Surgery Study Notes — Consolidated

Topics: Thyroid & Parathyroid Disorders | Testicular Disorders (Varicocele) | Hernia | Appendix | Shock

1. Thyroid & Parathyroid Disorders

1.1 Thyroglossal Fistula vs Branchial Fistula
Feature Thyroglossal Fistula Branchial Fistula
Site Midline Lower 1/3rd along
sternocleidomastoid
Cause Always acquired Congenital / Acquired
Note: An inflamed thyroglossal cyst can lead to a thyroglossal fistula.

1.2 Hyperthyroidism
Clinical Features
● Thin, irritable patient
● Weight loss despite good appetite
● Tachycardia
● Diarrhoea
● Tremors
● Heat intolerance
● Oligomenorrhoea (in females)

Causes and Thyroid Scan Uptake

Cause Uptake on Thyroid Scan
Graves' disease (m/c) Diffuse ↑
Solitary toxic nodule ↑ Single hot nodule
Toxic nodular goitre / Plummer's disease ↑ Multiple hot nodules
Factitious hyperthyroidism (↑ exogenous intake) ↓
Jod Basedow phenomenon (I2 induced hyperthyroidism) ↑
TSH secreting pituitary adenoma (↑TSH) ↑
Struma ovarii (ectopic thyroid tissue in ovary) ↓

Management — Drugs Only

1. PTU (Propylthiouracil)
 ● Mechanism: Inhibits Thyroid peroxidase enzyme; blocks peripheral T4 → T3 conversion
● S/E: Agranulocytosis (1st sign — sore throat)
● Safe in 1st trimester of pregnancy
2. Carbimazole
● Mechanism: Inhibits Thyroid peroxidase enzyme
● S/E: Agranulocytosis

1.3 Plummer's Disease vs Solitary Toxic Nodule

Feature Plummer's Disease / Toxic Nodular Solitary Toxic Nodule
Goitre
Age — 5th decade
Incidence Female : Male = 5:1; 2nd m/c cause Female > Male
of hyperthyroidism
Ix (Thyroid scan) Multiple hot & cold nodules Single hot nodule
Mx Drugs → Total thyroidectomy Drugs → RAI (Radioactive
iodine)

1.4 Hypothyroidism
Causes
● Iodine deficiency — m/c overall
● Hashimoto thyroiditis — m/c in the West
● Wolff-Chaikoff effect — iodine induced hypothyroidism
● Non-functioning pituitary adenoma — ↓TSH (exception)
● Sheehan syndrome — postpartum pituitary apoplexy
● Dyshormonogenesis — TPO enzyme deficiency
● Euthyroid sick syndrome — chronic non-thyroidal illness
● Refetoff syndrome — elderly patients with end-organ resistance to T4

Clinical Features
● Dull, lethargic
● Alopecia
● Bradycardia
● Constipation
● Weight gain
● Cold intolerance
● Menorrhagia
1.5 Hashimoto's Thyroiditis (Lymphocytic Thyroiditis)
Incidence
● Autoimmune condition; Female > Male
● Strong hereditary component
● Associated with: HLA DR3/B8; Down's & Turner's syndromes

Etiology — Autoantibodies against:

● Thyroid receptors (blocking receptors)
● TPO enzyme
● Thyroglobulin

Clinical Course (sequence)

● 1. Autoantibodies (+)
● 2. Lymphocytes infiltrate the gland
● 3. Destroy follicles
● 4. Stored hormones released
● 5. Hashitoxicosis (transient ↑T3, T4)
● 6. Continuous follicle destruction
● 7. Prolonged hypothyroidism

Other Features
● Diffuse goitre
● Long-standing cases may progress to: Lymphoma (m/c cancer), FTC, PTC

Investigations
● Autoantibody levels
● FNAC: Lymphocyte infiltration, Hurthle cells (HPE)

Management
● Low dose thyroxine, gradually titrated till TSH normalizes
● If goitre present → Total thyroidectomy

1.6 Subacute Thyroiditis (De Quervain's / Viral / Granulomatous)

● Associated with HLA B35

Clinical Course
● Sentinel event: URTI (viral), after 4–6 weeks
● Lymphocytic infiltration of gland
● Follicles destroyed
● Spike of hyperthyroidism
● Hypothyroidism (self-limiting)
● Euthyroid — single attack, follicles regenerate in 2–3 months
 ● Painful neck enlargement
● ↑ESR

