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Surgical Emergencies

How have surgical emergencies been categorized?
Pediatric surgical emergencies.
Adult surgical emergencies, age 19 and older.

What are examples with diagnosis of surgical emergencies?
There are more than 226 such examples of surgical emergencies.

Types of surgical emergencies.

Abscesses

Appendicitis

Acute Pancreatitis

Acute mesenteric ischemia

Acute abdominal conditions

Amebic liver abscess

Biliary Colic & Cholecystitis

Bleeding from esophageal varices

Cholecystitis (gallbladder infection)

Complications of peptic ulcer, including perforated ulcer and bleeding ulcer

Diverticulitis

Gall bladder and bile duct disease

Intestinal volvulus

Incarcerated hernia

Incarcerated and Strangulated Inguinal Hernias

Intestinal obstruction

Massive Upper GI Haemorrhage

Peritonitis

Perforated Abdominal Viscus

Pelvic infections with abscesses

Perforated typhoid ulcers

Ruptured intestine

Rectal Bleeding

Stercoral perforation

Small Bowel Obstruction

Spleen Removal

Thrombosed hemorrhoids

Acute airway obstruction/Airway obstruction

Tension pneumothorax

Massive haemothorax

Pneumothorax

Open pneumothorax

Flail chest segment with pulmonary contusion

Cardiac tamponade.

Injury to the Colon and Rectum (stab wound)

Hemorrhoids

Fissures (painful tears in the anal lining)

Abscesses and fistulaes (infections located around the anus and rectum).

Hemorrhage of rectum and anus

Abortion With Hemorrhagic Shock

Acute Abdominal Pain During Pregnancy

Amniotic Fluid Embolism

Antepartum Hemorrhage Placenta previa/accreta/percreta Placental abruption/Uterine rupture

Bleeding ectopic pregnancy

Chorioamnionitis

Cesarean Section Under Local Anesthesia

Cesarean Section Without Anesthesia

Cardiopulmonary Resuscitation During Pregnancy

Cesarean delivery: elective/Placenta Previa (if stable) or urgent (if hemorrhaging)

Disseminated Intravascular Coagulation

Eclampsia

Ectopic Pregnancy with Shock

Intrauterine fetal demise

Multiple gestation

Placenta accreta / placenta percreta

Placental abruption

Placenta previa

Preeclampsia/eclampsia

Premature Rupture of Membranes

Preterm Labor and Delivery

Prolapsed Umbilical Cord

Postpartum Hemorrhage Uterine inversion/Uterine atony/Genital tract trauma

Postmortem Cesarean Section

Retained Placenta

Retained abortion

Severe Preeclampsia

Shoulder Dystocia

Surgical complications in pregnancy (appendicitis, cholecystitis, major abdominal trauma, bowel obstruction, intracranial hemorrhage, adnexal mass, etc)

Trauma During Pregnancy

Uterine Rupture

Uterine Inversion

Adnexal torsion

Tubo-ovarian abscess, hemorrhagic ovarian cysts

Gynecologic hemorrhage

Vulvovaginal trauma.

Acute subdural hematoma

Subarachnoid hemorrhage

Intracranial Hemorrhage

Brain AVM (arteriovenous malformation)

Spine Fracture

CaudaEquina

Penetrating Injury

Intracranial Lesions –Focal

Open Skull fracture

Head Trauma

Cushing response

Epidural Hematomas

Epidural Hemorrhage

Uncal Herniation

Pituitary Adenoma

Pituitary apoplexy

Traumatic Compression Fracture

Jumped facets

Ballistic trauma or gunshot wound (GSW)

Shunt malfunction

T7-8 corptectomyand T6-T9 fusion

Cord compression

Clinical signs of high ICP

Dental implants and bone grafting

TMJ evaluations and management

Corrective jaw surgery

Facial infection treatment

Treatment of facial trauma

General oral surgery

Cosmetherapy, including botox, juvederm, and restylane

Supracondylar humeral, femoral, and tibial conditions (such as slipped capital femoral epiphysis)

Septic arthritis

Limb- and life-threatening pathologies, including compartment syndrome

Dysvascular limb

Cervical spine trauma

Polytraumatized child

Fractures.

Open fractures (bone is exposed outside of a wound)

Open fractures or joints

Fractures with joint involvement

Isolated breaks

Stress fractures

Multiple fractures

Non-union fractures (fractures that do not heal)

Malunion fractures (fractures that heal incorrectly)

Acute compartment syndrome

Neurovascular injuries

Joint dislocations

Ligament sprains

Muscle strains

Tendon injuries

Septic joints

Cauda equina syndrome

Epistaxis

Peritonsillar abscess

Retropharyngeal abscess

Acute external otitis

Auricular hematoma

Mastoiditis

Facial nerve paralysis/Bell’s palsy

Ramsey-Hunt syndrome

Nasal fracture

Septal hematoma

Orbital blow-out fracture

Sudden sensorineural hearing loss (SSNHL)

The red herring tonsil

Dental abscess

Facial cellulitis

Ludwig’s angina

Deep neck space infections

Angioedema

Sinusitis: complications

Appendicitis

Intussusception

Pyloric Stenosis

Necrotizing Enterocolitis

Testicular Torsion

Incarcerated Inguinal hernia

Hirschsprung’s Enterocolitis

Incarcerated Hernia

Inguinal Hernia

Incarcerated Inguinal Hernia

Small Bowel Obstruction

NEC Pneumoperitoneum

Malrotation with volvulus

Bowel Obstruction

Jejunal Atresia

The Acute Groin

Bleeding Meckel’s

Toxic Megacolon

Foreign Bodies

Esophageal Foreign Bodies

Bronchial Foreign Body

Imperforate Anus: Anal atresia

Anesthetic implications

Burn Care

Bite Wounds

Burns and Frostbite

Cleft lip and palate repair

Compartment Syndrome

Examination of Hand Injuries

Facial Lacerations

Frontal Sinus Fractures

Frontal Sinus Fractures

Hand and Forearm Tendon Injuries

Hand and Wrist Fractures and Dislocations

Hand Infections and Injection Injuries

Hand Injuries

Ischemic Limb / Amputated Part

Laceration repair

Major Burn

Mandibular Fractures

Maxillofacial injuries

Nasal and Nasal-Orbital-Ethmoid (NOE) Fractures

Necrotizing Fasciitis

Orbit and Zygoma Fractures

Pressure Sores

Septic Joint

Suppurative Flexor Tenosynovitis

The Traumatized Face

Wound Management

Renal Trauma

Ureteral injury

Bladder Trauma

Urethral injury

Testicular Trauma

Genital Trauma

Penile trauma

Non traumatic

Acute Urinary Retention

Acute Scrotum Epididymo-orchitis/Testicular Torsion

Hematuria

Priapism

Paraphimosis

Renal Colic

Testicular torsion

Urinary Retention

Fournier's Gangrene

Acute ischaemia

Bleeding due to trauma (incl. iatrogenic)

Venous

Deep Venous Thrombosis (Phlegmesia Caeurlia Dolens)

Pulmonary Embolism

Lymphatic

Cellulititis

Compartment Syndrome

Occlusive Peripheral Vascular Disease

Peripheral vascular disease

Includes any disease affecting the peripheral vascular system

Occlusive – essentially blocked arteries Ruptured aortic aneurysm

Aortic dissection

Internal bleeding

Limb ischemia

What should physician surgeon medical emergency know?
You have to know everything of these entities.

General surgery emergencies

Thoracic surgery emergencies

Colon and rectal surgery emergencies

Obstetrics emergencies

Gynecologic surgery emergencies

Neurological surgery emergencies

Ophthalmic surgery emergencies

Oral and maxillofacial surgery emergencies

Orthopaedic surgery emergencies

Otolaryngology emergencies

Pediatric surgery emergencies

Plastic and maxillofacial surgery emergencies

Urology emergencies

Vascular Surgery Emergencies

General surgery emergencies

Acute Abdomen

1.Assess urgency
2.How sick is the patient?
3.Take a history
4.Examine the patient
5.Urineanalysis
6.BhCG
7.Formulate differential diagnosis
8.Investigations
9.Decide to discharge, admit, observe, operate

Stratification of the Acute Abdomen

1.Pain only
2.Pain + systemic symptoms
3.Peritonitis -systemic symptoms
4.Localised peritonitis + systemic symptoms
5.Generalised peritonitis -systemic symptoms
6.Generalised peritonitis +systemic symptoms

Peritonitis and Intra-abdominal sepsis

•Inflammation of the serosal membrane
•Constellation of signs and symptoms; abdominal pain, muscle wall rigidity, systemic signs of inflammation
•Classification

•Generalised vs localised
•Cause

Causes of Peritonism

	Upper GI	HPB	Small& Large Bowel	GU
Infection / Inflammation	Gastritis	Cholecystitis Pancreatitis	Gastroenteritis Meckel's diverticulitis Appendicitis TB IBD Diverticulitis	PID UTI Obstructive Uropathy
Perforation	Boerhaave syndrome Peptic ulcer Malignancy Trauma Iatrogenic	Gallbladder Malignancy Trauma Iatrogenic	Diverticular Stercoral Ischaemia IBD (Toxic megacolon) Tumour	Ruptured ovarian cyst Trauma Iatrogenic
Ischaemia			Mesenteric Hernia Close loop obstruction

Localised Peritonitis
•Bloods X-rays
•Establish differential diagnosis
•Initiate resucitation and management
•Watch, wait, act

What is emergency general surgery?

Appendicitis
Peritonitis

Evaluation of Acute Abdominal Pain in Adults

Acute abdomen

The term acute abdomen refers to a sudden, severe abdominal pain of unclear etiology that is less than 24 hours in duration. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment.

Causes

The differential diagnoses of acute abdomen include but are not limited to:
1.Acute appendicitis
2.Acute peptic ulcer and its complications
3.Acute cholecystitis
4.Acute pancreatitis
5.Acute intestinal ischemia (see section below)
6.Diabetic ketoacidosis
7.Acute diverticulitis
8.Ectopic pregnancy with tubal rupture
9.Ovarian torsion
10.Acute peritonitis (including hollow viscus perforation)
11.Acute ureteric colic
12.Bowel volvulus
13.Acute pyelonephritis
14.Adrenal crisis
15.Biliary colic
16.Abdominal aortic aneurysm
17.Hemoperitoneum
18.Ruptured spleen
19.Kidney stone
20.Sickle cell anaemia

Ischemic acute abdomen

Acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies on the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis. Certain elements of the history and physical examination are helpful (e.g., constipation and abdominal distension strongly suggest bowel obstruction), whereas others are of little value (e.g., anorexia has little predictive value for appendicitis).

Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain. It is also important to consider special populations such as women, who are at risk of genitourinary disease, which may cause abdominal pain; and the elderly, who may present with atypical symptoms of a disease.

Abdominal pain is a common presentation in the outpatient setting and is challenging to diagnose. Abdominal pain is the presenting complaint in 1.5 percent of office-based visits1 and in 5 percent of emergency department visits.2 Although most abdominal pain is benign, as many as 10 percent of patients in the emergency department setting and a lesser percentage in the outpatient setting have a severe or life-threatening cause or require surgery.2 Therefore, a thorough and logical approach to the diagnosis of abdominal pain is necessary.

