General Surgery 2

Question 1

What are the possible complications of massive haemorrhage?

Answer 1

• hypothermia (as transfusion blood is refrigerated)
• hypocalcaemia (as FFP and platelets contain citrate anticoagulant which may celate calcium)
• hyperkalaemia
• Acute onset pulmonary oedema (due to leucocyte antibodies in plasma causing leucocyte aggregation and degranulation in lungs)
• coagulopathy (as platelets and clotting factors are not replaced)

Question 2

Lidocaine

1. What is the maximum safe dose?
2. What is it available pre-mixed with and why?

Answer 2

1.
3mg/kg
BNF states 200mg (or 500mg if mixed with adrenaline)

2. adrenaline - this increases duration of action of lidocaine and reduces blood loss secondary to vasoconstriction

Question 3

Iatrogenic nerve injury in surgery

Which nerve is most likely to be damaged in the following operations

1. Posterior triangle lymph node biopsy
2. lloyd davies stirrups
3. Thyroidectomy
4. Anterior resection of rectum
5. inguinal hernia repair
6. Varicose vein surgery
7. Posterior approach to hip
8. Carotid endarterectomy

Answer 3

1. accessory nerve
2. common peroneal nerve
3. laryngeal nerve
4. hypogastric autonomic nerves
5. ilioinguinal nerve (as joins halfway along the canal)
6. sural and saphenous nerves
7. sciatic nerve
8. hypoglossal nerve

Question 4

Pilonidal Disease

1. What is it?
2. What clinical features are seen?
3. How is it managed?

Answer 4

1. disease where sinuses and cysts form near the upper part of the natal cleft of the buttocks
2. most commonly presents:
   - in men around 20 years old
   - when the acute inflammation occurs (I.e. pain, purulent discharge, fluctuant swelling)
3. • asymptomatic: managed conservatively encouraging hygiene
   • acute: incision + drainage
   • chronic/recurrent: excision of sinus + obliteration of underlying cavity

Question 5

What can be the complications of gastrectomy?

Answer 5

• small capacity (early satiety)
• dumping syndrome (diarrhoea, nausea, vomiting due to rapid stomach emptying)
• bile gastritis (reflux + vomiting bile)
• B12 deficiency:
  
  • anaemia
  • subacute combined degeneration of the spinal cord: ataxic gate, loss of sensation and reflexes starting at bottom of lower limbs

Question 6

Septic Shock

1. Define
   a) sepsis
   b) severe sepsis
   c) septic shock
2. What can be the surgical causes of sepsis?
3. How should patients needing surgery be managed?
4. What parameters should you aim for when trying to haemodynamically stabilise patients with septic shock?

Answer 6

1. a) an infection triggering systemic inflammatory response syndrome
   2 or more of the following:
   - temp <36 or >38
   - HR >90
   - RR >20
   - WBC count <4000 or >12000

b) sepsis + organ failure

c) sepsis + refractory hypotension
(hypotension despite administering fluids)

2. • failure of anastomoses
   • abscess formation
   • extensive superficial infection e.g. necrotising fasciitis
3. for those requiring surgery, undertake minimum possible as patients do not tolerate prolonged surgery
4. CVP - 8-12 cm
   MAP - >65

Question 7

Neurogenic shock

1. What is the most common cause?
2. What is the pathophysiology of this?
3. How pharmacological management should take place?

Answer 7

1. spinal cord transection
2. this leads to either decreased sympathetic and/or increased parasympathetic tone

this results in peripheral vasodilation and, consequently, decreased preload and therefore decreased cardiac output

therefore decreased peripheral tissue perfusion

3. peripheral vasoconstrictors

Question 8

Anaphylaxis

1. What clinical features are seen?
2. How should it be managed?

Answer 8

1. general:
   - itch
   - urticaria
   - oedema
   - erythema
   GI:
   - D+V
   Cardio:
   - tachycardia + shock
   Resp:
   - wheeze
   - cyanosis
   - stridor
3. O2
4. IM adrenaline 0.5mg (need to know dose)
5. get IV access: IV hydrocortisone + chlorphenamine, fluids if required
6. salbutamol of wheeze

Question 9

What should you suspect if you see “nutcracker” oesophagus on barium swallow?

Answer 9

diffuse oesophageal spasm

Question 10

What should you suspect in a deceleration injury with a widened mediastinum?

Answer 10

aortic disruption

Question 11

What is a contusion?

Answer 11

bruising due to blunt force trauma which can lead to organ dysfunction

Question 12

Haemothorax

1. How should this be managed?
2. When should thoracotomy be considered?

Answer 12

1. wide bore chest drain
2. • > 1.5L blood loss
   • ongoing blood loss >200ml/hr for >2 hrs
   • cardiac tamponade
     
     • > indicated by raised CVP

Question 13

What clinical features can be seen in a urethral tear / disruption?

Answer 13

• blood at urethral meatus

- high riding prostate on PR

Question 14

In abdominal trauma which investigation would you carry out if you wished to find out the following:

1. bleeding if hypotensive
2. organ injury if normotensive
3. fluid if hypotensive

Answer 14

1. diagnostic peritoneal lavage
2. CT scan
3. USS

Question 15

The spleen is a very commonly injured intra-abdominal organ. When is the following management indicated?

1. conservative
2. laparotomy with conservation
3. resection

Answer 15

1. • minimal blood loss
   • small sub capsular haematoma
   • minimal blood loss
2. • increased amounts of intraabdominal bleeding
   • moderate haemodynamic instability
   • tears or lacerations affecting <50%
3. • hilar injuries
   • major associated injuries
   • major haemorrhage

Question 16

Defining haemorrhagic shock

How is each class defined?

1. Class I
2. Class II
3. Class III
4. Class IV

Answer 16

1. 
Blood loss: <750ml (<15%)
HR: <100 
BP: normal 
RR: 14-20
Urine output: >30mls 

2. 
Blood loss: 750-1500mls (15-30%)
HR: >100 
BP: normal 
RR: 20-30
Urine output: 20-30mls

3. 
Blood loss: 1500-2000mls (30-40%) 
HR: >120
BP: decreased
RR: 30-40
Urine output: 5-15mls 

4. 
Blood loss: >2000mls 
HR: >140
BP: decreased
RR: >35
Urine output: <5mls