Management
● Symptomatic treatment; Steroids

1.7 Postpartum Thyroiditis

● Etiology: Autoimmune thyroiditis (2nd m/c cause)
● Seen 2–12 months postpartum (in 10%)

Clinical Features
● Same as Hashimoto thyroiditis
● Anti-TPO antibodies positive
● 10-fold risk of developing Hashimoto's later
● Mx: Correction of hypothyroidism

1.8 Riedel's / Fibrosing Thyroiditis

Associations
● IgG4-related disease
● Peyronie's disease
● Dupuytren's contracture

Clinical Features (Fibrosis)

● Within the gland → Painless enlargement → Woody hard consistency
● In vicinity of gland → Pressure symptoms:
○ RLN involvement → Hoarseness
○ Trachea involvement → Stridor

D/D and Management

● D/D: Anaplastic cancer
● Ix: USG-guided core biopsy
● Mx: Steroids, Tamoxifen

1.9 Summary — Thyroiditis Comparison

Feature Hashimoto's Thyroiditis Subacute / De Quervain's Riedel's
Thyroiditis Thyroiditis
H/O — URTI —
Neck swelling Painless Painful Painless, hard
Feature Hashimoto's Thyroiditis Subacute / De Quervain's Riedel's
Thyroiditis Thyroiditis
gland
Clinical course Hyperthyroidism → Hyperthyroidism → —
prolonged hypothyroidism → spontaneous
hypothyroidism recovery

1.10 Goitre
1. Diffuse Goitre — Etiology
● Iodine deficiency
● Pregnancy / Puberty (increased demand states)
● Hashimoto's thyroiditis
● Graves' disease
● Untreated diffuse goitre → Multinodular goitre (due to variable TSH stimulation)

2. Multinodular Goitre (MNG)

● Etiology: Long-standing iodine deficiency
Multinodular Goitre Isolated Nodule Dominant Nodule
Findings Multiple nodules Single palpable nodule + Single palpable nodule
rest of gland not palpable + rest of gland palpable

Risk of Malignancy in Thyroid Swellings

● Solid swellings carry twice the risk compared to cystic ones
● Males have 4 times greater risk than females

3. Retrosternal Goitre (thyroid swelling behind the sternum)

1° Mediastinal 2° Retrosternal / Plunging
Goitre (m/c)
Incidence 10% 90%
Site Ectopic thyroid tissue in Starts in the neck and plunges
mediastinum into mediastinum
Blood supply Mediastinal vessels Neck vessels

Clinical Features
● Goitre with lower limit not palpable
● Pressure symptoms: Dyspnoea / stridor
● Pemberton sign: raising the hand → swelling presses on thoracic inlet → blocks venous drainage → facial
congestion
Investigations
● CECT neck and thorax — investigation of choice
● Chest X-ray

Management
● Neck/cervical incision and removal of goitre — m/c approach
● Median sternotomy indicated in: recurrent mediastinal goitre, 1° mediastinal goitre, goitre larger than
thoracic inlet, malignant retrosternal goitre

1.11 Hypoparathyroidism
● Cause: Vascular insult to parathyroid glands — inferior thyroid artery injury (m/c)

Clinical Features
● Symptoms start 48–72 hours after surgery
● Earliest symptom: Perioral numbness → tingling/paresthesia → Tetany → Respiratory distress (cause of
death)

Signs
● Chvostek sign: Twitching of facial muscles on tapping over facial nerve
● Trousseau sign (carpopedal spasm / obstetrician's hand): spasm of hand when BP cuff inflated above
systolic BP — due to neuromuscular hyperexcitability; seen in hypocalcemia and hypoparathyroidism

Management
● Monitor symptoms, serum calcium (ionized > total), and serum PTH (half-life: 7 minutes)
Major symptoms OR S.Ca2+ < 8 mg/dl Minor symptoms & S.Ca2+ > 8 mg/dl
IV Calcium gluconate + Oral Ca2+ + Oral Vit D3 Oral Ca2+ + Oral Vit D3

Permanent Hypoparathyroidism
● Due to removal of parathyroid glands
● Occurs in 1% of cases
● Symptoms last > 1 year
● Reviewed after a few days/weeks

Other post-thyroidectomy complications

● Keloid
● Recurrence
2. Testicular Disorders — Varicocele
Definition
● Dilated, tortuous pampiniform plexus of veins
● One of the m/c causes of male infertility
● Countercurrent mechanism is lost in varicocele → ↑ scrotal temperature → ↓ spermatogenesis

