PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

October 6, 2020 ● Spinal anesthesia the needle will be inserted on the

space of L3 and L4
I. Ward ● The surgeon do not touch the patient when it is the
anes who touches the patient

After induction of anesthesia the surgeon conducts a

physical exam prior to operating. To check if the operative
site is the operative site. Approximate the margins prior
excision
After the induction of anesthesia, abdomen is quite soft
now (you can palpate for phlegmon or periappendiceal
abscess)

● Rule of sterility to prevent inoculation of

microorganisms. Reduces risk of SSI.
● Maintain sterility all throughout the operation
● Antisepsis is for nidus you haven’t taken out yet.

● Captain of the ship the most senior surgeon would

tell who will be 2nd or 1st assist
● Surgeon sits directly on the site of the operative site.
And has the direct view of the operative side.
● 1st assist will be on the opposite side of the direct
operative site. L 7.5% Povidine iodine wash/ Betadine wash
● 2nd assist will be beside the main surgeon. R 10% Antiseptic solution of Betadine wash
● Prior to that we give the role of the anesthesia for
the induction of anesthesia. Eto yung time na uupo Cutasept - spray area; combines asepsis and antisepsis
muna yung surgeon while the anesthesiologist does
their part.

● The Lighter is the 7.5% we scrub it centrifugally and

thoroughly away from center
● The Darker is the 10% is to be paint it centrifugally
● To remove all possible nidus of the infection - asepsis

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Kelly Curve

Sterile area unless instructed to do draping areas

Don’t touch anything in this area unless you are sterile.

Straight Kelly - holds tissues and soft

Army navy retracts operative site

Main scissors? used to tie the thighs and the strings

Babcock Holds the hollows viscus (visceral organs esp.
bowel)

Metzenbaum - Used to cut organs

First knife; Blade 15, in OR we use 15 and 10

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
Mixter (Right angle/Lahey forceps) is angled 45 deg for
those areas hard reach and you want to clamp t
This is for ligation.
Needle holders - To show what you’re exposing.
Tissue forceps toothed
Baby Richardson
Towel clips- hold towels and skin
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● Non abs used in fascial tissues and non-abs tissues
● Abs suturing used to permanently close the incision
site. Abs is for mucosal areas. Braided is multi layer
● Know the Tensile strength and low infection rate
● Braided prone to infection
● Soaked suture especially sa indigent dati
● Low reactivity rate
● Tensile strength 50% or number of days na
mawawala yung tensile strength.
● Monofilaments are single.
Question:
1. Doc aside from the concentration of iodine 7.5% from
10 % how does it differ?
● 10% antisepsis while the 7.5% is used in sepsis.
● Sa 10% more of disinfection on the part of
antisepsis.
● 7.5% is used to take out the debris during the
aseptic technique
● 7.5% soap like properties magnets all the oil and
moisture on the area of the operative site. Kaya
namin pinapascrub para pati yung debris is
matangal.
● 10% Disinfect on anti sep. Removes the later part
removes all the remaining bacteria na hindi
nakuha dun sa first.
2. When do we stop antibiotics?
● Look at WBC (request for CBC) - if WBC is going
on normal state then you stop the IV antibiotics
and continue with oral ones then you stop it
after.
3. When doing asepsis and antisepsis,
● In asepsis, be sure to scrub it off thoroughly!
There is an impression of scrubbing on the
abdomen. You should have enough pressure,
when the anesthesia has been inducted, you
need to scrub it off to remove tissues and
sources of infection.
4. Monofilaments vs Braided,
● Monofilaments are more expensive because they
are not prone to infection. It is more resistant to
infection than braided because braided is
composed of more filaments and bacteria goes
into the mix in areas where braid is. Choose
monofilament for skin to oppose tissue but
braided is stronger and is used for areas like the
back. There is a lot of skin at the back.
Monofilament is used for suturing the face and it
is less scarring.
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
II. SISS Session 2
CASE: “Diagnostic adjuncts during primary survey in
trauma” with Dr. Wallace Medina”
Diagnostic Adjuncts during primary survey in trauma
A lot of cases are trauma.
Adjunct will help us in evaluation of trauma patients. The
intention of the American college of surgeons in
developing ATLS is to be a global standard, an organized
consistent approach to acutely injured patients to optimize
outcome.
Adjunct - Help, assessing, evaluating during primary
evaluation. Their presence is in advantage.
Principle - key or core in management of trauma in any
case came in the department.
To lower mortality, lower morbidity
Up until now, there is a continuing contribution of different
countries (More than 60 countries are adapting ATLS which
was introduced in 1980, 20 years in existence!)
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To fulfill “First do no harm”, you stop the trauma process.
Do something and one of the things you should do is to
have a proper assessment of the patient.
Px has air leak then stops the air leak. If hypotensive, then
reverse the hypotensive.
Prioritization, a principle bound in triage. Who needs
attention first (who is a greatest threat to life first) so that
you would be able to reverse the ongoing process that is
critical to the patient.
One of the causes of delay to come up with a definitive
diagnosis that is not part of the early assessment
evaluation of trauma, DEFINITE DIAGNOSIS IS NOT
IMMEDIATELY IMPORTANT. Identify the life threatening
matter.
TIME is an essence when the talk of trauma management
such as the golden hour. It also tells you of how urgent we
have to give a form of management to our patient. Time
and urgency goes hand in hand. During the early stage of
assessment, we need to repeatedly do this, repeatedly
assess, repeatedly intervene, repeatedly reassess so that
we would know if there are responders, transient
responders, or non-responders. The endpoint is we have to
bring back to their normal vital signs and these three 3
mnemonics (AIR) have to be done simultaneously.
That’s the reason why we need to do this as quickly? These
are the basic principles which have been started and
recommended by the ATLS.
It is a simultaneous collaboration of assessment and
resuscitation. This cannot be overemphasized unlike
before the emergency room is being manned by 1 person
so there would obviously be a delay in the resuscitation
and assessment which leads to higher mortality and
morbidity. The key in dictum in achieving urgent care is
SIMULTANEOUS ASSESSMENT AND RESUSCITATION.
Remember the mnemonic AIR (ASSESS, INTERVENE,
REASSESS).
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

