6 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Character Hypertrophic scar Keloid

Race Black
Genetic Yes
Sex Male = Female Female > Male
Age Children
Border
Site Flexor Triangle—sternum, right and left
shoulder
Cause Tension Unknown
Natural Subsides with time Rarely subsides

Salmon patch Port-wine stain Strawberry angioma

disappears at 7 yr

FLUIDS AND ELECTROLYTES

Hyperkalemia & Hypokalemia
Characteristics Hyperkalemia Hypokalemia

2. Etiology Hypoaldosteronism Drugs (Insulin, alpha blocker & beta2

Trimethoprime agonist).
Pentamidine Metabolic alkolosis.
Hyperaldosteronism
Cushing syndrome.
Diabetic ketoacidosis
Bartter syndrome.
Congenital adrenal hyperplasia.
Hypoventilation
3. Clinical presentation

weakness.
or asystole.
4. Electrocardiogram (ECG) Tall peaked T wave* Prominent U wave*
Sine wave pattern Flattening/inversion of ‘T’ wave.
Increased PR and increased QRS duration ST depression
Prolonged ‘QT’ interval
5. Treatment

3
(severe)
 Basics in General Surgery 7

HYPERCALCEMIA AND HYPOCALCEMIA

Characteristics Hypercalcemia Hypocalcemia
Eq/L. Eq/L
2. Etiology Milk alkali syndrome Tumor lysis syndrome.
Sarcoidosis Hypoparathyroidism.
Multiple myeloma Chronic renal failure.
Ca-breast, kidney, bronchus Heparin, protamine, glucagon.
Lithium excess Acute pancreatitis.
Hyperthyroidism Hypoalbuminemia.
Hyperparathyroidism
3. Clinical presentation

cases)

4. Treatment Diuresis
Calcitonin and biphosphonates. Thiazide
Glucocorticoids
Dialysis

HYPERNATREMIA AND HYPONATREMIA

Characteristics Hypernatremia Hyponatremia

2. Etiology Diarrhea Chronic renal failure (CRF)

Nephrotic syndrome and cirrhosis.
SIADH
Central diabetes insipidus (DI) Diuretic
3. Clinical presentation

4. Treatment

FLUID THERAPY: TWO TYPES OF FLUIDS CRYSTALLOIDS AND COLLOIDS

Crystalloids Colloids
1. May be isotonic/hypertonic 1. Hypertonic solution.
2. Expands plasma volume for less time
3. Cheap 3. Expensive.
4. Can precipitate cerebral edema. 4. Decreased cerebral and pulmonary edema.
5. For blood loss replacement 3 times of the lost be given
Contd...
 8 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Contd...

FLUID THERAPY: TWO TYPES OF FLUIDS CRYSTALLOIDS AND COLLOIDS

6. Examples are 6. Examples are
Ringer lactate Dextrans
Normal saline Albumin
Glucose solution. Gelatins
Dextrose with N.S. Hydroxyethyl starch
Hypertonic saline Blood replacement.

CHOICE OF FLUID
1. Ringer lactate (Balanced salt solution) 2. Colloids
Intestinal obstruction Renal failure
1st 24 hours of burn Liver failure (albumin)

3. Normal saline 4. Hypertonic saline

Hyponatremia Cerebral and pulmonary edema
Brain injury Hyponatremia
Diabetic ketoacidosis
Hypochloremic metabolic alkalosis.

Types of wound
Clean uncontaminated Clean contaminated Infected wound (Infec- Unclean
(Infection rate < 2%) (Infection rate upto 30%) tion rate> 50%) contaminated

heart, brain, joint and trans- surgery, biliary and -

plant surgery. pancreatic surgery age with spillage of pus
appendicectomy, from gallbladder.
gastrojejunostomy

with enterotomy and

spillage of content.
Type of wound suturing
Primary suturing—done for clean Delayed primary suturing—done for lacer- Secondary suturing—done
wound within 6 hour. ated wound within 48 hour
day