Pathophysiology — Why Left-Sided is more common than Right

● 1. Longer left testicular vein
● 2. Left testicular vein opens at 90° to left renal vein
● 3. Loaded sigmoid colon can press on left testicular vein
● 4. Left adrenal vein opens opposite the left testicular vein (vasoconstriction due to
↑adrenaline/noradrenaline)
● 5. Left renal vein may get blocked due to spread of Renal Cell Carcinoma (2° / secondary varicocele)

Clinical Features
Symptoms
● Asymptomatic
● Infertility
● Dull, dragging pain

Signs
● Swelling
● "Bag of worms" texture
● Getting above the swelling: positive

Investigation
● Doppler ultrasound — investigation of choice

Grading
Grade Feature
I Impalpable, detected only on Doppler
II Palpable; detected on Doppler
III Visible

Treatment
● Treat only if symptomatic
● Sperm counts improve in only 30–40% of cases
● 1st line: Percutaneous embolization of gonadal veins
● Most effective method: Microsurgical varicocelectomy
● Recurrence (due to dual blood supply): treated with surgical ligation
3. Hernia
3.1 Definition and Types
● Definition: Protrusion of a viscus or part of a viscus through the wall containing it
Components: Sac, Content, Defect, Blood supply

Uncomplicated Hernia
● Reducible
● Cough impulse: positive

Reducibility vs Compressibility
Reducibility Compressibility
On pushing/reducing the swelling down, No counterforce required to reproduce the
counterforce is required to reproduce the swelling
swelling
Seen in hernias Seen in vascular swellings / cystic hygromas

Complicated Hernia
● Obstructed hernia (previously AKA incarcerated hernia):
○ Irreducible
○ Cough impulse: negative
○ Blood supply intact
● Strangulated hernia = Obstructed hernia + Compromised blood supply
○ Overlying skin: inflamed
○ Cough impulse: negative
○ Irreducible
Rule: All obstructed hernias should be treated as strangulated unless proven otherwise.

3.2 Basics of Hernia Surgery

Taxis
● Process of manual reduction of hernia
● Contraindicated in obstructed and strangulated hernia — can lead to reduction en masse
● Reduction en masse: reduction of contents + the ring, causing obstruction (Zollinger classification VII /
combined type)

Omentocele vs Enterocele
Feature Omentocele Enterocele
Content Omentum Bowel
Feature Omentocele Enterocele
Peristalsis Absent (−) Present (+)
Consistency Doughy —
Reducibility Easy to reduce Difficult to reduce 1st part, but
1st part easy to reduce after
Percussion Dull note Tympanic note
Bowel sounds Absent (−) Present (+)

Named Hernias by Content

Content Named Hernia
Bowel Enterocele
Appendix Amyand's hernia
Meckel's diverticulum Littre's hernia

Types of Hernia Surgery

Herniotomy Herniorrhaphy Hernioplasty
Identify sac (glistening white); Suture two edges of the defect Mesh placed to cover the
open sac; push contents down; together defect
cut excess sac and close sac;
defect left intact

Herniorrhaphy
● Disadvantage: Highest recurrence rate
● Indications — surgery of choice in:
○ Congenital inguinal hernia
○ Congenital hydrocele
○ Inguinal hernia in children
● Rationale: high muscle tone spontaneously blocks the defect → no recurrence

Hernioplasty
● Surgery of choice; least recurrence rate
● Contraindicated in infected hernias

Types of Mesh
● Synthetic mesh: Contraindicated in infection/strangulation. Examples: Prolene; Vipro (Vicryl + Prolene);
PTFE (Polytetrafluoroethylene) — can be placed in intraperitoneal space (no adherence)
● Biological mesh: Can be used when infection is present. Examples: Acellular human dermis (AlloDerm);
Acellular porcine dermis
● Fenestrated mesh: fibrous ingrowth occurs through holes, anchoring mesh in place; larger pores preferred
for strong fibrous pillars
 ● Solid biological mesh (e.g. AlloDerm): sutures anchor the mesh in place

Mesh Materials
● Prolene: Hydrophobic → less bacterial contamination
● Polyester: Hydrophilic → faster cellular ingrowth
● PTFE: Does not adhere to bowel inside peritoneal cavity