Pain location	Possible diagnoses
Right upper quadrant	Biliary: cholecystitis, cholelithiasis, cholangitis Colonic: colitis, diverticulitis Hepatic: abscess, hepatitis, ma Pulmonary: pneumonia, embolu Renal: nephrolithiasis, pyelonephritis
Epigastric	Biliary: cholecystitis, cholelithiasis, cholang Cardiac: myocardial infarction, pericarditis Gastric: esophagitis, gastritis, peptic ulcer Pancreatic: mass, pancreatitis Vascular: aortic dissection, mesenteric ischemia
Left upper quadrant	Cardiac: angina, myocardial infarction, pericarditis Gastric: esophagitis, gastritis, peptic ulcer Pancreatic: mass, pancreatitis Renal: nephrolithiasis, pyelonephritis Vascular: aortic dissection, mesenteric ischemia
Periumbilical	Colonic: early appendicitis Gastric: esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction Vascular: aortic dissection, mesenteric ischemia
Right lower quadrant	Colonic: appendicitis, colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: nephrolithiasis, pyelonephritis
Suprapubic	Colonic: appendicitis, colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: cystitis, nephrolithiasis, pyelonephritis
Left lower quadrant	Colonic: colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: nephrolithiasis, pyelonephritis
Any location	Abdominal wall: herpes zoster, muscle strain, hernia Other: bowel obstruction, mesenteric ischemia, peritonitis, narcotic withdrawal, sickle cell crisis, porphyria, IBD, heavy metal poisoning

Thoracic surgery emergencies

What are examples of life threatening thoracic conditions?
Airway obstruction
Tension pneumothorax
Massive haemothorax
Open pneumothorax
Flail chest segment with pulmonary contusion
Cardiac tamponade.

Colon and rectal surgery emergencies

Injury to the Colon and Rectum (stab wound)
Hemorrhoids
Fissures (painful tears in the anal lining)
Abscesses and fistulaes (infections located around the anus and rectum).
Hemorrhage of rectum and anus

How should you manage a stab wound that caused prolapse of intestines?
Do not do any laparotomy.
Do not cut any site or location in this situation.
Relocate the intestines to original location and suture the stab wound.
Critical monitoring of the individual is required.

Make a police report of the case with punishments of criminals who inflicted stab wound with all other criminal conspirators.

How many of you have come across a case of stab wound with prolapse of intestines?
Where have you reported such cases up to now?

Obstetrics emergencies

6 Pregnancy Warning Signs

Vaginal Bleeding
Baby’s Activity Level Significantly Declines
Contractions Early in the Third Trimester
Leakage of Fluid from the Vagina
Headache
Severe Nausea and Vomiting
A Persistent Severe Headache, Abdominal Pain, Visual Disturbances, and Swelling During Your Third Trimester

The first principles of dealing with obstetric emergencies are the same as for any emergency (see to the airway, breathing, and circulation), but remember that in obstetrics there are two patients; the fetus is very vulnerable to maternal hypoxia

Abruption of the placenta
Placenta praevia
Postpartum haemorrhage
Amniotic fluid embolism
Inversion of uterus
Infection
Psychological conditions
Stillbirth and intrauterine death

Clinical features of abruption of the placenta

Symptoms

•Abdominal pain

•Severe shock with symptoms beyond vaginal blood loss

•Vaginal bleeding—usually old blood

Signs

•Shock

•Spasm of uterus—described as woody

•Tender uterus

•Fetal parts hard to feel

•Often no fetal heart is heard

All emergency protocols should have been considered beforehand and mutually agreed by obstetricians, midwives, general practitioners, and paramedics. Everybody then knows their immediate priority, and hazards to the woman can be minimised.

Abruption of the placenta

An abruption is a death threat to the fetus and a hazard to the mother. When the placenta separates from its bed (probably because of the rupture of a malformed blood vessel), the damage to the fetus follows not just because of the barrier that the clot makes between the placental bed and villi but also because the release of prostaglandins causes a major degree of uterine spasm. This interferes with perfusion of the placenta, which remains attached. Blood tracking into the myometrium often goes as far as the peritoneum over the uterus, causing much pain and shock, with spasm of the uterine muscle.

Emergency treatment of abruption

Treat the shock

•Give oxygen

•Insert intravenous lines

•Arrange a cross match of 6 units of blood

•Give morphine (if fetus dead)

Deliver the fetus

•By caesarean section (if fetus is alive and gestation is mature)

•By rupturing membranes (if cervix is ripe or fetus is dead)

Treat disseminated intravascular coagulopathy

•Urgent haematological consultation

•Check platelet count

•Give cryoprecipitate (fresh frozen plasma)

•Transfuse with fresh blood if available

In major degrees of placental abruption the woman is shocked well beyond the apparent amount of blood loss and needs urgent transport into hospital. A wide bore intravenous line should be set up and blood sent for cross matching of at least six units of blood. Until this blood arrives, other plasma expanding fluids, such as Haemaccel, should be used.

If the fetus is still alive and gestation sufficiently advanced, caesarean section is the best management. However, if the fetus is dead, conservative management can be pursued provided that the woman does not continue deteriorating—for example, by developing a coagulopathy. Most women with a severe abruption that kills the fetus will go into spontaneous labour soon and have an easy delivery, but caesarean section is occasionally necessary for maternal indications alone. Treatment must be aimed at the shock and at preventing disseminated intravascular coagulopathy.

Usually the placenta is implanted on the anterior wall of the uterus, but sometimes it is posterior when the abruption is less painful and not so severe that the mother is shocked; the fetus may still be at risk, however. Diagnosis in these cases is by recognition of the excessively frequent contractions produced by the prostaglandin release and the abnormal pattern of the fetal heart rate secondary to fetal hypoxia; these are best shown with cardiotocography, a priority investigation in all women admitted with abdominal pain in pregnancy.

Placenta praevia

The blastocyst occasionally implants in the lower part of the uterus. Stretching and thinning of the uterine muscle of the lower segment in the third trimester may sheer off part of the placental attachment. This is accompanied by painless bleeding.

Clinical aspects of placenta praevia

Symptoms

•Vaginal bleeding—bright red, painless, recurrent

Signs

•Soft, pain free uterus

•Easy to feel fetus—often high head, breech, or transverse lie

•No fetal distress

•Do not do a digital vaginal examination

•A speculum examination in an inpatient to exclude any local bleeding is acceptable

Often the fetus is not affected by the first small bleeds, but they should be taken seriously for there is a risk that the mother could have a much larger bleed. Hence, women with bright red, painless vaginal bleeding are considered to have placenta praevia until proved otherwise and should be admitted to hospital. Vaginal ultrasound examination is the best technique for investigating possible placenta praevia, but, although it has a high sensitivity and specificity for central placenta praevia in the third trimester, it is much less precise in the late second trimester or for marginal placenta praevia. Management should therefore always be based on appropriate clinical judgment.

If placenta praevia is confirmed the woman should stay in hospital for at least 48 hours after the bleeding has stopped. Management is conservative, even to the level of giving blood transfusions for severe bleeds, until the fetus is mature (at about 36 weeks). Studies do not show any benefit in keeping women in hospital until delivery, provided that they have a telephone at home and live close enough to the hospital to be brought in by the emergency services within 20 minutes if they start bleeding again (Love et al, 1996). Unless it is very obvious—for example, a complete placenta praevia on ultrasound examination, together with a transverse lie of the fetus—placenta praevia is sometimes confirmed by examination under general anaesthesia in theatre, proceeding in most instances to caesarean section performed by a senior obstetrician. Occasionally, if the placenta is anterior and only just engaging in the lower segment, the membranes may be ruptured and a vaginal delivery expected, as the head coming down into the mother’s pelvis will compress the bleeding placental bed against the back of the pubis symphysis. The same cannot be said for any degree of posterior placenta praevia.

After delivery, a postpartum haemorrhage is likely because the placental bed is situated over less well contracting uterine muscle and may well bleed despite oxytocic stimulation. This often requires blood transfusion.

Postpartum haemorrhage

After a normal delivery a woman commonly loses up to 300 ml of blood. As her blood volume has increased because of fluid retention during pregnancy, this is a loss which can be coped with readily. However, a loss of >500?ml measured clinically in the first 24 hours is considered to be a primary postpartum haemorrhage. Blood loss is commonly underestimated by the attending practitioners. The mother should be watched carefully and treatments given to prevent any further loss.

Management of primary postpartum haemorrhage

Preventive

•Intramuscular oxytocin at the end of the second stage of labour

Curative

•Repeat oxytocic administration

•Rub up a contraction

•Check completeness of the placenta—if it is not delivered or a lobule is missing, prepare for manual removal

•Bimanual compression

•Intramyometrial prostaglandin E2 or carboprost

•Surgical ligation—uterine arteries, internal iliac arteries, or braces (or Lynch) suture of uterus

•Hysterectomy

If the uterus has not contracted firmly, manual stimulation may work by rubbing up a contraction, and a further oxytocic is given. If the placenta is incomplete the uterine cavity is explored for the remaining lobules whose presence in the uterine cavity may prevent the organ contracting down. If neither of these conditions exists, trauma to the lower uterus, cervix, or upper vagina may be the cause of the bleeding. Such traumas should be looked for (in theatre with a good light) and sutured appropriately. A rare cause of continuing primary postpartum haemorrhage is a rupture of the uterus. This needs diagnosis and treatment with either hysterectomy or abdominal resuturing.

After the first 24 hours, any bleeding is a secondary postpartum haemorrhage. It is commonly associated with infection, which should be treated vigorously with intravenous antibiotics. If it persists, suction evacuation of the uterus should be undertaken by a senior obstetrician; perforation of the soft uterus is a major risk in this situation.

A complication of severe and prolonged blood loss is a consumptive coagulopathy, when the mother’s blood does not clot owing to interference with the clotting cascade. The continuing cooperation of a senior haematologist is essential. The mother continues to bleed not just from the placental bed but from other sites in the body. This needs firm and prompt correction so that full coagulation can be restored. Giving cryoprecipitate (frozen precipitate) provides the missing components.

Amniotic fluid embolism

Occasionally, when the uterus is contracting strongly and there is an opening between the amniotic sac and the uterine veins, a bolus of amniotic fluid is pumped into the circulation. This passes through the heart, and an accumulation of amniotic cells becomes trapped in the pulmonary circulation. The amniotic fluid may cause local disseminated intravascular coagulation, which may spread. This rare condition can occur late in the last trimester or during labour.

Amniotic fluid embolism used to be diagnosed on histology only after a postmortem examination but is now sometimes diagnosed before death. The symptoms include collapse while having strong contractions, shock without any blood loss, sudden dyspnoea, and the production of frothy sputum. Treatment is supportive, with steroids, intravenous plasma expansion, and urgent delivery. This obstetric emergency is rare and has a bad prognosis for both mother and fetus, usually owing to delay in diagnosis.

Inversion of uterus

Very rarely, if misapplied pressure has been used on the uterine fundus or traction on the cord of a non-separated placenta in a multiparous woman, the uterus can dimple and invert. This is a very shocking event as the fundus turns inside out and goes through the cervix into the vagina. Treatment requires an experienced obstetrician, who will try to return the uterus under general anaesthesia. This can be very difficult.

Infection

After delivery the genital tract has several sites of potential ingress of bacteria. The placental bed itself is a large raw area, and ascending infection from the lower genital tract may be assisted by previous intrauterine procedures—for example, forceps delivery. Infection of the cervix or, uncommonly, of the episiotomy site, may also occur; the breast can also be a site of infection in the puerperium.

Treating infections

•Infections manifest themselves by local inflammation (swelling and tenderness) and a raised temperature
•Treatment is local heat to the area, analgesia, and broad spectrum antibiotics until the results of bacteriological swabs are available
•Co-amoxiclav and erythromycin are both good choices because they deal with penicillinase-producing staphylococci and streptococci, especially group B
•Metronidazole is often added for uterine infections
•If the infection persists, anaemia may follow, which may ultimately require a blood transfusion

Psychological conditions

Pregnancy and childbirth are times of high psychological stimulation. Any pre-existing psychological disorder may be exaggerated at this time and requires treatment. Many women go through mood swings (blues) in relation to childbirth, which can usually be managed by sympathetic support. If postnatal depression persists for a week or so, mild antidepressants may be needed, and the Edinburgh postnatal depression questionnaire may be helpful in diagnosing the condition. If the condition continues, formal psychiatric help is needed.