o Room for PUI, Covid, and non covid

Universal precautions; proper attire, the gowns, the
googles and all.
Important equipments once patient arrived at hospital:
1. Stethoscope
2.pulse oximeter,
3.ET tube, 1 for pneumothotax.
Overview of Trauma management (ATLS) 4. Tracheostomy tube.
● Preparation (Pre-hospital)
● Triage Triage
● Primary survey starts when the patient goes to Only in the situation:
the hospital. Assess life threatening situation ● Multiple injuries
and assess if patient is unstable ● Unconscious
● Resuscitation ● Mass casualties
● Adjuncts to primary survey
● Secondary Survey phase once the patient is Initial assessment:
stabilized. More detailed assessment of patient ● Primary survey- evaluates physiology. Three
● Adjuncts to secondary survey designed for important physiology core: Oxygenation,
stable patient Ventilation and Perfusion
● Tertiary survey phase of reassessment of ● Evaluation of respiratorion and the Main killers
patient. 25-30% you will be able to detect to mortality rate.
injuries that were missed during the ● Secondary survey – evaluates anatomy. Detailed
aforementioned assessment. anatomical assessment. Examine head to toe
● Definitive Care decide whether you will do front to back only be done when stable patient
conservative management or proceed to
surgery
When you do a secondary survey, the patient is in a stable
where all the laboratories will be done.
Preparation
● Pre-arrival phase (Pre-hospital) – notify
receiving (EMS), Role of team leader, Vital
information (age, sex, MOI, V/S, Injuries).
These are essentials.
o Emergency medical team needs to notify
Early Intervention is focused on life threatening condition
the receiving hospital which has to be a
trauma center
Primary Survey; design to assess and treat life threatening
o In a trauma center there is always a team
conditions.
leader usually it is General surgeon for
some it is an Emergency physician who will
QUESTION: GIVE AT LEAST TWO LIFE THREATENING
tap the members and make them known
CONDITIONS DURING PRIMARY SURVEY:
of their individual roles
1. Tension pneumothorax
o The referring EMS has to provide the Vital
2. Cardiac tamponade
information.
Any condition that targets the airway is life threatening.
o 1-44y/o peak of trauma
o Mechanism of Injury very important
Areas of FOCUS in PRIMARY SURVEY:
oftentimes missed. Is it a blunt trauma,
● Airway
secondary to motor vehicular crash,
● Breathing
penetrating trauma secondary to stab
● Circulation
wound or gunshot.
● Disability
● In-hospital phase – Universal precautions of
● Exposure
trauma team (PPE), experts, test 24 hrs
● FAST- adjunct. Some books includes FAST it is
available, OR-RTX-ICU
one of the best adjunct during primary
o Minimum PPE is level 3
If any condition comprises the aforementioned then we
o CT scan especially if dealing with head
have to prioritize.
injury, ICU must be manned properly by
an internist, OR has to be equipped well