Mesh Overlap and Weight

● Ideal overlap: cover 5 cm beyond the defect in all directions (to prevent recurrence when mesh shrinks)
● Low weight mesh (<40 g/m²): less shrinkage
● High weight mesh (>80 g/m²): more shrinkage
● Ideal hernia mesh: low weight, thin fibers, large pores
● Plug mesh complication: meshoma due to excessive collagen deposition → can lead to pain due to nerve
entrapment

3.3 Inguinal Hernias

● m/c hernia overall
● m/c type in both males and females: Indirect inguinal hernia

Anatomy
● Internal inguinal ring: modification of fascia transversalis
● External inguinal ring: modification of external oblique aponeurosis

Hesselbach's Triangle
● Boundaries: Inferior epigastric vessels (lateral), Rectus abdominis / outer border of rectus (medial),
Inguinal ligament (inferior)
● Direct hernia: passes through Hesselbach's triangle
● Indirect hernia: passes lateral to Hesselbach's triangle, through the deep inguinal ring

Myopectineal Orifice of Fruchaud

● Superior boundary: Arching fibers of internal oblique
● Medial boundary: Outer border of rectus
● Lateral boundary: Tendon of iliopsoas
● Inferior boundary: Pectineal / Cooper's ligament
● Significance: covers the defects of inguinal hernia, femoral hernia, and obturator hernia

3.4 Clinical Examination of Inguinal Hernia

Position
● Examine standing and lying down
● Helps differentiate:
○ Inguinal hernia: above and medial to pubic tubercle
 ○ Femoral hernia: below and lateral to pubic tubercle
● Steps: appreciate cough impulse; assess abdominal muscle tone; complete vs incomplete hernia

Types by Descent
Bubonocele Funicular Inguinoscrotal / Complete
Sac does not cross superficial Sac crosses superficial ring Sac crosses superficial ring and
ring reaches the scrotum, alongside
the testis

Clinical Tests
● Deep ring occlusion test: Single best test
● Ring invagination test: little finger placed in the superficial ring through the scrotum — tip of finger
suggests indirect hernia, pulp of finger suggests direct hernia (low sensitivity)
● Zieman's 3-finger test: 1 finger each at superficial ring, deep ring, and femoral ring; respective finger lifted
when patient coughs (low sensitivity)

Investigations
● Indications for USG: doubtful diagnosis, non-palpable hernia

3.5 Management of Inguinal Hernia

Open Surgery
● 1. Herniotomy
● 2. Herniorrhaphy
○ a. Bassini repair: Reflected portion of inguinal ligament sutured with conjoint tendon
○ b. Shouldice repair (4-layer repair):
■ 1st layer: Double breasting of fascia transversalis
■ 2nd layer: Double breasting of inguinal ligament with conjoint tendon (corresponds to
Bassini repair)
■ 3rd layer: Double breasting of external oblique aponeurosis
● 3. Lichtenstein's tension-free mesh hernioplasty

Laparoscopic Inguinal Hernia Surgery (m/c method done)

● Indications: can be done for all hernias; bilateral inguinal hernia; recurrent inguinal hernia
Feature TEP (Total Extra-Peritoneal TAPP (Trans-Abdominal Pre-
Repair) Peritoneal Repair)
Peritoneum Remains intact Peritoneum breached
Space Extraperitoneal space created Pre-peritoneal space created
Advantage Technically better Less technically demanding
Disadvantage More demanding, requires —
high precision
Stoppa's Repair
● Open pre-peritoneal repair
● Mesh held in place due to Pascal's law
● Used in recurrent inguinal hernia

Complications of Open Inguinal Surgery

● Hemorrhage
● Injury to vas / cord structures
● Nerve injury — m/c: Ilioinguinal nerve
● Nerve entrapment — m/c: Iliohypogastric nerve
● Chronic inguinal pain — due to nerve entrapment beneath mesh / pubis osteitis
● Recurrence — least (<2%) with hernioplasty
● Wound infection

3.6 Triangle of Doom vs Triangle of Pain

Boundary Triangle of Doom Triangle of Pain
Medial Vas deferens Testicular vessels
Lateral Testicular vessels Peritoneal reflection
Inferior Peritoneal reflection —
Superior — Iliopubic tract

Contents
Triangle of Doom Triangle of Pain
External iliac artery; External iliac vein; Genital Lateral cutaneous nerve of thigh; Femoral
branch of genitofemoral nerve nerve; Femoral branch of genitofemoral nerve