Three levels of psychiatric state associated with childbirth

Postpartum blues (1 in 5 mothers)

•Transient and treatable by reassurance

Puerpural depression (1 in 10 mothers)

•Low mood, lack of energy, guilt, irritability, and insomnia
•Treated by counselling (midwives and health visitors)
•Antidepressants—refer to GP if depression continues

Puerpural psychosis (1 in 500 mothers)

•Affective, depressive, or manic behaviour; insomnia; confusion; perplexity

•Refer to psychiatrist and admit to mother and baby unit

At the extreme of the spectrum of disease a puerperal psychosis may occur; both the mother and her baby should be admitted to a dedicated maternity/psychiatric unit as both are at risk. Here the mother can have expert psychiatric nursing and medical care while looking after her own baby. There is a 25% risk of recurrence in a future pregnancy.

Stillbirth and intrauterine death

In _______ 3-4 babies per 1000 are stillborn and another 3-4 per 1000 die in the first week of life. The grief reactions in both the woman and her partner need careful management by the midwifery and medical staff. The couple may go through a phase of anger; all hospital and community staff should be trained to cope with this. Midwifery and medical staff must be prepared to listen and offer their sympathies without attributing blame.

Parents should be encouraged to agree to a postmortem examination of the fetus and placenta by a skilled paediatric pathologist. Getting permission for this from the couple requires sensitivity. If a full postmortem examination is declined, a limited examination of the baby may be acceptable (x ray examination, computed tomography, blood samples from the heart area for chromosome analysis, and bacteriological swabbing of the relevant areas of the body).

Cultural attitudes of the parents influence these decisions and must be respected. It is probable that the couple will not object to full histological examination of the placenta.
Here are further guidelines.

Gynecologic surgery emergencies

Adnexal torsion
Tubo-ovarian abscess, hemorrhagic ovarian cysts
Gynecologic hemorrhage
Vulvovaginal trauma.

Neurosurgical Emergencies
Neurological surgery emergencies

Subarachnoid hemorrhage
Intracranial Hemorrhage
Brain AVM (arteriovenous malformation)
Spine Fracture
CaudaEquina
Penetrating Injury
Intracranial Lesions –Focal
Open Skull fracture
Head Trauma
Cushing response
Epidural Hematomas
Epidural Hemorrhage
Uncal Herniation
Pituitary Adenoma
Pituitary apoplexy
Traumatic Compression Fracture
Jumped facets
Ballistic trauma or gunshot wound (GSW)
Shunt malfunction
T7-8 corptectomyand T6-T9 fusion
Cord compression
Clinical signs of high ICP
Here are further guidelines.

New Surgical Technique

Surgical Skills

Do you know various surgical skills?
What are various surgical skills?

What is a surgical technique?
A systematic surgical procedure by which a medical condition is treated.

What questions should you answer in case you introduce new surgical technique?
Is this a new surgical technique or already listed in surgical skills practiced by others on human beings?

New Surgical Technique

Is there any specific name for this new surgical technique?
What is the name of this new surgical technique?
Have you discussed with other doctors the benefits, complications, and harms due to this new surgical technique?
For what type of patients is diagnosis and treatment with this new surgical technique useful?
How is this surgical technique going to improve the condition of the patient?
How is this surgical technique performed, from beginning to end?
For what medical condition is this surgical technique the only option of treatment?
What issues is this medical condition causing the patient?
What complications can occur due to this surgical technique?

Orthopaedic surgery emergencies

Top 10 pediatric orthopaedic surgical emergencies: a case-based approach for the surgeon on call.

Pediatric patients who require orthopaedic surgical emergency care are often treated by orthopaedic surgeons who primarily treat adult patients. Essential information is needed to safely evaluate and treat the most common surgical emergencies in pediatric patients, including hip fractures; supracondylar humeral, femoral, and tibial conditions of the hip (such as slipped capital femoral epiphysis and septic arthritis); and limb- and life-threatening pathologies, including compartment syndrome, the dysvascular limb, cervical spine trauma, and the polytraumatized child.

Open fractures (bone is exposed outside of a wound)
Open Fractures or Joints
Fractures with joint involvement
Isolated breaks
Stress fractures
Multiple fractures
Non-union fractures (fractures that do not heal)
Malunion fractures (fractures that heal incorrectly)
Acute Compartment Syndrome
Neurovascular injuries
Joint dislocations
Ligament sprains
Muscle strains
Tendon injuries
Septic Joints
Cauda Equina Syndrome
Here are further guidelines.

Fractures
Open Fractures

Annotation of definition

Cause

Symptoms

Diagnosis and Treatment

Description

Doctor Examination and Initial Treatment

Gustilo Classification for Open Fractures

What are Fractures?
A fracture is the medical term for a broken bone.

What are common types of fractures?

Some fracture types are:
• A Greenstick fracture is an incomplete fracture in which the bone is bent. This type occurs most often in children.
• A transverse fracture is when the broken piece of bone is at a right angle to the bone's axis.
• An oblique fracture is when the break has a curved or sloped pattern.
• A comminuted fracture is when the bone breaks into several pieces.
• A buckled fracture, also known as an impacted fracture, is one whose ends are driven into each other. This is commonly seen in arm fractures in children.
• A pathologic fracture is caused by a disease that weakens the bones.
• A stress fracture is a hairline crack.

Compare healthy bone with different types of fractures:
(a) closed fracture
(b) open fracture
(c) transverse fracture
(d) spiral fracture
(e) comminuted fracture
(f) impacted fracture
(g) greenstick fracture
(h) oblique fracture

What are the most common types of fractures?
The most common types of fractures in older adults are fractures to the pelvis, hip, femur, vertebrae, humerus, hand, forearm, leg, and ankle.

What is an open (compound) fracture?
An open (or compound) fracture occurs when the skin overlying a fracture is broken, allowing communication between the fracture and the external environment.
What is Human Anatomy?

How will study of this subject help in diagnosis of human medical conditions, medical advice as per international standards and recent advances, as per preventive and curative concepts of medicine?
Let's examine this question.
Which splints and casts should be used for various injuries?
What bones, muscles, arteries, veins, nerves, are associated with this injury or fracture?
Which structures and movements are affected with this injury or fracture?
What will happen if you don't immediately manage an injury or fracture?
Where and when will you use a nail, screw, rod, plate in fixation of a fracture?
This is an orthopedics question. To answer this question correctly.
You have to know about human bones, muscles, arteries, veins, nerves and all related subjects.

What are the most common fractures?
How many total fracture cases were reported every year from last 20 years?
What are the most common fractures reported at your hospital every year?
How many reported fractures were operated?
How many developed post operative deformities?
Do you know anyone who developed post operative deformity?
Did you developer any post operative deformity?

Bones

How many bones are in the human body?
What is the longest bone in the human body?
What is the smallest bone in the human body?
What are the bones of upper limb?
What are the bones of lower limb?
What comes under axial skeleton?
What muscles originate from each bone?
What are the main foramen of base of skull?
What structures pass through each foramen?
How do bones form?
How do bones grow?
What types of cells form bone?
What is the structure of bone?
What materials make up bone?
How do muscles attach to bones?
What is the function of bone?
What are the differences between a human skeleton and a chimpanzee skeleton?
Why do teeth come in different shapes?
How long does it take a bone to heal normally after a fracture? What is the difference between a splint and a cast?
Which splints and casts should be used for various injuries?
How each is applied?
What should be proper position of the injured extremity?
Why is this the proper position of the injured extremity?

Muscles of upper limb

What are the muscles that move the glenohumeral joint?
What is axial skeleton?
What are the muscles originating on axial skeleton?
What are the muscles originating on scapula?
What are the muscles that move the scapula?
How can the deltoid muscle both extend and flex the arm?
What are the arm muscles that move the elbow joint or forearm?
What are the types of movement?
What are the hand muscles?
What is the origin, insertion, nerve supply and type of movement?
What movements are associated with this muscle?
How does exercise help build muscles?

Cranial nerves

How many total cranial nerves are there?
What is the location of the nucleus of cranial nerves?
What is the pathway from the nucleus to the nerve supply?
How many spinal nerves are there?
Blood

What are the constituents of human blood?
What is hematopoiesis?
Where are hematopoietic stem cells located?
What are the different types and functions of blood cells?
Why and how does total cell count increase during infection?
Here are further guidelines.

Cause

The most common causes of fractures are:
• Trauma. A fall, a motor vehicle accident, or a tackle during a football game can all result in fractures.
• Osteoporosis. This disorder weakens bones and makes them more likely to break.
• Overuse. Repetitive motion can tire muscles and place more force on bone. This can result in stress fractures. Stress fractures are more common in athletes.

Symptoms

Many fractures are very painful and may prevent you from moving the injured area. Other common symptoms include: •Swelling and tenderness around the injury
•Bruising
•Deformity — a limb may look "out of place" or a part of the bone may puncture through the skin

Doctor Examination

Your doctor will do a careful examination to assess your overall condition, as well as the extent of the injury. He or she will talk with you about how the injury occurred, your symptoms, and medical history.

The most common way to evaluate a fracture is with x-rays, which provide clear images of bone. Your doctor will likely use an x-ray to verify the diagnosis. X-rays can show whether a bone is intact or broken. They can also show the type of fracture and exactly where it is located within the bone.

Treatment

Medication
Splint
Cast (or brace)
Traction
Internal fixation - implantation of plates, screws, pins and rods to set bones and facilitate healing
External fixation – pins, screws and rods placed outside the body to set bones and facilitate healing. External fixators are sometimes used prior to surgical treatment.
Surgery, including minimally invasive surgery performed through small incisions
Bone stimulator (non-surgical) and bone grafting (surgical) for non-union fractures
Evaluation of non-union fractures to identify why a bone did not heal correctly. For example factors such as diabetes, smoking or a thyroid condition may affect a bone’s ability to heal.

Splint

Commonly used splints

Sugar Tong - Used for the forearm or wrist. They are named "sugar-tong" due to their long, U-shaped characteristics, similar to a type of utensil used to pick up sugar cubes
Ulnar Gutter - Used for the forearm to the palm
Volar Wrist Splint - Used for the wrist
Thumb Spica - Used for the thumb
Posterior Lower Leg
Posterior Full Leg
Posterior Elbow
Finger Splints - Used for the fingers
Ankle Stirrup - Used for the ankles
Wrist/arm splint - Used for the wrist or arm
Nasal splint

Cast (or brace)

Cast Types and Maintenance Instructions

What is a cast?
A cast holds a broken bone in place as it heals. Casts also help to prevent or decrease muscle contractions, and are effective at providing immobilization, especially after surgery.

Casts immobilize the joint above and the joint below the area that is to be kept straight and without motion. For example, a child with a forearm fracture will have a long arm cast to immobilize the wrist and elbow joints.

What are casts made of?
The outside, or hard part of the cast, is made from two different kinds of casting materials.

•Plaster (white in color)
•Fiberglass (comes in a variety of colors, patterns, and designs)

Cotton and other synthetic materials are used to line the inside of the cast to make it soft and to provide padding around bony areas, such as the wrist or elbow.

Special waterproof cast liners may be used under a fiberglass cast, allowing the child to get the cast wet. Consult your child's doctor for special cast care instructions for this type of cast.

What are the different types of casts?
Below is a description of the various types of casts, the location of the body they are applied, and their general function.

Type of cast

Location
Uses
Short arm cast
Long arm cast
Arm cylinder cast

Applied below the elbow to the hand.	Forearm or wrist fractures. Also used to hold the forearm or wrist muscles and tendons in place after surgery.
Applied from the upper arm to the hand.	Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery.
Applied from the upper arm to the wrist.	To hold the elbow muscles and tendons in place after a dislocation or surgery.