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
Airway assess oxygenation , the simplest and most
practical way to assess such physiologic core is to ask the
patient what happened.If the patient appropriately
responds this will confirm the airway is patent to permit
speech and assume adequate perfusion of the CNS and the
cardiovascular system and confirm patient has good
sensorium.
If a patient appropriately responds when asked if there is
an appropriate airway we can also assume there is
adequate perfusion since there is CNS…..
What will you do in a patient who is restless (combative)
and primary survey is not possible?
ANS: Most practical way is to sedate the patient then
proceed with the primary survey (systematic evaluation
and assessment).
For breathing and circulation
Your approach is look and listen.Need to inspect jugular
venous distension (cardiogenic type or problem) that will
lead to life threatening conditions such as tension
pneumothorax, pericardial tamponade.
Visualization of the jugular vein.
Position of the trachea needs to be emphasized due to life
threatening conditions such as massive pleural effusion
together with tension pneumothorax.
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This will give you a clue that you are dealing with life
threatening conditions that need immediate treatment.
Assess for the respiratory rate,listen for the percussion
massive hemothorax and tension pneumothorax have a
different findings
For chest injuries palpate for Crepitation.
Need to listen to air entry, no need for a diagnostic.
Adjuncts pulse oximetry for oxygenation and perfusion
status
Capnometry (assess the exchange of gases or the level of
carbon dioxide) assess the ventilation and also the
perfusion
For Circulation Evaluation
-External bleeding (hemorrhage control). :Obvious
bleeding can be assessed first before ABC & you can just
apply direct pressure to address the bleeding first,
remember the Do not harm. After control. Proceed to
ABCDE.
-Level of consciousness-just ask a simple question of what
happened, AVPU (Alert, Verbal response, Pain stimuli and
Unresponsive)
-Skin color & temperature: are signs that might lead to
shock or manifest as shock
-Pulse rate, character and site-weak ( 3 sites where you will
feel the pulse, 1. Radial pulse if able to feel at that site-the
systolic will be > 80 mmHg if not next would be 2. Femoral
area, if able to feel in that area-systolic would be 70 mmHg
and last 3.Carotid artery, if pulse can only be felt in that
area then systolic pressure would be 60) needs
resuscitation if pressure at 60 is not appreciated.
For the brain to function well need a systolic pressure of 90
mmHg at least ( goal)
-Capillary perfusion test( pressing the nail bed and
returning for <2 secs then the perfusion is okay.
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

The blood loss would be 20% or 1.5L. Recommended blood

is PRBC.
★ 1L blood loss: give 3L Crystalloid(Plain LR,
PlainNSS).
★ 1L blood loss: give 1L colloid( Dextran, D5W)
Why: to replace 3rd space loss
● Crystalloid, when infused. look for the vein. the
volume is in ECF, 15% interstitial, 5% plasma.The
crystalloid also fills up the Interstitial aside from
the Intravascular(Plasma). That’s the principle
behind it why you are giving fluid to replace 1L Exposure
because the volume contribution is not only -Completely undressed
concentrated plasma -External wounds-number matters, trajectories, anatomic
● Colloid (albumin, starch, dextran). Distributed zones( give the assessor the particular injury of patient)
straight to plasma, also known as the plasma -Prevent hypothermia (All trauma patient
expander. thermoregulation is compromised, no vasoconstriction if
they are exposed to cold environment)
Triad of doom: Hypothermia, DIC (coagulopathy), acidosis
(killers of trauma patient
-Cover with a warm blanket ( to avoid complications) to
prevent hypothermia).