Complications
● Triangle of Doom: bleeding if stapler/tacker applied
● Triangle of Pain: Meralgia paresthetica — shooting pain along lateral aspect of thigh due to entrapment of
lateral cutaneous nerve of thigh (m/c)
● No cautery used in triangle of pain (electrical hazard zone) — to prevent thermal injury to nerves
● Trapezoid of disaster = Triangle of doom (medial) + Triangle of pain (lateral)

Corona Mortis / Circle of Death

● Inferior epigastric artery (branch of external iliac) connected by an aberrant obturator artery to the
obturator artery (branch of internal iliac)
● The aberrant obturator artery lies behind the pubic tubercle
● Injury to this artery → torrential bleeding
3.7 Richter's Hernia
● Defect: very narrow
● Seen in: Paraumbilical hernia, Femoral hernia, Obturator hernia
● Pathophysiology: only a portion of the bowel wall (part of circumference) protrudes and gets
strangulated, while bowel lumen continuity is often preserved — proximal part contracts vigorously
causing rapid transit
● Signs: gastroenteritis-like features, which can progress to strangulation/peritonitis
4. Appendix
4.1 Anatomy
Position of Appendix
● Retrocecal position: most common
● Other positions: pelvic, subcecal, pre-ileal, post-ileal, paracecal
● Junction of a superior taenia coli (of the caecum) marks the base of the appendix
● McBurney's point: junction of lateral 1/3rd and medial 2/3rd of a line joining the umbilicus to the anterior
superior iliac spine (ASIS)

Development
● Arises from the caudal limb of the midgut loop → rotation → tubular structure → position fixed after
rotation

Blood Supply
● Appendicular artery: branch of ileocolic artery (a branch of superior mesenteric artery)
● End artery — deficient collateral supply to tip of appendix
● Site of perforation: antimesenteric border

4.2 Acute Appendicitis

Incidence
● m/c cause of acute abdomen in young patients

Causes of Luminal Obstruction

● Fecolith (m/c)
● Lymphoid hyperplasia
● Carcinoid tumour
● Round worm infestation

Symptoms
● 1. Periumbilical pain (visceral pain) → 2. Migrates to right iliac fossa (parietal pain, after 4–6 hours)
● 3. Nausea & vomiting
● 4. Fever

Signs
● Tenderness at McBurney's point
● Blumberg sign: rebound tenderness
● Rovsing sign: pain in right iliac fossa on palpating left iliac fossa
● Psoas sign: pain on hip extension → retrocecal appendix
● Obturator sign: pain on internal rotation of flexed hip → pelvic appendix
Non-Specific Signs
● Dunphy sign: pain on coughing
● Aaron sign: pain in epigastrium on pressing over McBurney's point
● Ten Horn sign: pain on gentle traction of right spermatic cord
● Baldwin's sign: pain on raising extended leg while lying on left lateral position, suggesting retrocecal
appendicitis
● Cope's Psoas test / obturator test: pain suggestive of pelvic appendicitis

Investigations
● Total leucocyte count (TLC): raised
● Neutrophilia: present (>75%)
● CRP: raised
● Imaging: USG (initial), CECT abdomen (Ix of choice in adults), Pregnant women: USG preferred, Children:
USG preferred

Alvarado Score (MANTRELS Score)

Component Points
Migration of pain to right iliac fossa 1
Anorexia 1
Nausea/vomiting 1
Tenderness in right iliac fossa 2
Rebound tenderness 1
Elevated temperature (fever) 1
Leucocytosis 2
Shift of WBC count to left (left shift/neutrophilia) 1
● Total score = 10. Score ≤4: unlikely appendicitis. Score 5–6: possible. Score ≥7: probable appendicitis
(surgery indicated)

Differential Diagnosis
● Right-sided: Ureteric colic, Meckel's diverticulitis, Mesenteric lymphadenitis
● Females: Ectopic pregnancy, Ovarian cyst torsion/rupture, Pelvic inflammatory disease

4.3 Management
Conservative
● IV fluids
● IV antibiotics
● NPO (nil per oral)

Definitive
● Appendicectomy — Open or Laparoscopic
Steps of Open Appendicectomy
● 1. Locate the appendix. Landmark: junction of taenia coli
● 2. Ligate the appendicular artery, ligate the base of appendix
● 3. Cut the appendix