Type of cast
Location
Uses
Shoulder spica cast
Minerva cast
Short leg cast
Leg cylinder cast

Applied around the trunk of the body to the shoulder, arm, and hand.	Shoulder dislocations or after surgery on the shoulder area.
Applied around the neck and trunk of the body.	After surgery on the neck or upper back area.
Applied to the area below the knee to the foot.	Lower leg fractures, severe ankle sprains/strains, or fractures. Also used to hold the leg or foot muscles and tendons in place after surgery to allow healing.
Applied from the upper thigh to the ankle.	Knee, or lower leg fractures, knee dislocations, or after surgery on the leg or knee area.

Type of cast
Location
Uses
Unilateral hip spica cast
One and one-half hip spica cast
Bilateral long leg hip spica cast

Applied from the chest to the foot on one leg.	Thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.
Applied from the chest to the foot on one leg to the knee of the other leg. A bar is placed between both legs to keep the hips and legs immobilized.	Thigh fracture. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.
Applied from the chest to the feet. A bar is placed between both legs to keep the hips and legs immobilized.	Pelvis, hip, or thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.

Type of cast
Location
Uses
Short leg hip spica cast

Applied from the chest to the thighs or knees.

To hold the hip muscles and tendons in place after surgery to allow healing.

Type of cast
Location
Uses
Abduction boot cast

Applied from the upper thighs to the feet. A bar is placed between both legs to keep the hips and legs immobilized.

To hold the hip muscles and tendons in place after surgery to allow healing.

How can your child move around while in a cast?
Assistive devices for children with casts include:
•Crutches
•Walkers
•Wagons
•Wheelchairs
•Reclining wheelchairs
Cast care instructions
•Keep the cast clean and dry.
•Check for cracks or breaks in the cast.
•Rough edges can be padded to protect the skin from scratches.
•Do not scratch the skin under the cast by inserting objects inside the cast.
•Can use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.
•Do not put powders or lotion inside the cast.
•Cover the cast while your child is eating to prevent food spills and crumbs from entering the cast.
•Prevent small toys or objects from being put inside the cast.
•Elevate the cast above the level of the heart to decrease swelling.
•Encourage your child to move his or her fingers or toes to promote circulation.
•Do not use the abduction bar on the cast to lift or carry the child.
Older children with body casts may need to use a bedpan or urinal in order to go to the bathroom. Tips to keep body casts clean and dry and prevent skin irritation around the genital area include the following:
•Use a diaper or sanitary napkin around the genital area to prevent leakage or splashing of urine.
•Place toilet paper inside the bedpan to prevent urine from splashing onto the cast or bed.
•Keep the genital area as clean and dry as possible to prevent skin irritation.
When to call your child's doctor
Contact your child's doctor or healthcare provider if your child develops one or more of the following symptoms: •Fever as directed by your healthcare provider or:
• Your child is younger than 12 weeks and has a fever of 100.4°F (38°C) or higher because your baby may need to be seen by their healthcare provider.
• Your child has repeated fevers above 104°F (40°C) at any age.
• Your child is younger than 2 years old and their fever continues for more than 24 hours or your child is 2 years old and older and their fever continues for more than 3 day
•Increased pain
•Increased swelling above or below the cast
•Decreased ability to move extremity in the cast
•Complaints of numbness or tingling
•Drainage or foul odor from the cast
•Cool or cold fingers or toes
•If the cast becomes wet or soiled
•Blister, sores, or rash develop under the cast

All forms of treatment of broken bones follow one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed. In many cases, the doctor will restore parts of a broken bone back to the original position. The technical term for this process is "reduction."

Broken bone ends heal by "knitting" back together with new bone being formed around the edge of the broken parts.

Surgery is sometimes required to treat a fracture. The type of treatment required depends on the severity of the break, whether it is "open" or "closed," and the specific bone involved. For example, a broken bone in the spine (vertebra) is treated differently from a broken leg bone or a broken hip.

Doctors use a variety of treatments to treat fractures:

About Casts

Casts and splints support and protect injured bones and soft tissue. When you break a bone, your doctor will put the pieces back together in the right position. Casts and splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle spasm.

Splints and casts are sometimes applied after surgery.

What are the different kinds of casts?
A cast, which keeps a bone from moving so it can heal, is essentially a big bandage that has two layers — a soft cotton layer that rests against the skin and a hard outer layer that prevents the broken bone from moving.

These days, casts are made of either:
•plaster of paris: a heavy white powder that forms a thick paste that hardens quickly when mixed with water. Plaster of paris casts are heavier than fiberglass casts and don't hold up well in water. •synthetic (fiberglass) material: made out of fiberglass, a kind of moldable plastic, these casts come in many bright colors and are lighter. The covering (fiberglass) on synthetic casts is water-resistant, but the padding underneath is not. You can, however, get a waterproof liner. The doctor putting on the cast will decide whether a fiberglass cast with a waterproof lining is appropriate.

Orthopedic cast

Cast types

Upper extremity casts
Lower extremity casts
Cylinder cast
Body casts
EDF cast
Spica cast
Mobility and hygiene

Other casts

Cast-cutting
Removal of Plaster Casts

How is a cast put on?
First, several layers of soft cotton are wrapped around the injured area. Next, the plaster or fiberglass outer layer is soaked in water. The doctor wraps the plaster or fiberglass around the soft first layer. The outer layer is wet but will dry to a hard, protective covering. Doctors sometimes make tiny cuts in the sides of a cast to allow room for swelling.

Can plaster of paris casts get wet?
Absolutely not! A wet cast may not hold the bone in place because the cast could start to dissolve in the water and could irritate the skin underneath it, possibly leading to infection. So your child shouldn't swim and should use a plastic bag or special sleeve (available online or sometimes at pharmacies) to protect the cast from water. And instead of a shower, your child may need to take a sponge bath.

Can synthetic (fiberglass) casts get wet?
Although the fiberglass itself is waterproof, the padding inside a fiberglass cast is not. So it's still important to try to keep a fiberglass cast from getting wet. If this is a problem, talk to the doctor about getting a waterproof liner. Fiberglass casts with waterproof liners let kids continue bathing or even go swimming during the healing process. Although the liner allows for evaporation of water and sweat, it's still fragile. Also, only certain types of breaks can be treated with this type of cast. Your doctor will determine if the fracture may be safely treated with a waterproof cast.

Cast Immobilization

A plaster or fiberglass cast is the most common type of fracture treatment, because most broken bones can heal successfully once they have been repositioned and a cast has been applied to keep the broken ends in proper position while they heal.

Functional Cast or Brace

The cast or brace allows limited or "controlled" movement of nearby joints. This treatment is desirable for some, but not all, fractures.

Traction

Traction is usually used to align a bone or bones by a gentle, steady pulling action.

External Fixation

In this type of operation, metal pins or screws are placed into the broken bone above and below the fracture site. The pins or screws are connected to a metal bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position while they heal.

In cases where the skin and other soft tissues around the fracture are badly damaged, an external fixator may be applied until surgery can be tolerated.

An external fixator applied to a broken thighbone.

Open Reduction and Internal Fixation

During this operation, the bone fragments are first repositioned (reduced) in their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone. The fragments may also be held together by inserting rods down through the marrow space in the center of the bone.

A specially designed metal rod, called an intramedullary nail, provides strong fixation for this thighbone fracture.

The broken bones of the forearm are held in position by plates and screws while they heal.

Recovery

Fractures take several weeks to several months to heal, depending on the extent of the injury and how well you follow your doctor's advice. Pain usually stops long before the fracture is solid enough to handle the stresses of normal activity.

Even after your cast or brace is removed, you may need to continue limiting your movement until the bone is solid enough for normal activity.

During your recovery you will likely lose muscle strength in the injured area. Specific exercises will help you restore normal muscle strength, joint motion, and flexibility.

Prevention

Preventing Falls and Related Fractures

Several factors can lead to a fall. Loss of footing or traction is a common cause of falls. Loss of footing occurs when there is less than total contact between one’s foot and the ground or floor. Loss of traction occurs when one’s feet slip on wet or slippery ground or floor. Other examples of loss of traction include tripping, especially over uneven surfaces such as sidewalks, curbs, or floor elevations that result from carpeting, risers, or scatter rugs. Loss of footing also happens from using household items intended for other purposes – for example, climbing on kitchen chairs or balancing on boxes or books to increase height.

A fall may occur because a person’s reflexes have changed. As people age, reflexes slow down. Reflexes are automatic responses to stimuli in the environment. Examples of reflexes include quickly slamming on the car brakes when a child runs into the street or quickly moving out of the way when something accidentally falls. Aging slows a person’s reaction time and makes it harder to regain one’s balance following a sudden movement or shift of body weight.

Improving Balance
Do muscle-strengthening exercises.
Obtain maximum vision correction.
Practice using bifocal or trifocal glasses.
Practice balance exercises daily.

Changes in muscle mass and body fat also can play a role in falls. As people get older, they lose muscle mass because they have become less active over time. Loss of muscle mass, especially in the legs, reduces one’s strength to the point where she or he is often unable to get up from a chair without assistance. In addition, as people age, they lose body fat that has cushioned and protected bony areas, such as the hips. This loss of cushioning also affects the soles of the feet, which upsets the person’s ability to balance. The gradual loss of muscle strength, which is common in older people but not inevitable, also plays a role in falling. Muscle-strengthening exercises can help people regain their balance, level of activity, and alertness no matter what their age.

Changes in vision also increase the risk of falling. Diminished vision can be corrected with glasses. However, often these glasses are bifocal or trifocal so that when the person looks down through the lower half of her or his glasses, depth perception is altered. This makes it easy to lose one’s balance and fall. To prevent this from happening, people who wear bifocals or trifocals must practice looking straight ahead and lowering their head. For many other older people, vision changes cannot be corrected completely, making even the home environment hazardous.

Safety first to prevent falls: At any age, people can change their environments to reduce their risk of falling and breaking a bone.

Outdoor safety tips:

In nasty weather, use a walker or cane for added stability.
Wear warm boots with rubber soles for added traction.
Look carefully at floor surfaces in public buildings. Many floors are made of highly polished marble or tile that can be very slippery. If floors have plastic or carpet runners in place, stay on them whenever possible.
Identify community services that can provide assistance, such as 24-hour pharmacies and grocery stores that take orders over the phone and deliver. It is especially important to use these services in bad weather.
Use a shoulder bag, fanny pack, or backpack to leave hands free.
Stop at curbs and check their height before stepping up or down. Be cautious at curbs that have been cut away to allow access for bikes or wheelchairs. The incline up or down may lead to a fall.

Indoor safety tips:

Keep all rooms free from clutter, especially the floors.
Keep floor surfaces smooth but not slippery. When entering rooms, be aware of differences in floor levels and thresholds. Wear supportive, low-heeled shoes, even at home. Avoid walking around in socks, stockings, or floppy, backless slippers. Check that all carpets and area rugs have skid-proof backing or are tacked to the floor, including carpeting on stairs. Keep electrical and telephone cords and wires out of walkways.
Be sure that all stairwells are adequately lit and that stairs have handrails on both sides. Consider placing fluorescent tape on the edges of the top and bottom steps.
For optimal safety, install grab bars on bathroom walls beside tubs, showers, and toilets. If you are unstable on your feet, consider using a plastic chair with a back and nonskid leg tips in the shower.
Use a rubber bath mat in the shower or tub.
Keep a flashlight with fresh batteries beside your bed.
Add ceiling fixtures to rooms lit by lamps only, or install lamps that can be turned on by a switch near the entry point into the room. Another option is to install voice- or sound-activated lamps.
Use bright light bulbs in your home.
If you must use a step-stool for hard-to-reach areas, use a sturdy one with a handrail and wide steps. A better option is to reorganize work and storage areas to minimize the need for stooping or excessive reaching.
Consider purchasing a portable phone that you can take with you from room to room. It provides security because you can answer the phone without rushing for it and you can call for help should an accident occur.
Don’t let prescriptions run low. Always keep at least 1 week’s worth of medications on hand at home. Check prescriptions with your doctor and pharmacist to see if they may be increasing your risk of falling. If you take multiple medications, check with your doctor and pharmacist about possible interactions between the different medications.
Arrange with a family member or friend for daily contact. Try to have at least one person who knows where you are. If you live alone, you may wish to contract with a monitoring company that will respond to your call 24 hours a day. Watch yourself in a mirror. Does your body lean or sway back and forth or side to side? People with decreased ability to balance often have a high degree of body sway and are more likely to fall.