Disability means assessing

-Level of consciousness-GCS 15 is the perfect score. Below
15 is significant and need for further evaluation CT scan
CT scan ideally is design for stable patient if talking about
traumatic brain injury this is an exception in having it for There is selective utilization of these.
primary survey Skeletal survey (chest x ray, cervical spine, FAST, eFAST)
Airway can already assess this. ----------------------------------------------
Important parameters:. Eye, verbal, motor response

-Pupillary size & reaction-Unequal pupil-emergency

GCS of 9 or < 9 need to provide adequate airway use
endotracheal intubation provided no facial injuries
No deprivation of oxygen to 5-10 minutes, because it will
result in permanent damage to the brain.
-lateralizing signs- refer to neurosurgery

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Chest x ray is the most available radiologic form of ● Pericardiac

evaluation screening primarily thoracic injuries – some ● Thoracoabdominal
would even claim cardiac injuries but I think the primary ● Cardiac box
use of chest x ray if you are entertaining thoracic injuries
whether it is secondary to blunt or penetrating stab wound
or gunshot wound. Chest xray would be vital or an
essential adjunct for this particular patient. However, in a
systematic review, the accuracy rate of xray in detecting
pneumothorax and massive means 1.5L lose hemothorax
and other injuries that are life threatening is only 54%
which is not a good value and the xray can detect the
blood amounting to 175cc. 60% rule is need to address.
These are the conditions that can be detected by a simple
xray. In rib fractures, take note of a possible flail chest –
flail chest is a condition which involves multiple fractures
that results in paradoxical breathing. Usually this flail chest
can result in pulmonary contusion.

Cardiac injuries would claim that certain injuries such as

pericardial effusion secondary to myocardial contusion
and this can be seen via the widening of the cardiac
shadow and also the presence of pneumomediastinum –
FAST is for the focus assessment in trauma and this can be
this are the things that they look for, but then again the
done for unstable patients, usually this is designed to
accuracy in detecting cardiac surgeries is inferior to that of
assess the four areas – for the Chest you have the
the thoracic surgeries using chest xray.
pericardial, and for the other areas, it would belong to the
intra abdominal. So you have the perihepatic, pelvic and
Intra abdominal injuries can also be detected by the
your perisplenic.
presence of elevation of the diaphragm or the presence of
The main purpose of your FAST is to quantify the
the pneumoperitoneum below the subdiaphragmatic air
volume present – any fluid in the aforementioned areas
and presence of intestine in the thoracic cavity – these
would signify accumulation of blood (which signifies
are all signs that there is already concomitant
bleeding). Sometimes, in a patient who is unstable and you
intrabdominal injuries.
have positive fast, it is already enough criteria for you to
send the patient to the operating area. This is reader
dependent so you need to know the sensitivity and
specificity of the one who’s reading FAST and also the
same thing applies to eFAST.

EFAST is superior that xray in detecting thoracic injuries

whether it is a pneumothorax or a hemothorax. If it is
done in the trauma center, the one who’s doing this would
be an ER physician. If done by an ER physician, the
sensitivity is only 70%, however in a prospective study
where there is an expert/specialty then sensitivity can
ANS: B (Apical lung portion ) reach up to 92% so if the reader tells you that there is no
blood, then you are 100% specific – this is of course
eFAST only assessed two portions: considering that the one reading it was really trained for
● Apical portion - Pneumothorax such task.
● Base portion - Hemothorax
FAST assessed.

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

The detection of blood is 20cc. However if the blood

reaches 100cc then the sensitivity would be 100%. If they
were able to detect blood using the efast or the fast, then
more or less the blood is 100c. You just need to correlate it
with the status of the patient.