Incisions Used
● Grid iron incision (m/c)
● Lanz incision
● Rutherford Morrison incision
● Layers encountered (open): skin, subcutaneous tissue, external oblique, internal oblique, transversus
abdominis, peritoneum

Complications Following Appendicectomy

● Bleeding from appendicular artery
● Faecal fistula
● Right iliac fossa abscess
● Wound infection

4.4 Appendicular Lump

● Occurs when omentum & bowel loops wall off an inflamed appendix, forming a mass

Management Algorithm
● Ochsner-Sherren regimen (conservative management) → if resolves, interval appendicectomy after 6
weeks
● If it progresses to abscess: USG-guided drainage; if diffuse peritonitis: emergency laparotomy

4.5 Appendicitis in Pregnancy

● Site of maximum tenderness shifts upward and laterally with increasing gestation, due to displacement of
the appendix by the gravid uterus
● Ix: USG preferred (avoid radiation); MRI if inconclusive
● Laparoscopic appendicectomy: safe in all trimesters
● Risk of fetal loss higher with perforated appendix vs unperforated

4.6 Appendicular / Carcinoid Tumour of Appendix

● m/c neuroendocrine tumour / carcinoid tumour of the GI tract

Clinical Features
● Usually incidental finding after appendicectomy
● Rarely symptomatic — mimics appendicitis
● Carcinoid syndrome: flushing, diarrhoea, wheeze — rare, occurs with liver metastases

Management
● Tumour <1 cm, at the tip, no invasion: Appendicectomy is sufficient
● Tumour >2 cm or base involvement or mesoappendix invasion: Right hemicolectomy
5. Shock
5.1 Hypovolemic / Hemorrhagic Shock
● Most common type of shock

Types
Overt / Visible Hemorrhage Concealed Hemorrhage
Easy to diagnose and treat Difficult to diagnose. Sites: Neck, Thorax,
Abdomen/Pelvis, Long bones
● Isolated head injury does NOT cause hypovolemic shock
● Hypotension in a head injury patient — suspect: Brain herniation, Neurogenic shock (injury above T6
level), or Polytrauma

Arterial vs Venous Bleed

Feature Arterial Venous
Bleed Spurter Gradual ooze of blood
Hypotension Occurs early Occurs late (due to
compensation)
Presentation Early Late
● Laceration of artery → vasoconstriction leads to increase in tear size → bleeds more
● Transection of artery → bleeds less

5.2 Classification of Hypovolemic Shock

Parameter Class I Class II (Mild) Class III Class IV (Severe)
(Moderate)
Blood loss (mL) <750 750–1500 1500–2000 >2000
Heart rate Normal Normal/↑ ↑↑ ↑↑ (non-
recordable)
Blood pressure Normal Normal ↓ Non-recordable
Pulse pressure Normal ↓ ↓↓ ↓↓
Respiratory rate Normal Normal ↑ ↑↑
Urine output Normal Normal ↓↓ Anuric
Mental status Normal Anxious, thirsty Confused Coma
Fluid Oral fluids IV crystalloids IV crystalloids + Massive blood
replacement colloid transfusion
Pathophysiology of Class II Shock (compensated)
● Blood loss → activation of sympathetic system → noradrenaline, adrenaline release
● Result: Tachycardia (earliest sign), peripheral vasoconstriction (shunts blood to vital organs, causes cold
extremities), ↑ peripheral vascular resistance

Class III Shock (Decompensated)

● SBP starts falling, confused patient

Reactionary vs Secondary Hemorrhage

Reactionary Hemorrhage Secondary Hemorrhage
Occurs Within 24 hours After 7–14 days
Reason Dislodgement of clot / slippage Sloughing of vessel wall due to
of knot (granny's knot) infection

5.3 Response to Hypovolemic Shock / Dynamic Fluid Response

● 500 mL to 1 L crystalloid given → response checked
Parameter Responder Transient Responder Non-Responder
HR, SBP, JVP change Persistent Improve then worsen No/worsening change
improvement after 10–20 min
Implication Ongoing bleeding Ongoing losses Active, ongoing
controlled bleeding