Medications That May Increase the Risk of Falling

Unfortunately, as you get older, you're more likely to need daily medications. And all medications have side effects, some of which can increase your risk of having a fall. Medications that can cause dizziness or lack of coordination are:
•Sedatives or sleeping pills
•Drugs that lower high blood pressure, which can sometimes cause hypotension, blood pressure that is too low • Antidepressants
•Anticonvulsants, which are used to treat epilepsy and some psychological conditions
•Muscle relaxants, which may be used for back pain or other problems
•Some medicines for heart conditions

Injury Prevention - Seat Belts

Seat Belts

Lap/shoulder safety belts, when used correctly, reduce the risk of death to front seat occupants by 45% and risk of moderate to critical injury by 50%.

Food and Your Bones

Proper diet and exercise may help in preventing some fractures. A diet rich in calcium and Vitamin D will promote bone strength. Weightbearing exercise also helps keep bones strong.

Getting the calcium and vitamin D you need is easier than you think -- if you eat the right foods.

Breakfast Foods	Average Calcium (mg)
Cereal, calcium-fortified, 1 cup	100 - 1000
Soy milk, calcium-fortified, 8 ounces	80 - 500
Milk (nonfat, 2%, whole, or lactose-reduced), 1 cup	300
Yogurt, 1 cup	300 - 400
Orange juice, calcium-fortified	200 - 340

Lunch, Dinner, and Snack Foods	Average Calcium (mg)
Canned sardines, 3 ounces	320
Swiss cheese, 1 ounce	270
Cheddar cheese, 1 ounce	200
Canned salmon, 3 ounces	200
Turnip greens, 1 cup	200
Kale cooked, 1 cup	90
Broccoli, raw, 1 cup	90

What is emergency surgery?

Surgical emergency is a medical emergency which requires immediate surgical intervention (the only way to solve the problem successfully).

How should emergency surgeries be classified?

Extremely urgent emergency surgery

Attempting to stop massive bleeding after a gunshot wound.

Repairing a brain aneurysm that is causing the brain to fill with blood.

Trauma complications that need emergency surgery.

Cesarean section

Urgent emergency surgeries

Appendectomy
Setting of a broken bone that needs internal setting

What cases need emergency surgery?
What cases need an emergency operating room (OR)?

The following conditions are surgical emergencies:

Acute trauma
Amputation
Acute appendicitis(Is acute appendicitis a surgical emergency? Urgent appendectomy has become the basis of management for acute appendicitis because of the disparity in morbidity and mortality rates between perforated and nonperforated appendicitis.)
Abscesses
Aortic dissection
Acute subdural hematoma
Acute airway obstruction
Acute mesenteric ischemia

Bleeding ectopic pregnancy
Bowel obstruction

Cardiac tamponade
Cholecystitis (gallbladder infection)

Diverticulitis

Gastrointestinal perforation

Incarcerated hernia
Intestinal blockage/obstruction
Intestinal volvulus
Internal bleeding

Limb ischemia

Neuroendocrine tumors causing acute homeostatic imbalance unresponsive to medication (often due to decompensation)

Pneumothorax
Paraphimosis
Peritonitis

Ruptured intestine
Ruptured aortic aneurysm

Retinal detachment
Retained abortion

Spleen Removal
Stercoral perforation

Thrombosed hemorrhoids
Testicular torsion

Urinary retention (not respond to other medical treatment)

Pediatric surgery emergencies

Appendicitis

Management of epistaxis in children

Balanoposthitis in children: Clinical manifestations, diagnosis, and treatment

Overview of inguinal hernia in children

Incarcerated Inguinal hernia

Intestinal malrotation

Intussusception in children

Infantile hypertrophic pyloric stenosis

Rectal prolapse

Intussusception

Pyloric Stenosis

Bowel Obstruction

Foreign Bodies

Hirschsprung’s Enterocolitis

Malrotation with volvulus

What are the important points about the history?
What are the pertinent physical findings?
How is the problem managed?
What is the differential diagnosis?
What further workup is needed?
When/if to do surgery?
Anesthesia for Common Pediatric Surgical Emergencies: Are You Well Equipped?
Postop management

Acute trauma

Pediatric orthopaedic surgical emergencies

Hip fractures; supracondylar humeral, femoral, and tibial conditions of the hip (such as slipped capital femoral epiphysis and septic arthritis); and limb- and life-threatening pathologies, including compartment syndrome, the dysvascular limb, cervical spine trauma, and the polytraumatized child.

Adults (age 19 and older)

Open Fractures

Acute Compartment Syndrome

Neurovascular injuries

Dislocations

Septic Joints

Cauda Equina Syndrome

Cardiothoracic

Cardiac tamponade

Acute airway obstruction

Pneumothorax

Gastrointestinal

Acute appendicitis

Bowel obstruction

Gastrointestinal perforation

Intestinal volvulus

Acute mesenteric ischemia

Peritonitis

Stercoral perforation

Genitourinary

Testicular torsion

Urinary retention

Paraphimosis

Priapism

Gynaecological

Bleeding ectopic pregnancy

Retained abortion

Neurological/Ophthalmic

Acute subdural hematoma

Retinal detachment

Vascular

Ruptured aortic aneurysm

Aortic dissection

Internal bleeding

Limb ischemia

Diagnosis accuracy importance.

Why is diagnosis accuracy essential to any physician surgeon medical emergency, physician surgeon elective surgery?
We will take an example of acute abdominal pain.
There are more than 22 causes of acute abdominal pain.
Acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Out of more than 22 causes of acute abdomen, only two causes of acute abdomen need surgical intervention under verified conditions of seniors.
Do not go ahead with surgery without second and third consultation from senior physicians for verification of diagnosis and appropriate treatment.

Surgical Skills

Do you know various surgical skills?
What are various surgical skills?

What is a surgical technique?
A systematic surgical procedure by which a medical condition is treated.
Here are further guidelines.

Seniority

What should other physicians who claim to be surgeons know?
Physician surgeon medical emergency
Physician surgeon elective surgery

These are the only two types of entities of physicians with surgical abilities.

How should seniority of physician surgeon medical emergency, physician surgeon elective surgery be categorized?
Guide to physician surgeon medical emergency, physician surgeon elective surgery is most senior, for example the individual circulating these guidelines www.qureshiuniversity.com/surgeryworld.html Doctor Asif Qureshi.

You must know Doctor Asif Qureshi guides at least 812 other various professions, for example www.qureshiuniversity.com/professionsworld.html

Do not expect Doctor Asif Qureshi to reach out to your operating room and, for example, in cholecystectomy for gallstones do 8-inch Incision, clamp at two ends of gall bladder, cut, suture the stump, and close in 3 layers. Juniors have to perform these services.

Do not expect Doctor Asif Qureshi to reach out to medical emergency room and, for example, trauma with head injury with scalp laceration that needs closure in 2 layers of two ends of lacerated scalp. Juniors have to perform these services. Doctor Asif Qureshi has done these services while he was a junior physician.

If you do not understand anything from www.qureshiuniversity.com/surgeryworld.html you are encouraged to ask questions.

Consultant physician surgeon medical emergency, physician surgeon elective surgery.

Senior resident physician surgeon medical emergency, physician surgeon elective surgery.

Junior resident physician surgeon medical emergency, physician surgeon elective surgery.

How many subcategories of surgeries are there?
14 subcategories of surgical categories have to be recognized that can be emergency or elective.

What should physician surgeon medical emergency know?
You have to know everything of these entities.

General surgery emergencies

Thoracic surgery emergencies

Colon and rectal surgery emergencies

Obstetrics emergencies

Gynecologic surgery emergencies

Neurological surgery emergencies

Ophthalmic surgery emergencies

Oral and maxillofacial surgery emergencies

Orthopaedic surgery emergencies

Otolaryngology emergencies

Pediatric surgery emergencies

Plastic and maxillofacial surgery emergencies

Urology emergencies

Vascular Surgery Emergencies

What should physician surgeon elective surgery know?
You have to know everything of these entities.

General surgery elective surgeries

Thoracic surgery elective surgeries

Colon and rectal elective surgeries

Obstetrics elective surgeries

Gynecologic elective surgeries

Neurological elective surgeries

Ophthalmic elective surgeries

Oral and maxillofacial elective surgeries

Orthopaedic elective surgeries

Otolaryngology elective surgeries

Pediatric elective surgeries

Plastic and maxillofacial elective surgeries

Urology elective surgeries

Vascular elective surgeries

How are other regions categorizing surgical categories?
In some regions, even anethesiologist is expected to have physician surgeon medical emergency, physician surgeon elective surgery abilities.
Here are various subcategories of surgery in other regions that needs to be updated.

Anesthesiology	The specialty of anesthesia during surgery and pain management.
Bariatric Surgery	The specialty of treating obesity with surgery.
Cardiac Surgery	The specialty of treating heart problems with surgery.
Cardiothoracic Surgery	The specialty of treating heart, lung and other problems in the chest with surgery.
Colon & Rectal Surgery	The specialty of treating problems of the small and large intestine, the rectum and anus with surgery.
General Surgery	The specialty of treating common abdominal problems such as hernias and appendicitis with surgery.
Gynecologic Surgery	The specialty of treating problems with the female reproductive system with surgery.
Maxillofacial Surgery	The specialty of treating problems of the mouth, jaw, neck and facial bones with surgery.
Neurosurgery	The specialty of treating the central nervous system, including the brain and spinal cord, with surgery.
Obstetrics	The specialty of treating women before, during and after childbirth which may include surgery such as a C-section.
Oncology	The specialty of treating cancer with surgery.
Ophthalmology	The specialty of treating conditions of the eye with surgery.
Oral Surgery	The specialty of treating dental problems with surgery, such as wisdom tooth removal and root canals.
Orthopedic Surgery	The specialty of treating problems of the bones, joints, ligaments and tendons with surgery.
Otolaryngology (Ear, Nose and Throat, ENT )	The specialty of treating problems of the ears, nose and throat with surgery.
Pediatric Surgery	The specialty of treating health problems of children with surgery.
Plastic Surgery: Cosmetic & Reconstructive Surgery	The specialty of improving the appearance for cosmetic reasons, or to correct defects for a more appealing appearance.
Podiatry Surgery (Podiatry)	The specialty of treating problems of the feet with surgery.
Thoracic Surgery	The specialty of treating problems in the chest cavity, except the heart, with surgery.
Transplant Surgery	The specialty of replacing failing organs with donated organs with surgery.
Trauma Surgery	The specialty of treating injuries from car crashes, gunshot wounds, stabbings and other traumatic injuries with surgery.
Vascular Surgery	The specialty of treating problems of the blood vessels with surgery.

Critical, emergency, urgent surgeries have to be performed by physician surgeon medical emergency.

Surgery: Is it really indicated?

A statement mentions that the surgery department lacks equipments and infrastructure.
What type of equipment do you need?
If you audit existing surgeries, you will discover that most of them are not required, and there has been wrong clinical diagnosis.
A diagnosis of appendicitis: on operation, no findings of appendicitis.
A diagnosis of cholecystitis or cholelithiasis: on operation, no findings of cholecystitis or cholelithiasis.
A medical doctor is required to make correct clinical diagnoses. A surgeon is basically a medical doctor.
They ask for number of unwanted investigations but after that they still cannot reach a correct diagnosis and treatment.