When your patient is stable during circulatory assessment,

NGT is primarily used for decompression. Why do we need
to decompress? Because in a patient whose belly is
distended, it will compromise one of our physiologic (?)
and that is oxygenation – if this being compromised then
your patient would eventually might succumb to death. So
you need to decrease that distended abdomen by
inserting an NGT. The decompression would increase the
intrathoracic pressure and also at the same time, remove
the gastric contents that can further contaminate the
abdomen if in case you need to operate the patient.
There was a practice before that NGT could also tell you if
the injury is in the upper GI by observing breathing.
However, so many studies have been done and the results
are inconclusive. At this present time, you don’t rely on
NGT to detect or to rule our injury in the upper GI, rather
the main purpose of the NGT is to decompress.
then you need to insert IFC at the emergency room and
monitor the perfusion. This is for monitoring the perfusion
because we all know that if there would be decreased
intravascular volume, then your kidney would try to
conserve then there would be anuria in your patient
which would result in acute tubular necrosis that may be
irreversible if you let it happen.
This is also used to detect urinary tract injuries, but the
results are misleading so we don’t do it anymore. So a
normal urine doesn’t really tell you that your patient is
really free from GUT problems. One of the common causes
of anuria is kinking of the foley catheter, since this is a
practical way of assessing the resuscitation, you have to
always check the patency to the foley catheter.

There were some who would use this intraoperatively ,

and what is the purpose of that? If the abdomen is filled
with blood then you can use this to hold it, so this would
assist the handing of the stomach as you do your
assessment in the anterior or posterior part of the
stomach. This is done repeatedly (twice or thrice) to
ABG and Serum lactate before is a favorite parameter that
assume that there is really no involvement of any part of
they use as an indicator of adequate resuscitation,
the GI tract – because if that happens, this would lead to
however they have found lately that there is a limited role
catastrophic results (feces, chemicals would be coming
especially in the serum lactate in blunt abdominal trauma.
out), this will excite. Severe inflammatory process and your
Now they are forgoing the role of ABG, lactate – but there
patient would definitely die.
are some studies that high levels of lactate would be a
prognostic factor and this is associated with an increased
mortality rate.

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

ECG/EKG – EKG findings suggest cardiac injury. When Vital Signs

there is blunt chest trauma secondary to steering wheel · BP: 130/70 mmhg
injury and to rule out cardiac injury then would request for · HR: 85 min
an ECG as part of the diagnosis. It may also be used in · RR: 20 min
pulseless activity. · Temp: 36.7 C
EKG findings: Arrhythmias, ST elevation, cardiac · Weight: 60kg
tamponade, Pulseless activity

However, total reliance with the ECG – sensitivity is only

54% and the specificity is 74%, the negative predictive
value is good – means that when it is normal then your
83% correct that there is no injury to the heart. The
positive predictive value is only 41%, this is for blunt
cardiac injury. If you really want to make sure that there is
cardiac injury, the current approach is ECG with troponin I
– because they found out that Troponin I is more than 90%
sensitive – so that’s what we request if we are entertaining
significant cardiac injury (myocardial
contusion/concussion)
For those patients, especially those hooked to a ventilator,
they found out that this has been a predictor of mortality
(End tidal CO2), if the level is 18 mmHg and below then
this would really make a stormy hospital course in the
patient. The lower the value, the poorer the prognosis.
ETC CO2/CAPNOMETRY - USED FOR INTUBATION,
DETECTING SHOCK, AND PULMONARY CONDITIONS.
Use of pulse oximetry which detects the oxygenation as
well as the perfusion. While the captometry, it detects
ventilation and perfusion.
Blood pressure, although not a good way to measure
perfusion – instead they are determinants of shock.
Hemodynamic instability is global indication to do
exploration to the patient
Case
Cardiac box is bounded superiorly by
clavicle, laterally by nipple, inferiorly by
subcostal or xiphoid process, any lesion in
the cardiac box you have to think of cardiac
injury
Male usually nipple is at 5th ICS but some book claims 4th
ICS
How will you manage the case?
· ANS: Standard procedure Primary survey
first
· In all trauma patients, primary survey first
Primary Survey
· Airway: patient is able to communicate
· Breathing: No dyspnea, No tachypnea,
Clear Breath sounds
· C: Circulation: stable BP (slightly
hypertensive), Normal HR
· Disability: Awake, coherent, GCS 15
(E4V5M6)
· Exposure: NO other injuries noted