Management Principles
● Recognize active bleeding, hypotension, transient/non-responder status
● Damage control resuscitation: prioritize coagulation during active bleeding phase; prioritize perfusion
once hemostasis achieved
● Goal (bleeding phase): coagulation function, coronary perfusion, permissive hypotension (keep BP at
lower limit of normal), balanced transfusion (1:1 RBC and FFP), treat coagulopathy (tranexamic acid,
platelets, fibrinogen)
● Goal (perfusion phase): end-organ perfusion, adequate preload and afterload (fluids and pressors),
thromboprophylaxis
● Monitoring: cardiovascular (BP, HR, CO, SVR); electrolytes (Ca2+, K+); coagulation (PT, fibrinogen,
ROTEM/TEG); perfusion (pH, base excess, lactate, temperature); organ function (PaO2/FiO2, UO, GCS);
intra-abdominal pressure

5.4 Monitoring of Shock

Occult Hypoperfusion
● Normal CVS parameters (HR, SBP normal), normal urine output, but low SvO2 (mixed venous oxygen
saturation) and acidosis
Indicators — Initial Fluid Requirement
● Best indicator: PCWP (Pulmonary Capillary Wedge Pressure) — left-sided heart pressure, more accurate,
needs Swan-Ganz catheter, difficult to monitor
● CVP (Central Venous Pressure) — right-sided heart pressure, m/c used

Fluid Resuscitation
● Best indicator: Urine output
● Adults: ≥0.5 mL/kg/hour
● Children: >1 mL/kg/hour

Shock Index
● Shock Index = Heart rate / Systolic BP; >0.9 indicates higher mortality rate
● Modified Shock Index = HR / MAP (Mean Arterial Pressure) — most sensitive
● Rate over Pressure Evaluation (ROPE): HR/PP (pulse pressure); <15 = stable, >15 may indicate
decompensating shock

Monitors for Organ/Systemic Perfusion

Site Investigation
Systemic perfusion Base deficit, lactate, mixed venous oxygen
saturation (SvO2), best end-point of
resuscitation
Muscle Near-infrared spectroscopy, tissue oxygen
electrode
Gut Stomach mucosa most sensitive to hypovolemic
insult (forms stress ulcers); gastric tonometry,
gut mucosal pH
Kidney Urine output
Brain Consciousness level

5.5 Blood Transfusion

Massive Blood Transfusion
● Defined as any one of the following: replacing entire circulating blood volume in 24 hours; >10 units of
blood in 24 hours; >4 units in one hour

Complications of Massive Transfusion

● Hypothermia
● Hypocalcemia / hypomagnesemia — Reason: citrate (anticoagulant) chelates Ca2+ and Mg2+
● Metabolic alkalosis — Reason: citrate toxicity
● Hyperkalemia >> hypokalemia — Reason: stored blood → RBCs lysed → K+ released → ↑serum K+
● Coagulopathy (m/c cause of death) — reasons: dilutional coagulopathy, acidosis, hypothermia.
Prevention: limit crystalloids; use PRBC:Platelet:FFP in 1:1:1 ratio
 ● Hemolytic reaction — reason: mismatched transfusion
● Febrile reactions (m/c) — prevented by use of a leukoreduction filter
● Transfusion related acute lung injury (TRALI)
● Transfusion associated cardiac overload (TACO)

TACO vs TRALI
Feature TACO TRALI
Mechanism Due to cardiac overload Antibody against HLA antigen;
non-cardiogenic pulmonary
edema (within 6 hours)
Implicated donors — Multiparous women, patients
receiving FFP
Clinical features Facial puffiness, pedal edema, Breathlessness, CXR: ARDS
breathlessness, X-ray: pattern (patchy infiltrates)
pulmonary edema
Management Lasix/diuretics Supportive management for
ARDS

Perioperative RBC Transfusion Criteria

Hemoglobin level (g/dL) Indication
<6 Probably will benefit from transfusion
6–8 Benefit only if ongoing losses / impending
surgery
>8 Not indicated if risk factors absent

Blood Substitutes
● 1st generation: Perfluorocarbon
● 2nd generation: Stroma-free hemoglobin
● Next generation: Polyethylene glycol (PEG) hemoglobin; Hemospan (PEG-hemoglobin); Pyridoxylated
hemoglobin polyoxyethylene conjugate (PHP)
● Anti-shock garment: used for hypovolemic shock in peripheral locations, e.g. women with PPH
(postpartum hemorrhage) in rural areas

5.6 Other Types of Shock

Cardiogenic Shock
● Examples: Myocardial infarction, Cardiac tamponade, Arrhythmias
● Pathophysiology: Heart does not function properly → ↓CO → O2 not pumped → preload accumulates →
↓SvO2, ↑JVP, ↓SBP, ↑PVR (peripheral vascular resistance), cold extremities
Neurogenic Shock
● Example: Spinal cord injury above T6 level
● Pathophysiology: Loss of sympathetic drive → vasodilation + bradycardia → ↓PVR, ↓HR → warm
extremities