Absorbable suture materials Time of absorption

1. Plain catgut
2. Chromic catgut 90 day
3. Polyglactin
4. Polyglyconate 180 day
5. Polyglycolic acid (Vicryl)
6. Polydiaxanone (PDS) 180 day (longest absorbable suture material)
7. Polyglycaprone
 Basics in General Surgery 9

FMGE QUESTIONS

1. Commonest complication of parenteral nutrition 7. All of the following conditions result in chronic
includes all, except: (Sep 2003) thick walled pyogenic abscess, except: (Sep 2008)
a. Hyperglycemia a. Inadequate surgical drainage
b. Hyperkalemia b. Virulent strain of offending organism
c. Hyperosmolar dehydration c. Prolonged course of antibiotic therapy
d. Azotemia d. Presence of foreign body
Ans: d (Azotemia) Ans: b (Virulent strain of offending organism)
2. Which of the following is preferred cannulation 8. Cock’s peculiar tumor is: (March 2006)
site for total parenteral nutrition: (Sep 2003) a. Infected sebaceous cyst
a. Subclavian vein
b. Great saphenous vein c. Cyst in the skull
c. Median cubital vein d. Tumor of the skull
d. External jugular vein Ans: b (Osteomyelitis of skull)
Ans: a (Subclavian vein)
9. Cellulitis is most commonly caused by: (Sep 2006)
3. Which is best method for supplementing nutri- a. Clostridia
tion in patients, who have undergone massive re- b. Staphylococci
section of the small intestine is: (Sep 2004) c. Streptococci
a. Parenteral d.
b. Enteral Ans: c (Streptococci)
c. Gastrostomy
10. All of the following are complications in a patient
d. All of the above
on total parenteral nutrition, except: (March 2006)
Ans: a (Parenteral)
a. Hyperchlosterolemia
4. Which of the following solution is a colloid: b. Hyperglycemia
(March 2004) c. Hypotriglyceriedemia
a. Normal saline d. Hypophosphatemia
b. Albumin Ans: c (Hypotriglyceridemia)
c. Ringer lactate The metabolic complications associated with PN in
d. Dextrose 5% adult patients include hyperglycemia, hypoglycemia,
Ans: b (Albumin) hyperlipidemia, hypercapnia, refeeding syndrome, ac-
id-base disturbances, liver complications, manganese
5. Which of the following is true regarding tubercu-
lous lymphadenitis: (Sep 2005) toxicity and metabolic bone disease.
a. History of contact with TB patient may be 11. Bed sore is an example of: (Sep 2003, 2009)
present a. Tropical ulcer
b. Commonly seen in the young and children b. Trophic ulcer
c. Mostly in the cervical region c. Venous ulcer
d. All of the above d. Post-thrombotic ulcer
Ans: d (All the above) Ans: b (Trophic ulcer)
6. Pneumoperitoneum is created by: (Sep 2008) Tropical ulcer is a lesion occurring in cutaneous leish-
maniasis. It is caused by a variety of microorganisms, in-
2
b. C cluding mycobacteria. It is common in tropical climates.
c. C 2 Ulcers occur on exposed parts of the body, primarily on
d. N2 anterolateral aspect of the lower limbs and may erode
Ans: c (CO2) muscles and tendons and sometimes, the bones.
 10 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Trophic ulcer (Neurogenic ulcer): Trophic ulcers oc- 17. Bezold abscess is seen in: (Sep 2010)
cur in diseases and injuries to the spinal cord and pe- a. Sternocleidomastoid muscle
ripheral nerves; for example, they may arise on the foot b. stylohyoid muscle
after injury to the sciatic nerve. It may also result from c. Sartorius muscle
local circulatory impairment as in bed sore. d. semimembranosus muscle
Ans: a (Sternocleidomastoid muscle)
12. Marjolin ulcer is: (Sep 2003)
Bezold’s Abscess is an abscess in the sternocleidomas-
a. Malignant ulcer found on the scar of burn.
toid muscle, where pus from a mastoiditis escapes into
b. Malignant ulcer found on infected foot
the sternocleidomastoid. It is a rare complication of
c. Trophic ulcer
acute otitis media.
d. Meleney gangrene
Ans: a (Malignant ulcer found in scar of burn) 18. Best prophylaxis by surgeon in preventing the gas
gangrene as a complication is: (Sep 2009)
13. Which of the following catheter material is most
a. Antibiotics
suited for long term use is: (Sep 2007)
b. Strict antiseptic protocol
a. Latex
c. Sterilization methods
b. Silicone
d. All the above
c. Rubber
Ans: d (All the above)
d. Polyurethane
Ans: b (Silicone) 19. The following are absorbable suture materials,
Silicone materials can be used for even upto 12 weeks except: (Sep 2010)
a. Catgut
14. Potts puffy tumor is: (Sep 2005)
b. Polyglycolic acid
c. Prolene
b. Abscess in the skull
d. Polydiaxone
c. Carcinoma of the frontal bone
Ans: c (Prolene)
d. None of the above
Ans: a (Osteomyelitis of frontal bone) 20. The ulcer which has undermined edge is due to
the cause: (Sep 2010)
15. Most common mode of spread to cervical lymph-
a. Arterial
node in TB is: (Sep 2005)
b. Venous
a. Hematogenous
c. Tuberculous ulcer
b. Lymphogenic
d. Malignancy
c. Contact
Ans: c (Tuberculous ulcer)
d. None
Ans: a (Hematogenous) 21. Dermoid cyst are commonly seen in: (Sep 2011)
a. Finger
16. Collar stud abscess seen in: (Sep 2005)
b. Skin
a. TB
c. Skull
b. Syphilis
d. Hip
c. Actinomycosis
Ans: c (Skull)
d. Staphylococcal
Ans: a (TB)
 INTRODUCTION