M.L, 52 years old, Male stabbed by unknown assailant at

What Diagnostic Adjuncts would be most useful at this
the left anterior chest
time?
· ANS: CXR
MOI: Stabbing (unknown weapon)
Since the area concern is thoracic. Look signs of cardiac
DOI: 3/27/2020
injury as well
POI: Pasay City
TOI: 6 am
3 radiographic findings that are suggestive of Cardiac
Injury:

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

● Widened cardiac shadow suffice the penetration and injury to the organ that is
● Effusion?? concerned. At this point maybe the surface is not anymore
● Pneumopericardium entertaining the injury. However, 4 hours from the time of
● Pericardial opacity injury patients complain of difficulty of breathing and
chest pain, these are the objective. At this point, there is
significant instability and of course there is decrease in
breath sound.

What will be the management of the patient? Some of

you are radical and will operate, some will do less invasive
procedure like your CTT

If cardiophrenic is obliterated - 500 cc

If costophrenic is obliterated - 250 cc
Secondary survey:
· HEENT: Anicteric sclera, Pink palpebral
conjunctivae, (-) lymphadenopathy
· Heart: Adynamic precordium, Normal Rate,
regular rhythm, no murmur
· Chest/Lungs: Symmetrical chest expansion,
clear breath sounds (L), (-) crackles and wheezes
· Abdomen: Unremarkable Answer CTT mid axillary line and you can see here the
· Extremities: Grossly Normal Extremities, CRT actual stub site, so CTT was inserted, and post CTT there
<2s was reversal, re assess the life basic principle, reassess
· GUT: Unremarkable from intervention suction was done the given intervention
the CTT, and then reassess. So (pneumotic air)? Was
Proceed if normal CXR applied to the patient.
Stab wound is non-penetrating
If Gunshot or stab wound
If unstable in the1st part of examination

You will ask yourself if this penetrating or not, unstable at

the early part of assessment. Then most probably, you can

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

After reassessment there was reversal of vital signs. You

will see that the initial output is 500cc. So after the CTT.
The only time that they have completed the insertion.

So you can see the CTT directed going inferiorly. You can
see the lungs, there are still opacities here, the dense area
probably there is more blood present, so the initial
drainage was 500cc. So the trachea is on the midline and
there’s no tension or massive diffusion of hemothorax or
others for this patient.
So at this point in time, what will be your plan of
management to our patient. When you assess, the
problem this time would be that there is a decrease and
we have the manifestation of gastric shock. So since the
initial output is blood, because of shock, it's hemorrhagic
and so most of you

Answer Fluid resuscitation in this case.

Hemodynamic Instability
Bleeding

So, 2 hours after, the patient continue again complaint of

dyspnea and chest pain, this time, the patient’s BP is
palpatory 60 and those other vital signs, but still the
patient can be communicated, there is no change in
sensorium and the additional 300cc however, your patient
is not anymore excreting urine.