Q: Who is a surgeon?
A: A surgeon is a medical doctor with additional training in specific medical procedures. Getting the title of surgeon does not mean he or she is a competent medical doctor. Not all surgeons can perform all medical procedures. Not all medical doctors can perform all medical procedures. Making an eight-inch incision and closing in three layers does not prove you are a surgeon or a medical doctor. Doing a burr hole and closing does not prove you are a surgeon. This is a medical or surgical procedure that can be taught in a few weeks. Doing medical or surgical procedures does not prove you are a competent medical doctor.

The ability to reach to a correct diagnosis and provide treatment is a requirement of all medical doctors while maintaining good character and good behavior.

Surgical Skills

A-Z Surgical Specialties

What are the surgical specialties?

General Surgery

Thoracic Surgery

Colon and Rectal Surgery

Obstetrics

Gynecologic Surgery

Neurological Surgery

Ophthalmic Surgery

Oral and Maxillofacial Surgery

Orthopaedic Surgery

Otolaryngology

Pediatric Surgery

Plastic and Maxillofacial Surgery

Urology

Vascular Surgery

What type of suggestions should a medical doctor (MD) forward to improve training programs in health care and medical education?

What do you have to do in case you need to be a surgeon?

What questions should a medical doctor or surgeon ask an anesthetist?

What are the different types of surgery?
What are the surgical specialties?

Neurosurgery

Q: What is neurosurgery?
Q: What is a neurosurgeon?
Q: Who sees a neurosurgeon?
Q: What might neurological care involve?
Q: What areas of care are available?
Q: Who is a neurosurgeon?
Q: What does neuroscience care involve?
Q: Where is the neuroscience patient cared for?
Q: What medical conditions require brain surgery?
Q: What risks are associated with brain surgery?
Q: How is brain surgery done?
Q: What are other names for brain surgery?
Here are further guidelines.

Cardiothoracic surgery

Q: Who are usually included in the Cardiovascular Thoracic Surgery Department team?
Q: What is an MCh in cardiovascular and thoracic surgery?
Q: How many MCh's in cardiovascular and thoracic surgery are required in the state?
Q: What skills and knowledge are needed for an MCh in cardiovascular and thoracic surgery?
Q: What are the duties and responsibilities of a person with an MCh in cardiovascular and thoracic surgery?
Q: What equipment does cardiovascular and thoracic surgery need?
Q: What other resources does cardiovascular and thoracic surgery need?
Here are further guidelines.

Oral and maxillofacial surgery

How many plastic surgeons are required in the state?
What specific skills and knowledge should be imparted to plastic surgeons?
What specific cases do plastic surgeons treat?
How should plastic surgery research in the state go ahead?
How many plastic surgery operations were done in the state over the past 10 years?
What was the diagnosis and treatment?
How many total cleft lip and cleft palate children have been born in the state over the past 10 years?
At what were they operated on?
What was the outcome of the operation?
How is cleft palate surgery done?
How is cleft lip surgery done?

Orthopaedic surgery

Urology

General surgery

Do all cases of appendicitis need surgery?
Do all cases of cholecystitis or gallstones need surgery?

Dr. Qureshi's technique

Q: What are the advantages of laparoscopy?
A: It is less invasive, cost effective, results in fewer infections, and shorter hospital stay. Also, early return to work, minimal postoperative complications, and cosmetic advantages, too.

Can appendicitis be managed with endoscopic/Laparoscopy removal without general anesthesia?
Q: What does the surgeon use to close the wound?
Q: What is the difference between sutures, staples and Steri-Strips?
Q: Do all sutures dissolve?
Q: Is it painful to have sutures and staples removed?
Q: How is the wound bandaged?
Q: How should I care for my wound?
Q: Is it normal for the wound to itch?
Q: How do I take care of my wound at home?
Q: When can I take a shower?
Q: Does it take a long time for the wound to heal?

Do you have a question?
Can you make me wiser? How?
Can you make us wiser? How?
Would you like to add anything?

Who among you has done laparoscopic surgery?
How many surgeries have you done so far?
What was the diagnosis?
What were the indications?
What were the results?
Were there any post- procedure complications?
What were these complications?
What is been done to prevent these complications?
Who is the manufacturer of the equipment?
What is the material of the existing equipment?
What is been done to enhance the efficiency of a laparoscopy?
What is been done to train others?
Who has the responsibility to fund this research and development?

Operating Rooms of the Future
Surgical Emergencies

In case of any surgical recommendations, get second and third consultation immediately from supervisors before any surgical recommendations.

Anesthesia

Surgical Instruments

How many surgical instruments are there for human surgery?
There are hundreds of surgical instruments for human surgery.

Can you name various surgical instruments?
Instruments used in general surgery.

What are six classes of surgical instruments by functions?
Six classes of surgical instruments by function.
1. Cutting surgical instruments
2. Grasping or holding surgical instruments
3. Haemostatic forceps surgical instruments (instruments used to stop blood flow)
4. Retractors surgical instruments
5. Clamps and distractors surgical instruments
6. Accessories and implants surgical instruments

What minimum resources are required by physician surgeon medical emergency and physician surgeon elective surgery in general surgery emergency or elective surgery?
1. Surgical needle holder
2. Surgical needle with thread
3. Scalpel
4. Haemostatic forceps
5. Suction tips and tubes
6. Dressing (medical)
7. Surgical table
8. Physician for assistance
9. General anesthesia (anesthetist)
10. Guide, for example Doctor Asif Qureshi at www.qureshiuniversity.com/surgeryworld.html from a distance.

If any juniors or students are around, this must be recorded.

In various surgeries other than general surgery emergency or elective, these surgery resources are required plus some extra surgical instruments.
Nowadays, computer and Internet with guidelines at www.qureshiuniversity.com/surgeryworld.html are essential.

What are several classes of surgical instruments?
There are several classes of surgical instruments:
Graspers, such as forceps
Clamps and occluders for blood vessels and other organs
Retractors, used to spread open skin, ribs, and other tissue
Distractors, positioners and stereotactic devices
Mechanical cutters (scalpels, lancets, drill bits, rasps, trocars, Ligasure, Harmonic scalpel, surgical scissors, rongeurs etc.)
Dilators and specula, for access to narrow passages or incisions
Suction tips and tubes, for removal of bodily fluids
Sealing devices, such as surgical staplers
Irrigation and injection needles, tips and tubes, for introducing fluid
Powered devices, such as drills, dermatomes
Scopes and probes, including fiber optic endoscopes and tactile probes
Carriers and appliers for optical, electronic, and mechanical devices
Ultrasound tissue disruptors, cryotomes, and cutting laser guides
Measurement devices, such as rulers and calipe

Cardiothoracic surgery, neurosurgery, orthopedic surgery, plastic surgery, other categories have some extra instruments compared to general surgery emergency or elective surgery.

Inside operating room

Is there a difference between operating room equipment and surgical instruments?
Yes, there is.

What are examples of operating room equipments?
What are examples of surgical instruments?

Operating Room Equipment

Operating room management

Operating Room Skills

Operating Room Skills Checklist

Surgical instruments

Surgical Documentation

What is emergency surgery?
How should emergency surgeries be classified?
What cases need emergency surgery?
What cases need an emergency operating room (OR)?
What cases need elective surgery?
What cases need an elective operating room (OR)?
What are examples of emergency surgeries?
Is there a difference between operating room equipment and surgical instruments?
What are examples of operating room equipments?
What are examples of surgical instruments?

Emergency Operating Room

Proposed operation
_______________________________

Urgency of case (choose)

Immediate (e.g. haemorrhage or laparotomy for septic shock)

Emergency (e.g. laparotomy for patient with organ dysfunction, tender obstruction, peritonitis)

Urgent (e.g patient with sepsis not as severe as above such as mild appendicitis)

Scheduled (e.g. non-elective but non-critically ill patient with obstruction, perianal abscess without systemic sepsis, diagnostic laparoscopy)

Delay from time of booking (in hours)
_______________________________

Time of day (choose)
_______________________________

Cause of delay
_______________________________

OPERATING ROOM ORIENTATION MANUAL

Goals & Objectives

After 30 minutes of orientation, the JMS should be able to:

Discuss the principles of aseptic technique
Demonstrate surgical scrub, gowning, and gloving
Identify hazards in the surgical setting
Identify the role of the scrub person, circulating nurse, and medical student
Discuss ways the JMS can participate in the care of the patient and thereby become an active, useful member of the surgical team

Lockers

Lockers are available for your use during the hours between 0700-1800 while you are in the operating room.
You must bring your own lock.
Locks must be removed by 1800.
Any locks not removed between 1800-0700 are subject to being cut and contents removed for later disposition.

Surgical Operating Suites

DRESS CODE - SURGICAL ATTIRE

All persons who enter the semirestricted and restricted areas of the surgical suite should be in hospital laundered surgical attire intended for use only within the surgical suite at UTMB.

All possible head and facial hair, including sideburns and neckline, should be covered when in the surgical suite. All persons entering an operating room or centerwell area should wear a mask.

All personnel entering the suite should have all jewelry confined or removed. Watches and plain wedding bands are acceptable. Earrings must be covered by the scrub cap. Nail polish and artificial nails should not be worn within the suite.

Protective barriers (gloves, masks, protective eyewear, and face shields) are provided by the hospital and should be utilized to reduce the risk of exposure to potentially infective agents.

Shoes should be dedicated to the OR and shoe covers are not required. If shoe covers are necessary, the wearer should remove them before leaving the operating room to avoid tracking blood and debris through the department.

SURGICAL HAND SCRUB

A five (5) minute anatomical timed scrub will be used for all surgical hand scrubs.

Fingernails must be free of polish/enamel and of medium length. No jewelry is permitted on the hands and arms while performing as a member of the surgical team. **Remember to put your mask on prior to starting you scrub.** Wash hands and arms with solution to 2 inches above the elbow. Clean fingernails with file. Take sterile brush in right hand. Wet brush with water and soap. Scrub fingernails of left hand. Start scrubbing fingers of left hand, one at a time, treating each finger as four-sided; palm, knuckles, and back of hand. Repeat with right hand.

Scrub right wrist and continue up arm to 2 inches above elbow. Repeat with left arm. Discard brush. Rinse both hands and arms under running water keeping hands above level of elbow so that water runs off the elbows and not the hands.

Gloving Procedure - Open

Avoid contact of sterile gloves with ungloved hands during closed-glove procedure.

For closed-glove method, never let the fingers extend beyond the stockinette cuff during the procedure. Contact with ungloved fingers constitutes contamination of the glove. For open-glove method, touch only the cuff of the glove with ungloved hand, and then only glove to glove for other hand. If contamination occurs during either procedure, both gown and gloves must be discarded and new gown and gloves must be added.

When removing gloves after a procedure is finished, the gloves are removed after the gown is removed inside out, using glove-to-glove, then skin-to-skin technique.

Gloving Procedure - Closed

Points to Remember about Aseptic Technique

Adherence to the Principles of Aseptic Technique Reflects One's Surgical Conscience.

1. The patient is the center of the sterile field.

2. Only sterile items are used within the sterile field.
A. Examples of items used.
B. How do we know they are sterile? (Wrapping, label, storage)

3. Sterile persons are gowned and gloved.
A. Keep hands at waist level and in sight at all times.
B. Keep hands away from the face.
C. Never fold hands under arms.
D. Gowns are considered sterile in front from chest to level of sterile field, and the sleeves from above the elbow to cuffs. Gloves are sterile.
E. Sit only if sitting for entire procedure.

4. Tables are sterile only at table level.
A. Anything over the edge is considered unsterile, such as a suture or the table drape.
B. Use non-perforating device to secure tubing and cords to prevent them from sliding to the floor.

5. Sterile persons touch only sterile items or areas; unsterile persons touch only unsterile items or areas.
A. Sterile team members maintain contact with sterile field by wearing gloves and gowns.
B. Supplies are brought to sterile team members by the circulator, who opens wrappers on sterile packages. The circulator ensures a sterile transfer to the sterile field. Only sterile items touch sterile surfaces.