Features of shock

Hypovolemic shock Obstructive shock

Distributive shock

Contd...
 12 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Contd...

INTRODUCTION

Hypovolemia Obstructive Distributive

SEVERITY OF SHOCK

Mild Moderate Severe

+ ++ ++ +++

RESUSCITATION
Fluid therapy

Contd...
 Shock, Blood Transfusion and Organ Transplantation 13

RESUSCITATION
Monitoring of response Mixed venous oxygen saturation
Urine output (Best monitor) The percentage saturation of oxygen returning to heart
from body is a measure of oxygen delivery and extraction
by tissues.

HEMORRHAGE

Primary hemorrhage

5 L blood (70
mL/kg
L in children and adults and
80 mL/kg
L in neonates)

1 2 3 4
Blood volume lost as percentage of total

TRANSFUSION

BLOOD PRODUCTS
Whole blood

Contd...
 14 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Contd...
BLOOD PRODUCTS
Packed red cells

Cryoprecipitate Platelets

Autologous blood

COMPLICATIONS OF BLOOD TRANSFUSION

Management of Coagulopathy

9
 Shock, Blood Transfusion and Organ Transplantation 15

Mismatched transfusion in anesthetized patient presents as

Temperature of storage Shelf life

BETTER INDICATOR FOR TRANSFUSION

SEPTIC SHOCK
Features:
Causes of vasodilatory shock

Sepsis:

Severe sepsis:

Septic shock:
16 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

ORGAN TRANSPLANTATION
Allograft:

Xenograft:
Orthotopic graft:

Heterotopic graft

ABO blood group antigens and human leukocyte antigens (HLAs) are
the most important.
ABO blood group com-
patible hyperacute graft rejection
Rhesus (Rh) antigen compatibility*

Hyperacute Acute

Most common cause of graft failure

 Shock, Blood Transfusion and Organ Transplantation 17

HLA MATCHING

IMMUNOSUPPRESSION

Side effects

Pneumocystis carinii

in situ

Cold storage time

Optimal storage time
 18 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

FMGE QUESTIONS

1. Hemorrhage leads to: (Sep 2003, 2007)

Ans: a (Liver transplant)

8. Which of the following are colloids? (Sep 2007)

Ans: c (Hypovolemic shock)