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
Ans: Plain NSS
Since there is hemorrhagic shock. What fluid is
appropriate?
So let us dissect this, so A. isotonic, in excess hypotonic. B
is isotonic. C, hypotonic. D, is colloid. So the fluid of choice
when we resuscitate of course is the crystalloid, between
LR and NSS, I think the tonicity, when we say isotonic, it
has the same osmolality as with plasma which is part of
the blood. And therefore, between plain LR and plain NSS,
it's plain NSS that would really give an isotonic picture of
isotonic crystalloid.
so for resuscitation purposes, the isotonic and
hypotonicity of plain NSS is somewhere around 308 or
above, so you just check. Unlike the LR, the tonicity is less
than 480. It's slightly Hypotonic. so given the choice, plain
NSS would be better because it is isotonic.
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When you insert an IV to your patient and I ask you to
place NSS or LR where the distribution of this volume is to
the patient. Which compartment of this fluid goes.
So here, your patient's main problem is manifesting signs
and symptoms of shock is because the intravascular
volume has been depleted. And you all know that
intravascular underneath is your plasma. The
intravascular plasma belongs to extracellular fluid. Other
compartment cellular fluid will be interstitial. So when you
give crystalloid, the D5LR or NSS, this fluid will eventually
have distributed to the interstitial and to the plasma, two
compartments of this. And they found out that if you lose
in our patient. You have to Diffuse at least 3-4L of isotonic
crystalloid. You will be able to replace the loss.The
crystalloid also fills up the interstitial aside from the
intravascular. That’s the principle behind it why you are
giving fluid to replace 1L because the volume contribution
is not only concentrated plasma. That’s the reason why
when you are doing your assessment, you need to reassess
not only the vital signs but also to reassess during the
resuscitation such as urine output. especially in fast drip:
the most dependent part is the lungs when hydrating the
patient is lying down. The over resuscitation for your
desire to bring back the BP to 90 or even more could result
in congestion or overload because of volume distribution,
so there is the tendency that you’re going to overload the
interstitial compartment because that thing got
compromised. The exchange of gas will also compromise
and that delays the purpose of resuscitation because you
want the remaining blood to expand intravascular volume
so the remaining blood will be able to perfuse in other
organs in particular the central nervous system and if you
compromise ventilation then you need to reassess. Check
for the most dependent portion.
D5W, of course it’s an hypotonic, and this will be
distributed everywhere, so this will go to the intracellular.
On the other hand, colloid only volume of distribution is
intravascular or vascular peritoneum, so if you lose 1L of
blood you only can give 1L of blood to replace it for colloid
1L blood loss.
If you lose more than 1L infuse 3-4 liters of isotonic
crystalloid to replace 1l blood loss.
Dextran Intra vas or plasma 1 liter of dextran to replace 1
liter of blood loss.
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
If you operated on that patient what would be the
incision? And the next question is why? Why did you
choose that answer? What’s the reason behind?
Okay, so we can also check the heart, you know clamshell?
You do two, one is on the right, and one is on the left and
you crossed at sternum. That is clamshell incision.
So first in foremost, your patient is unstable so
anterolateral thoracotomy will provide lesser exposure
especially for unstable patients. So, it can be done with
speed. You can also assess the cardiac as well as the
thoracic Because the patient is unstable. You want fast
access, that’s the reason why anterolateral because your
patient is unstable.
PGI BY JANUARY 2021, GOD’S WILL!
In our case mechanism of injury is penetrating and this is
caused by stab wound so to differentiate gun shot from
stab wound these are some important things to take note
of, we all know that stab wound is low velocity it doesn't
guarantee you that your patient would have benign course
because I have seen a lot that resolves to the device of the
patient by a single stab wound all though it is more
predictable because you can see the trajection, you can
assume that this particular organs are involved in our case
the possible organs were definitely or structures lungs,
vessels and of course the cardiac because it’s near the one
of the anatomic zone, however for gunshot wound
because of its unpredictable pattern then almost always
there is no room for conservation just open the patient,
now the kind of wound that was inflicted to our patient
has a very low association intraabdominal injuries less
tissue damage and there is a room for conservative, but in
our case because of clinical presentation of the patient
then we have no other choice
100cc?? blood loss may result to pericardial tamponade.
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

What are the adjuncts that need to be done in our patient

CXR is inadequate during the primary survey as
mentioned by some of you during the 1st few inquiries in
our discussion you mention about eFast and Fast. Fast
would be better because fast can evaluate the cardiac
which is in proximity with the stab wound, the one
assessing it can say if there is a presence of diffusion that
may cause pericardial tamponade but PE of patient you
have adynamic precordium, no murmur, heart sounds are
heard but when the patient condition worsen you should
have done or repeated a Fast, eFast can also be done as
mention, it can detect very small amount not only that it
can tell us whether its associated pneumothorax, other
diagnosis adjunct that should have been done ECG,
coupled with troponin I, has a good measure of cardiac
injury involvement pulse oximetry done, initially good
02sat 94, 98 is acceptable 02sat, foley catheter is inserted
to know the adequacy of resuscitation in our case during
pre op, intra op and post op

