and neck=2% from that formula
• Infants – head and neck percentage of burns= 21% as per this formula

Depth of burns
First degree of burns: Superficial burns:
• Erythema+ pain
• Heals without scar in 7 days

2 Degree Superficial (Superficial partial thickness

burns)
• Characterised by Blisters.
• Superficial touch ( Cotton)- Sensation+
• Pin Prick – Sensation+
• Heals without scar in 3 weeks

2 Degree deep ( Deep partial thickness burns)

• Characterised by Blisters
• Superficial touch ( Cotton)- Sensation
Absent**
• Pin Prick – Sensation+
• Heals with scar in 5 weeks

3 degree (Full thickness burns)

• Eschar formation seen
• Painless burns.

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 • Superficial touch ( Cotton)- Sensation
Absent**
• Pin Prick – Sensation absent**
• Can result in contracture and
compartment syndrome

4th Degree burns

• Involving deep muscles and tendons**
• Most of them die due to cardiac arrest.

Management:
• IVF of choice- Ringer lactate*
• Amount of fluid to be infused is calculated by Parkland formula:
• TBSA% × weight (kg) × 4 = volume (ml) needed
• Half this volume is given in the first 8 hours, and the second half is given in the
subsequent 16 hours
• This formula is calculated from time of BURNS** ( Not from the admission)
• < 24 hours we must give crystalloids only and not colloids as they may have leaking
capillaries , which will lead to subcutaneous edema
• > 24 hours Colloids like Dextran, hemacel, albumin are given based on “ MUIR and
BARCLAY Formula”
• Paediatric fluid formula: ( Both crystalloid and colloid)
- Galveston
- Brooke

• Curreri formula- For giving Nutrition to burns patients

Management of Burns Wound:

1st and 2nd Degree Superficial burns:
• Topical ointments
• MC used- Silver sulphadiazine ( Cannot penetrate deeper tissues like Eschar)
• Silver nitrate ( Black staining may happen)
• Mafenide Acetate- Can penetrate deeper into eschar( Can cause Metabolic acidosis**)
• Best of all agents- Cerium Bromide ( Immunomodulator)- Costly
• Collagen sheets are available in 2nd degree superficial burns

2nd Degree Deep burns:

• SSG ( Thiersch graft is used)- Taken by Humby knife.

3rd Degree Burns:

• SSG
• Escharotomy is done to avoid compartment syndrome

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 Topic 2f- Miscellaneous topics

Compartment syndrome Leg:

• MC after closed limb injuries
• There are 4 compartments in leg*
• Cause: Arterial hemorrhage, venous ligation or thrombosis, crush injuries and reperfusion
injury
• Prominent early symptom – Pain and pain aggravated by passive stretching of muscles
• Hallmark of early compartment syndrome – numbness between 1st and 2nd toes**
• Absent of distal pulse is a late sign.

Indications of Fasciotomy in leg:

• In lower limbs – two incisions needed to release four compartments :Indications are
o >30 mmHg (or)
o When clinical signs are present
o Ischemia > 6 hours
o Gradient < 35mm Hg (Gradient = Diastolic pressure – Compartment pressure)
from Bailey and Love

• Lateral incision decompresses- Anterior and lateral compartments*

• Medial incision decompresses- Superficial and deep posterior compartments*

Abdominal Compartment syndrome:

• Pathology is there in abdomen causing ACS is Primary
• Due to resuscitation if the fluid collects and ACS happens is Secondary

Values:
• Normal IAP= 5-8 mmHg
• IAH is if the pressure > 12 mmHg ( at a time gap of 4-6 hours for 3 times)
• ACS is if the pressure > 20 mmHg ( at a time gap of 1-3 hours for 3 times)

Clinical features of ACS:

• Renal blood flow compromise- Decrease urine output
• Decreased venous return- Decreased Cardiac output and decreased Stroke volume
• Diaphragm compression- Increased CVP and decreased Respiratory efforts
• Increased Intracranial pressure can happen.

Measurement of Intra abdominal pressure:

IAP is indirectly measured using three way Foley Catheter of Intra Bladder Pressure: ( Gold
Standard method)
o GI (IAP <10 to 15 cm H2O)

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 o GII (IAP <16 to 25 cm H2O)
o GIII (IAP <26 to 35 cm H2O)
o GIV (IAP >36 cm H2O).

Other methods:
• Gastric mucosal pH
• Near Infrared Spectroscopy
• CECT scan

Management:
• Grade 3- Suggest Laparostomy
• Grade 4- Definite Laparostomy
• Laparostomy- Leave the abdominal wall open and leave it ( no procedure inside)
• The bowel contents will protrude out and ACS resolves.
• Measure serial IAP after laparostomy also
Covering of laparostomy:
- Bagotta bag ( Plastic sheet)
- Opsite dressing
- VAC devices

Disaster Surgery:
• Bomb blast- MC organ injured Ear drum> lungs ; MC in underwater blast is GIT (
Terminal ileum)
• Volcanoes- MC cause of death -Suffocation
• Earth Quakes-MC cause of death- Crush Injury
• Tsunami- MC cause of death- Drowning

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Topic 2g- Recent advances in Trauma
ATLS 10th edition Protocol

Topic Old Protocols ATLS- 10th Edition

1. Fluid infusion By two green ( 18 Gauge)
Venflon on both upper limb wrist
or cubital veins.

2 Litres of crystalloid infused

2. Massive Blood 10 Units of Whole blood replaced.

Transfusion

3. Intubation Intubation by Conventional

method

4. Four Classes of Does not take into account Base

Haemorrhagic Shock Deficit*

5. Tranexamic acid Doubtfully used

usage for Bleeding
Trauma Patients

6. Life threatening Immediate Life threatening:

Injuries • Airway Obstruction
• Tension pneumothorax
• Open Pneumothorax
• Pericardial Tamponade
• Massive Haemothorax
• Flail Chest
7. Tension Was a clinical diagnosis*
Pneumothorax
Insert wide bore needle in 2nd ICS
at Mid clavicular line for all.

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8. Aortic Rupture No Betablocker used
management

9. Urethral Injury Per rectal examination done

Examination by Per
rectal method
( Vermooten sign-
Floating Prostate in
membranous urethral
injuries)
10. Post Trauma Sodium valproate or Phenytoin
Seizure prophylaxis was used.
11. Cervical Spine X Routinely done Not done routinely:
ray -Indications
Indicated based on Canadian C’
Spine Rule
Or NEXUS criteria*

NEXUS- National Emergency X-

ray Utilisation Study:

Indicated for following cases:

Mnemonic:
• N- Neuro Deficit
• E- Ethanol intoxication
• X- eXtreme mechanism of
injury
• U- Unable to give History
(LOC+)
• S- Spinal tenderness+

12. Burns Fluid Parkland Formula: Superficial Burns or Scalds:

Resuscitation Amount of Fluid= 4X wt. in kgX (1st Degree and 2nd Degree)
TBSA of Burns Above 14 years:
• Fluid input= 2ml Ringer
lactate X weight in Kg X
TBSA
• Maintain Urine output 0.5
ml/kg/hr

Below 14 years:

RRM’S SURGERY SIXER APP BASED WORKBOOK 73

 • Fluid Input= 3ml RLX
Weight in Kg X TBSA (
Less than 14 years)
• Maintain Urine output 1
ml/Kg/Hr

Electrical Injury ( all ages :

• Fluid input= 4 ml RL X
weight in Kg X TBSA..
• Maintain Urine Output 1-
1.5 ml/ Kg/Hr

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RRM’S SURGERY SIXER APP BASED WORKBOOK 75
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