2. Which of the following is true for shock?
(March 2006, Sep 2007)
Ans: a (Albumin)
9. What is xenograft? (Sep 2010)

Ans: d (All the above)

3. In traumatic cases, shock is most likely due to:
(March 2006, Sep 2009) Ans: b (Graft from One species to other species)
10. For shock best guidelines to check for adequacy of

Ans: a (Injury to intra-abdominal solid organ)

4. Which of the following is ideal in moderate hem-
Ans: b (Urine output)
orrhagic shock? (Sep 2003, 2009, 2010)
11. Which of the following is the best parameter to as-

(March 2011)

Ans: b (Ringer lactate)

5. Cryoprecipitate contains: (March 2006)
Ans: a (Urine output)
12. Mismatched blood transfusion manifests intraop-
eratively as: (March 2011)
Ans: c (Factor VIII)
6. Highest chance of success in renal transplant is
possible when the donor is: (March 2007, 2009)
Ans: b (Excessive bleeding from surgical site)
13. Massive transfusion in healthy adult male can
cause hemorrhage due to: (March 2011)
Ans: c (Twin)
7. HLA matching is not necessary for: (Sep 2007)

Ans: b (Dilutional thrombocytopenia)

 Shock, Blood Transfusion and Organ Transplantation 19

Coagulopathy
Hypothermia
Alkalosis
Dilutional throm-
bo cytopenia*

14. Which of the following is triad of complication of

massive blood transfusion? (March 2011)

Ans: a (Alkalosis, hypothermia, coagulopathy)

16. Which of the following is the best parameter to as-
15. Which of the following should be avoided initial-
ly in hemorrhagic shock? (March 2011) U

Ans: a (Urine output)

Ans: b (Dextrose)
17. Features of hypovolemic shock are all, except:

Ans: b (Bradycardia)
 INTRODUCTION

Mechanisms of injury
Overt mechanism Covert mechanism

ADVANCED TRAUMA LIFE SUPPORT (ALTS)

Steps in ALTS Triage
1. Primary survey— “to sort”

2. Secondary survey— Red—

Yellow
Green
Black
Priority Color Example
I
II
III

Blunt trauma Seat belt injuries

chance fracture
 Trauma 21

Primary survey A-Airway

GCS < or equal to 8
cervical spine stability.
B-Breathing and ventilation

C-Circulation
Oxygen
Ventilation
- -

D-Disability

E-Exposure

Radiographs in trauma

Secondary survey

AMPLE
A- P- L
M E

HEAD INJURY
Physiology in brain Types of brain injury The principal causes of secondary brain injury
3.5 Primary
mL/100 gm/mt
- Secondary

55
mL/100 gm/mt
Glasgow coma scale (EVM-456)
Eye opening Verbal Motor

Other things that must be recorded Signs of base of skull fracture

(Hutchinson pupil)
 22 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

NICE GUIDELINES FOR CT SCAN IN HEAD INJURY

National institute for health and clinical excellence Urgent CT scan if none of the above but
(NICE)

PRIMARY TREATMENT FOR HEAD INJURY

The principle aim is to prevent secondary brain injury and best
achieved by avoidance of hypoxia and hypotension.
Increase ICP can be suggested by pupillary
dilatation.

TYPES OF HEAD INJURY

EXTRADURAL HEMATOMA

middle meningeal artery

Other common sites

Classical presentation of EDH (in less than 1/3rd cases only) Treatment
lucid interval -
-

CT scan lentiform (lens shaped or biconvex)

ACUTE SUBDURAL HEMATOMA

Differs from EDH in following points

Presents with impaired consciousness from the impact time itself

concavo convex
appearance.
Treatment
 Trauma 23

CHRONIC SUBDURAL HEMATOMA

tear of bridging veins

Clinical features

CT scan appearance is variable:

Treatment
Burr hole evacuation

SUBARACHNOID HEMORRHAGE
- But trauma is the commonest cause of SAH overall
Conservative treatment for trauma cases.