6. Unsterile persons avoid reaching over sterile field; sterile persons avoid leaning over unsterile area. A. Scrub person sets basins to be filled at edge of table to fill them.
B. Circulator pours with lip only over basin edge.
C. Scrub person drapes an unsterile table toward self first to avoid leaning over an unsterile area. Cuff drapes over gloved hands.
D. Scrub person stands back from the unsterile table when draping it to avoid leaning over an unsterile area.

7. Edges of anything that encloses sterile contents are considered unsterile.
A. When opening sterile packages, open away from you first. Secure flaps so they do not dangle.
B. The wrapper is considered sterile to within one inch of the wrapper.
C. In peel-open packages, the edges where glued, are not considered sterile.

8. Sterile field is created as close as possible to time of use.
A. Covering sterile tables is not recommended.

9. Sterile areas are continuously kept in view.
A. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated.

10. Sterile persons keep well within sterile area.
A. Sterile persons pass each other back to back or front to front.
B. Sterile person faces a sterile area to pass it.
C. Sterile persons stay within the sterile field. They do not walk around or go outside the room.
D. Movement is kept to a minimum to avoid contamination of sterile items or persons.

11. Unsterile persons avoid sterile areas.
A. Unsterile persons maintain a distance of at least 1 foot from the sterile field.
B. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it.
C. Unsterile persons never walk between two sterile fields. D. Circulator restricts to a minimum all activity near the sterile field.

12. Destruction of integrity of microbial barriers results in contamination.
A. Strike through is the soaking through of barrier from sterile to non-sterile or vice versa.
B. Sterility is event related.

13. Microorganisms must be kept to irreducible minimum.
A. Perfect asepsis is an idea. All microorganisms cannot be eliminated. Skin cannot be sterilized. Air is contaminated by droplets.

HAZARDS IN THE SURGICAL SUITE

Electrical

Cautery Units, Defibrillators, OR Beds, numerous pieces of equipment All equipment must be checked for electrical safety before use!!

Anesthetic Waste

Radiation

Leaded aprons and shields available for use during procedures.

Laser Safety

Protective eyewear for patient and operating team. Doors remain closed with sign - "Danger, Laser in Use." Sterile water available in the room and on sterile field. Smoke evacuation system is to be employed when applicable. Surgery high filtration masks should be worn during procedures that produce a plume.

General Safety

Apply good body mechanics at all times when transferring patients. Operating room beds and gurneys will be locked before patient transfer. Operating safety belts will be used for all patients. Never disconnect or connect electrical equipment with wet or moist hands. Discard all needles, razors, scalpel blades and broken glass into special identified containers.

UNIVERSAL PRECAUTIONS SUMMARY

Precautions should be followed to reduce the risk of exposure to bloodborne pathogens. Each healthcare worker should assess their possible risks and take precautions to reduce these risks. Universal Precautions are designed to protect healthcare workers from occupational exposure and should be followed when potential for exposure might occur.

Universal blood and/or body fluid precautions should be consistently used for ALL patients. Fundamental to the concept of Universal Precautions is treating all blood and/or body fluids as if they were infected with bloodborne pathogens and taking appropriate protective measures, including the following:

1) Gloves should be worn for touching blood and/or body fluids, mucous membranes, non-intact skin, or items/surfaces soiled with blood and/or body fluids. Gloves should be changed after contact with each patient and hands washed after glove removal. Though gloves reduce the incidence of contamination, they cannot prevent penetrating injuries from needles and other sharp instruments.

2) Gowns or aprons should be worn during procedures that are likely to generate splashes of blood and/or body fluids onto clothing or exposed skin.

3) Masks and protective eyewear should be worn during procedures that are likely to generate droplets of blood and/or body fluids into the mucous membranes of the mouth, nose, or eyes.

4) Needles and sharps should be placed directly into a puncture-resistant leakproof container which should be as close as possible to the point of use. Needles should not be recapped, bent, broken, or manipulated by hand.

5) Hands and skin surfaces should be washed after contact with blood and/or body fluids, after removing gloves, and between patient contact.

6) Gloves should be worn to cleanup blood spills. Blood spills should be wiped up and then an EPA registered tuberculocidal disinfectant applied to the area. The disinfectant should have a one minute contact time and the area rinsed with tap water. If glass is involved, wear double gloves or heavy gloves. Pick up the glass with broom and dust pan, tongs, or a mechanical device.

7) Healthcare workers with exudative lesions or weeping dermatitis should not perform direct patient care until the condition resolves.

8) Disposable resuscitation devices should be used in an emergency.

9) Occupational Exposures: Definition
- Puncture wounds
- Needlesticks/Cuts
- Splashes into the eyes, mouth, or nose
- Contamination of an open wound

10) Occupational Exposures:
- Wash the area immediately with soap and water
- If splashed in the eyes mouth or nose have them properly flooded or irrigated with water
- Notify supervisor as soon as possible
- Call Employee Health Center at (409) 772-5582 for information regarding blood and/or body fluid exposure management

SAMPLE EVALUATION FORM

COMPARATIVE DIVISION OF DUTIES

Scrub Nurse/Technician

A. Preoperative

Checks the card file for surgeon's special needs/requests. Opens sterile supplies.

Scrubs, gowns, and gloves and sets up sterile field. Obtains instruments from flash autoclave if necessary. Checks for proper functioning of instruments/equipment. Performs counts with circulator.

B. Preincisional

Completes the final preparation of sterile field. Assists surgeon with gowning/gloving. Assists surgeon with draping and passes off suction/cautery lines.

C. During the Procedure

Maintains orderly sterile field.

Anticipates the surgeon's needs (supplies/ equipment). Maintains internal count of sponges, needles and instruments. Verifies tissue specimen with surgeon, and passes off to circulator.

D. Closing Phase

Counts with circulator at proper intervals.
Organizes closing suture and dressings.
Begins clean-up of used instruments.
Applies sterile dressings.
Prepares for terminal cleaning of instruments and nondisposable supplies.
Reports to charge nurse for next assignment.

Circulating Nurse

A. Preoperative

Assists in assembling needed supplies.
Opens sterile supplies.
Assists scrub in gowning.
Performs and records counts.
Admits patient to surgical suite.

B. Preincisional

Transports patient to procedure room.
Assists with the positioning of the patient.
Assists anesthesia during induction.
Performs skin prep.
Assists with drapes; connects suction and cautery.
C. During the Procedure

Maintains orderly procedure room.
Anticipates needs of surgical team.
Maintains record of supplies added.
Receives specimen and labels it correctly.
Maintains charges and O.R. records.
Continually monitors aseptic technique and patients needs.

D. Closing Phase

Counts with scrub at proper intervals.
Finalizes records and charges.
Begins clean-up of procedure room.
Applies tape.
Assists anesthesia in preparing patient for transfer to PACU.
Takes patient to PACU with anesthesia and reports significant information to PACU nurse.
Disposes of specimen and records.
Reports to charge nurse for next assignment.

Medical Student

A. Preoperative

* Introduce self to nursing personnel.
** If "scrubbing in" on case, informs scrub person of glove and gown size.

B. Preincisional

* Assists with transfer of patient to OR bed.
* Brings patient a warm blanket.
* Performs patient catheterization if necessary.
* Performs skin prep.
** If "scrubbing in" on case, begin scrub early.
** If "scrubbing in" on case, assists surgeon and/or scrub person with draping when appropriate.

C. During the Procedure

* Answers physician pagers.
* Runs specimen to lab, when appropriate.

D. Closing Phase

* Assists with undraping of patient.
* Assists in preparing patient for transfer to PACU:
- Brings patient a warm blanket.
- Brings patient bed/stretcher into room.
- Assists with transfer of patient from OR bed to stretcher/bed.

For Surgeons

For Patients

Physician surgeon elective surgery

What should physician surgeon elective surgery know?

Annotation or definition of elective surgeries.

Basic abilities of a physician primary care, physician medical emergency room.

Surgical skills.

Seniority

Questions that need answers before, during, and after surgical procedure.

Types of elective surgeries.

Operating room equipment

Operating room management

Operating room skills

Operating room skills checklist

Patients

Surgical instruments

Annotation or definition of elective surgeries.

Elective surgery

What is elective surgery?
What are the different types of Elective Surgery?
Which kind of surgeries are termed Elective?
How is the patient diagnosed and prepared for an elective surgery?
What is the post-operative procedure for an elective surgery?
What are the complications of an Elective Surgery?
Are all Elective Surgeries successful?

What is elective surgery?
Elective surgery is a term used for non-emergency surgery which is medically necessary, but can be delayed for at least 24 hours.
People who need emergency treatment will not be placed on the elective surgery list.
Elective surgery is usually performed in an operating theatre or procedure room under some form of anaesthesia by a surgeon.
Elective surgery is different to cosmetic surgery, which is not performed in public hospitals.

An elective surgery is a planned, non-emergency surgical procedure. It may be either medically required (e.g., ________ surgery), or optional (e.g., breast augmentation or implant) surgery.

Elective surgery or elective procedure is surgery that is scheduled in advance because it does not involve a medical emergency. Semi-elective surgery is a surgery that must be done to preserve the patient's life, but does not need to be performed immediately.

By contrast, an urgent surgery is one that can wait until the patient is medically stable, but should generally be done today or tomorrow, and an emergency surgery is one that must be performed without delay; the patient has no choice other than immediate surgery, if they do not want to risk permanent disability or death.
Purpose

Elective surgeries may extend life or improve the quality of life physically and/or psychologically.

As a principle for elective surgery, patients are treated in accordance with their urgency category, but within each urgency category most patients are treated in the same order they are added to the waiting list. Elective surgery is different to cosmetic surgery, which is not performed in public hospitals.

Category	Clinical description	Meaning
Category 1 – Urgent	Has the potential to deteriorate quickly to the point where it may become an emergency.	Procedures that are clinically indicated within 30 days
Category 2 – Semi urgent	Causes pain, dysfunction or disability. Unlikely to deteriorate quickly. Unlikely to become an emergency.	Procedures that are clinically indicated within 90 days
Category 3 – Non-Urgent	Causes minimal or no pain, dysfunction or disability. Unlikely to deteriorate quickly. Does not have the potential to become an emergency.	Procedures that are clinically indicated within 365 days Here are further guidelines.

What should physician surgeon elective surgery know?
You have to know everything of these entities.

General surgery elective surgeries

Thoracic surgery elective surgeries

Colon and rectal elective surgeries

Obstetrics elective surgeries

Gynecologic elective surgeries

Neurological elective surgeries

Ophthalmic elective surgeries

Oral and maxillofacial elective surgeries

Orthopaedic elective surgeries

Otolaryngology elective surgeries

Pediatric elective surgeries

Plastic and maxillofacial elective surgeries

Urology elective surgeries

Vascular elective surgeries

These abilities are must in addition to be basically a physician with abilities of diagnosis and treatment in various healthcare settings.

You can ask assistance of computer, Internet with http://www.qureshiuniversity.com/surgeryworld resources.

Surgical incision

Alert for all physicians.

In what situations in surgical emergencies or elective procedures is incision not required?
If there is any stab wound that caused prolapse of intestines, do not do any incision.
Do not do any laparotomy.
Do not cut any site or location in this situation.
Relocate the intestines to their original location and suture the stab wound.
Critical monitoring of the individual is required.

In what situation is surgical incision required?
See surgical incisions details.

What are the types of surgical incisions?
Head and neck
Chest
Abdomen and pelvis
Eye

Head and neck

Wilde's incision

Descriptions of Common Neurosurgical Operations

Burr Holes and Craniotomy
Anterior Cervical Discectomy and Fusion
Lumbar Microdiscectomy
Lumbar Decompressive Laminectomy
Carpal Tunnel Release
Ulnar Nerve Decompression or Transposition

Chest

I do not recommend Median sternotomy procedures unless the likely advantage to patient is discussed and verified.