Obstructive Shock
● Type of cardiogenic shock; preload compromised due to improper filling of the heart
● Examples: Cardiac tamponade, Massive pulmonary embolism

Distributive Shock
● Redistribution of blood to the periphery
● Examples: Neurogenic shock, Anaphylactic shock, Warm septic shock (all show warm extremities)

Endocrine Shock
● Combination of cardiogenic and distributive shock
● Examples: Hypo/hyperthyroidism, Adrenal insufficiency

Anaphylactic Shock
● Example: mismatched blood transfusion
● Pathophysiology: Histamine release → vasodilation → pooling of blood → ↓PVR (potent vasodilator);
despite normal sympathetic system: ↓CO, ↑HR, ↓SBP
● Peripheral pooling of blood → ↓JVP, ↓CO, ↓SBP, with bradycardia and hypotension

Septic Shock
● a. Warm septic shock: hyperdynamic circulation → ↑CO, ↑HR, ↑SBP; raised SvO2 due to inability of
tissues to utilize O2
● b. Cold septic shock: late phase of sepsis; toxins inhibit myocardium → resembles cardiogenic shock

Comparison Table — Types of Shock

Parameter Hypovolemi Cardiogeni Neurogeni Anaphylac Septic Septic
c c c tic (Warm) (Cold)
PR ↑ ↑↓ ↓ ↑↑ ↑ ↑↓
CO ↓ ↓ ↓ ↓ ↑ ↓
SBP ↓ ↓ ↓ ↓ ↑ ↓
PVR ↑↑ ↑ ↓ ↓ ↓ ↑
JVP ↓ ↑ ↓ ↓ Normal ↑
SvO2 ↓ ↓ — — ↑↑ ↓
Skin/Extremities Cold Cold Warm Warm Warm Cold
5.7 Sepsis — Terminologies and Updates (Sepsis 3.0)
Old vs New Definitions
● Old definition: SIRS + evidence of infection
● New definition (Sepsis 3.0): qSOFA score ≥2 → suspect sepsis

SIRS (Systemic Inflammatory Response Syndrome)

● Body's response to inflammation; etiology can be infective or non-infective
● Mediators: IL-1, IL-6, TNF-alpha

SIRS Parameters (≥2 needed)

● Temperature >38°C or <36°C
● Heart rate >90 bpm
● Respiratory rate >20/min or PaCO2 <32 torr
● WBC >12000/mm³ or <4000/mm³, or >10% band forms in peripheral smear

Scores
● SOFA score (Sequential Organ Failure Assessment): rise ≥2 → suggests sepsis
● qSOFA (quick SOFA) — Parameters: GCS <15, RR >22/min (tachypnea), SBP <100 mmHg
● qSOFA ≥2: poor outcome / suggests sepsis

Current Definitions
● Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection
● Septic Shock: Sepsis with fluid-unresponsive hypotension; need for vasopressors/inotropes; Lactate >2
mmol/L
● MODS (Multi-Organ Dysfunction Syndrome): Failure of 2 or more organ systems

Key Updates
● The term "severe sepsis" is now out of use
● SIRS is out; qSOFA/SOFA are now in use

5.8 Sepsis Six — Six Things To Be Done in 60 Minutes

● Give 3: IV antibiotics; IV fluids; Oxygen
● Take 3: Cultures; Urine output; Serum lactate
Mnemonic: FABULOS — Fluid, Antibiotics, Blood cultures, Urine output, Lactate, Oxygen, In Sixty minutes.

Surviving Sepsis Guidelines / Sepsis Bundle

● Within 3 hours:
○ 1. Measure lactate
○ 2. Blood culture prior to antibiotics
○ 3. Broad spectrum antibiotics
○ 4. 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
● Within 6 hours:
 ○ 5. Vasopressors for refractory hypotension — target Mean Arterial Pressure (MAP) ≥65 mmHg
○ 6. If persistent arterial hypotension / lactate ≥4 mmol/L: measure Central Venous Pressure (CVP)
and Central Venous O2 saturation (ScvO2)
○ 7. Remeasure lactate if initially elevated
● Targets: CVP ≥8 mmHg, ScvO2 ≥70%