The stab wound is just below the nipple it is found in the

cardiac box what are the boundaries of your cardiac box,
cardiac superiorly you have the clavicle, laterally being
bounded by your the nipple and inferiorly by subcostal
margins once you have enter this anatomic zone, you have
to consider the possibility of cardiac injury and you have
answered it right aside from chest x ray you could have

but what has been suggested during our conference by the

cardio thoracic surgeon is that we should have done
pericardiocentesis and of course this pericardiocentesis is
eventually tell you that there would be effusion because
other findings in the Xray suggestive of cardiac injury aside
from what we mentioned widened cardiac shadow would
also be the presence of pericardial opacities and also
presence of pneumopericardium so these are 3 signs
radiologic possible myocardial condition but in our case
between pericardiocentesis and subxiphoid pericardial Fast should be done first aside from CXR.
window the thoracic surgeon would prefer more
Useful guide in approaching a patient whose injury is
subxiphoid pericardial window, this is direct visualization
found in the cardiac box
and the other one is blind procedure and of course you
don’t hope your finger to the chest injury because you If the patient is unstable, the patient is a candidate for Left
might convert a non-penetrating to a penetrating. anterolateral thoracotomy just below the nipple.

However, during a stable stage, then a Cardiac ultrasound

is effective. And the best exposure for cardiac injuries is
Sternotomy if the patient is stable.

PGI BY JANUARY 2021, GOD’S WILL! 15

 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
Those with check are present in our patient
The following are the indications for exploration
Trauma series: composed of: Cxr, Thoracic xray and pelvis
xray
In summary, these are the Adjuncts to Primary Survey. If
we only use the other diagnostic adjuncts during the initial
evaluation and not totally rely, then we could have done
more and we could have prepared the patient adequately
and we could have done the surgery much very well.
QUESTIONS:
1. If the wound is sucking and making sound, 3
tape os, no issue if dry or wet
No sound - 4 side tape
If there is sucking wound and you applied 4 sided
tape, you might cause iatrogenic injury because
that’s pneumothorax
2. When you sedate, the vital signs are important
and if it’s normal, you can say that there’s
adequate cerebral perfusion and you don’t have
to sedate the combative patients. Protect
yourself.
PGI BY JANUARY 2021, GOD’S WILL!
3. In emergency situations (motor vehicular crash),
if bleeding is really perfuse, control bleeding! You
can ask the patient. By instinct, the patient itself
will cover it and this goes before other areas of
concern (ATLS endorsement of px with profuse
bleeding).
a. Neck Pain complaint -> do stabilization
b. If px is lying down, put splints on lateral
neck
c. Don’t transfer patients who are
unstable.
4. You have to make sure that there is no cervical
spine injury before you do your chin lift and jaw
thrust.
5. In pregnant women for primary survey:
a. Non-invasive and if you want to look
for bleeding, use FAST.
b. Pulse Ox and ETCO2
c. You have 2 patients
d. Ask OB as part of the trauma team to
monitor FHT.
6. In the Cardiac Box, the parasternal (lateral) area
would vary in women. The nipple of the male is
equivalent to the inframammary line of the
women. Lift the breast, that’s where you place
the CTT and is your reference for the cardiac box
in females.
7. Most of these stab wounds are due to brawling
so you have to address medicolegal issues but
you should stabilize your patient in secondary or
tertiary survey. Sometimes, it gets addressed in
the OR.
8. CTT is for evacuation of huge amounts of blood.
Alternative for CTT: If this is a tension
pneumothorax (insert large needle gauge 14) but
this is just temporary. CTT is still the definitive.
9. Proper documentation should always be
practiced in case of litigation.
ASSIGNMENT:
TRIALS OF USING HORMONAL THERAPY (ADJUVANT
THERAPY FOR BREAST CANCER TRIAL)
ATLAS
ATTOM
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Transcribed by the future PGIs of January 2021

SRT INT JRT JT

PGI BY JANUARY 2021, GOD’S WILL! 17