Median sternotomy - This is the primary incision used for cardiac procedures. It extends from the sternal notch to the xiphoid process. The sternum is divided, and a finochietto retractor used to keep the incision open.

Thoracotomy - A division of the ribs from the side of the chest.

Abdomen and pelvis

Midline incision or midline laparotomy - The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba. The upper midline incision usually extends from the xiphoid process to the umbilicus.

A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly. Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery. Typically, a smooth curve is made around the umbilicus.

Pfannenstiel incision - The Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis. In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically. It is the incision of choice for Caesarean section and for abdominal hysterectomy for benign disease.

Chevron incision - This incision a cut is made on the abdomen below the rib cage. The cut starts under the mid-axillary line below the ribs on the right side of the abdomen and continues all the way across the abdomen to the opposite mid-axillary line thereby the whole width of the abdomen is cut to provide access to the liver. The average length of the incision is approximately 24 to 30 inches.

Cherney incision - Cherney described a transverse incision that allows excellent surgical exposure to the space of Retzius and the pelvic sidewall. The curvilinear skin and rectus fascial incision is made 2 finger breadths above the symphysis pubis and carried in Langer's lines from 2 fingerbreadths medial to one anterior superior iliac spine to the corresponding position medial to the opposite anterior superior iliac spine. The anterior rectus fascia is mobilized distally off the underlying rectus muscle bodies. The pyramidalis muscles are dissected free and sharply excised to expose the underlying rectus tendons. With an index finger, a plane is developed between the fibrous tendons of the rectus muscle and the underlying transversalis fascia. Using a sharp no.10 scalpel blade, the rectus tendons are transected transversely 1–2 cm distal to the superior edge of the pubic bone. Rectus muscle should never be cut. The rectus muscles are retracted and the peritoneum opened.The inferior epigastric vessels may need division. Closure is accomplished with 5 to 6 horizontal mattress sutures of permanent braided suture approximating the anterior rectus tendons to the intact distal anterior rectus fascia. Continuous monofilament suture closure of lateral edges of the rectus muscle to the anterior rectus fascia prevents hernia. Patients should wear a binder for at least 2 weeks. No incision provides wider pelvic exposure, and is relatively painless compared to midline incisions. Result is the most pleasing cosmetic result of any abdominal incision.

Gridiron's incision (Mc Burney's incision) - Described in 1894 by McBurney, used for appendectomy. An oblique incision made in the right lower quadrant of the abdomen, classically used for appendectomy. Incision is placed perpendicular to the spinoumblical line at Mc Burney's point, i.e. at the junction of lateral one-third and medial two-third of spino-umblical line.

Kocher’s incision - An oblique incision made in the right upper quadrant of the abdomen, classially used for open cholecystectomy. Named after Emil Theodor Kocher. It is appropriate for certain operations on the liver, gallbladder and biliary tract. This shares a name with the Kocher incision used for thyroid surgery: a transverse, slightly curved incision about 2 cm above the sternoclavicular joints;
Kustner’s incision - A transverse incision is made 5 cms above the symphysis pubis but below the anterior iliac spine. The subcutaneous tissue is then separated in the midline and the linea alba is exposed. A vertical midline incision is made through the linea alba. Care is taken to control and ligate any branches of the superficial epigastric vessels. This step of the incision is usually time consuming and is one of the limitations associated. This type of incision offers little extensibility and less exposure than a Pfannestiel incision.

Lanz incision - A variation of the traditional Mc Burney's incision, which was made at McBurney's point on the abdomen: The Lanz incision is made at the same point along the transverse plane and deemed cosmetically better. It is typically used to perform an open appendectomy. Variations exist on the method used to locate the incision. Some surgeons advocate that the incision is made approximately 2 cm below the umbilicus centered on mid clavicular-midinguinal line. Others imply use of McBurney's point to center the incision (1/3rd of the distance from the anterior superior iliac spine to the umbilicus). Maylard incision - A variation of Pfannenstiel incision is the Maylard incision in which the rectus abdominis muscles are sectioned transversally to permit wider access to the pelvis.[4] The Maylard incision is also called the Mackenrodt incision. The incision in the rectus muscles is performed with the help of cautery, scalpel or surgical stapler. It is important to identify the inferior epigastric vessels on the lateral surface of these muscles and ensure their isolation and ligation if the incision will span more than half the rectus muscle width. It is advisable not to separate the rectus muscles from the anterior rectus sheath to prevent their retraction, which in turn facilitates closure at the end of the procedure. Among the complications associated with this type of incision is delayed bleeding from the cut edges of the rectus muscles as well as the deep epigastric vessels. Furthermore depending on the patient's body habitus, this incision may not offer adequate exposure to the upper abdomen.

McBurney incision - This is the incision used for open appendectomy, it begins 2 to 5 centimeters above the anterior superior iliac spine and continues to a point one-third of the way to the umbilicus (McBurney's point). Thus, the incision is parallel to the external oblique muscle of the abdomen which allows the muscle to be split in the direction of its fibers, decreasing healing times and scar tissue formation. This incision heals rapidly and generally has good cosmetic results, especially if a subcuticular suture is used to close the skin.

McEvedy's incision - McEvedy's original incision was a lateral paramedian incision which used to incise the rectus sheath along its lateral margin and gain access by pulling the rectus medially. This incision became obsolete because of very high incisional hernia rate. A modification was introduced by Nyhus which used a transverse (oblique) skin incision 3 cm above the inguinal ligament and a transverse incision (oblique) to divide the anterior rectus sheath. The rectus muscle was then pulled medially. This modification prevented the high incisional hernia rate.

Turner-Warwick's incision - This type of incision is placed 2 cm above the symphysis pubis and within the lateral borders of the rectus muscles. The sheath overlying the rectus muscles at the symphysis pubis is released, 4 cm transversely, and the incision angled up to the lateral borders of the rectus muscles. The lateral edges of the incisions remain medial to the internal oblique muscles. The sheath may be released off the aponeurosis with the help of traction applied using Kocker clamps. The pyramidalis muscles are typically left attached to the aponeurosis. The rectus muscles are separated and the incision is made in the midline. This type of incision is good for exposure of the retropubic space but offers limited access to the upper pelvis and abdomen.

Eye

I do not recommend Mini Asymmetric Radial Keratotomy and Radial keratotomy procedures unless the likely advantage to patient is discussed and verified.

Mini Asymmetric Radial Keratotomy -Used in eye surgery to cure keratoconus and correct astigmatism. It consists of a series of microincisions of variable depth, with a length between 1.75 and 2.25 millimeters, always made with a diamond knife, designed to cause a controlled scarring of the cornea, which changes its thickness and shape.

Radial keratotomy - Used in eye surgery: corneal microincisions made to flatten the cornea and correct myopia.

Surgical tables

What are the types of surgical tables?
There are at least nine types of surgical tables.
C-arm tables
Examination table
Examination table powered
Lithotripsy tables
Operating room tables
Procedure Chairs
Ultrasound tables
Urology tables
Surgical table with table accessories

What type of surgical table is required for this surgery procedure?

Position on surgical table:

What are the types of surgical positions?
Supine
Lithotomy (stirrups)
Prone
Jackknife (3500 or 6001)
Right lat decubitus (bean bag)
Left lat decubitus (bean bag)
There are at least 14 positions on a surgical table.

Here are further facts.

Supine position	The most common surgical position. The patient lies with back flat on operating room bed.
Trendelenburg position	Same as supine position but the upper torso is lowered.
Reverse Trendelenburg position	Same as supine but upper torso is raised and legs are lowered.
Fracture Table Position	For hip fracture surgery. Upper torso is in supine position with unaffected leg raised. Affected leg is extended with no lower support. The leg is strapped at the ankle and there is padding in the groin to keep pressure on the leg and hip.
Lithotomy position	Used for gynecological, anal, and urological procedures. Upper torso is placed in the supine position, legs are raised and secured, arms are extended.
Fowler's position	Begins with patient in supine position. Upper torso is slowly raised to a 90 degree position.
Semi-Fowlers position	Lower torso is in supine position and the upper torso is bent at a nearly 85 degree position. The patient's head is secured by a restraint.
Prone position	Patient lies with stomach on the bed. Abdomen can be raised off the bed.
Jackknife position	Also called the Kraske position. Patient's abdomen lies flat on the bed. The bed is scissored so the hip is lifted and the legs and head are low.
Knee-chest position	Similar to the jackknife except the legs are bent at the knee at a 90 degree angle.
Lateral position	Also called the side-lying position, it is like the jackknife except the patient is on his or her side. Other similar positions are Lateral chest and Lateral kidney.
Lloyd-Davies position	It is a medical term referring to a common position for surgical procedures involving the pelvis and lower abdomen. The majority of colorectal and pelvic surgery is conducted with the patient in the Lloyd-Davis position.
Kidney position	The kidney position is much like the lateral position except the patient's abdomen is placed over a lift in the operating table that bends the body to allow access to the retroperitoneal space. A kidney rest is placed under the patient at the location of the lift.
Sims' position	The Sims' position is a variation of the left lateral position. The patient is usually awake and helps with the positioning. The patient will roll to his or her left side. Keeping the left leg straight, the patient will slide the left hip back and bend the right leg. This position allows access to the anus.

What should be the position of the patient on the surgical table?

Document that should be ready before any surgery operation room scheduling facts

Surgical procedure
Questions that need answers before, during, and after surgical procedure.
What questions should be answered before, during and after surgical procedure?

Questions to be answered before the surgery.

Preoperative instructions

Questions to be answered in postoperative notes.

Questions to be answered in follow-up consultations.

If the expected procedure or surgery is likely to harm the patient, do not go ahead with surgery. If all the questions are not answered, do not go ahead with surgery.

Questions to be answered before the surgery.

Where is the patient now?

What is the name of the individual who needs doctor consultation?

What is the date of birth of the individual who needs doctor consultation?

What is your mailing address?

What was your mailing address from birth until now?

What is your Email address?

Where do you live now?
How long have you lived at this address?

How long do you plan to live at this address?

What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency?

Questions to be answered before the surgery.
Who will do the expected procedure?

What is the expected procedure?

What is the expected date, time, and location of surgery?

What is the diagnosis of the patient?

Who verified the diagnosis of the patient?

What prominent mark is on the face or body of the individual for identification?

What is the profile of the patient’s primary care physician?

How will this procedure help or enhance the life of the patient?

Is the surgery really required?

If surgery is really indicated, these questions must be answered. Why do you recommend this operation?

What operation are you recommending?

Is there more than one way to do this operation?

Are there alternative to surgery?

What are the details of the operation?

What are the advantages of this operation?

What are the risks of having this operation?

What will happen if this operation is not done?

Who can give a second opinion?

What kind of anesthesia is required?

How long is the operation?

How long will it take to recover from the operation?

How much experience has the doctor had in diagnosing and treating such cases?

How much experience does the doctor have in this specific operation?

Has this type of operation been discussed publicly?

At what hospital will the operation be done?

How long will the doctor be available in the hospital?

Has the surgeon marked the site where he or she will operate with all the preoperative, operative, and postoperative guidelines?

What is the gender of the patient?
What best describes the patient?:
Child
Adolescent girl
Adolescent boy
Woman
Man

What best describes the surgery?
Cardiothoracic surgery
Eye surgery
General surgery
Neurosurgery
OB/GYN surgery
Oral and maxillofacial surgery
Orthopedic surgery
Otolaryngology
Pediatric surgery
Plastic surgery
Urology

Is this emergency surgery, urgent surgery, or elective surgery?
What are examples of emergency surgery, urgent surgery, and elective surgery?

Emergency surgery
www.qureshiuniversity.com/emergencysurgery.html

Urgent surgery
href://www.qureshiuniversity.com/urgentsurgery.html

Elective surgery
href://www.qureshiuniversity.com/electivesurgery.html

Physician surgeon medical emergency
Here are further guidelines.

Here are further guidelines.

Last Updated: March 13, 2017