CEREBRAL CONTUSIONS
Mechanisms
Coup—
Contrecoup—
CT scan: heterogenous with mixed areas of high and
low density:

Surgical management of increased ICT Medical management

Control of Intracranial pressure GOS—stands for Glasgow outcome score

Good recovery- 5
Moderate disability- 4
- Severe disability- 3

Steroid must not be used in severe head injury as they are associ-
ated with increased mortality.
 24 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

THORACIC TRAUMA
Introduction Management

three sides

Spiral CT provides most reliable result in chest

Dangerous dozen
Immediate life-threatening Potentially life-threatening

Site of ICD insertion

mid axillary line midclavicular
Indications for thoracotomy in cases of chest trauma

Pericardial tamponade

The ideal correct treatment for

pericardial tamponade is ster-
notomy or left thoracotomy with
repair of heart in operating room
or emergency room.

Tracheobronchial injury
 Trauma 25

Open pneumothorax Tension pneumothorax

-

Treatment

FLAIL CHEST

paradoxical movement -

Massive hemothorax Thoracic aorta disruption

Treatment :

Contd...
 26 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Contd...
Major vascular injuries: Points to remember

Blunt myocardial injury Diaphragmatic injury

All cases need operative repair and all repairs must be done via abdominal ap-
proach to rule out intra-abdominal viscus injury

chest.
Trauma to diaphragm and esophagus: Points to remember

Esophageal injury Pulmonary contusion

penetrating injury -

Esophagogram (barium) is the investigation of choice.

EMERGENCY THORACOTOMY
Indications for thoracotomy Types of emergency thoracotomy Planned emergency thoracotomy
-

ABDOMINAL TRAUMA
Diagnostic peritoneal lavage (DPL)
-
 Trauma 27

FAST/Focused abdominal sonogram of trauma CT scan

-

MCQ’s from this area

.
small intestine.
spleen*

INVESTIGATIONS OF ABDOMINAL INJURY

unstable patient Pringle maneuvre
is USG
CT scan
used only in stable
patients

SPLEEN

PANCREAS
penetrating trauma
-

W -

MC associated injury is duodenal rupture.

Stomach Bowel injuries Urological injuries

- -

Damage control surgery Deadly triad

Hypothermia
Acidosis
The aim is to resuscitate the patient Coagulopathy

the patient becomes stable.

 28 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

FMGE QUESTIONS

1. Trauma to spleen in a stable patient is best diag

diag-

Ans: c (CT scan)

- -
dominal bleeding in an unstable patient:
-

Ans: c (USG)
dle decompression)
coming out through nose. What could be the pos-

Ans: b (Oxygen administration)

L

-
Ans: d (GCS score of 0)
5. Minimum score in Glasgow coma scale:

Ans: d (3)
6. True statement regarding fracture base of the except:
except:

Ans: d (Mediastinal shift)

Ans: c (Early surgery is indicated for optimal outcome)
 Trauma 29

10. Condition which builds within hemithorax 15. According to the glassgow coma scale a verbal
sco
contralateral mediastinal shift and compromised
venous return to right side of heart is known as:

Ans: d (Tension pneumothorax)

Ans. c (Cribriform plate)

-

Ans: c (Altered mental status)

Ans: d (3)
13. In an adult pa
appropriate site for pleurocentesis done by insert-

A
Ans. d (All the above)

struck in the right temple by a baseball. While be- Ans: b (Extradural hemorrhage)

is unresponsive with the dilated right pupil when

he reaches the emergency department. The most
important step in initial management is:

Ans: a (Craniotomy)

Ans: b (Intra-abdominal-injury)
 30 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Explanation:

Ans: b (Tear of bridging veins)

Ans. b (Middle meningeal artery)

Ans: b (sponataneous pneumothorax) Ans: a (Thyroxine)

Explanation

Adrenaline

Glucagon

Ans: b (Apply pressure)

 Trauma 31

Ans: a or b
Explanation -
-

except:

33. Regarding compartment syndrome in lower limb:

the fasciotomy is done when pressure is above
____mm Hg
-

Ans: b (Early sign is absent distal pulse)

Earliest sign—pain on passive stretching Ans: c (30 mm Hg)

Explanation