4th edition POTTS compiled by Diann Adams & Timothy Williams Cardiothoracic pictures provided by Mario Guthrie (Class

2004) In e a! " tables# $% 2% '% 4% *% GI G& O(T)O POTS +naesthetics , resus%

Cover 2 ite!s in * !ins% POTTS 1. DESCRIPTION2. Interpretation 3. Diagnosis 4. Clinical & pathological eat!res. (e-ard the .uestion as an invitation to spea/ on sub0ect, 12rite a verbal essay on sub0ect3 e.g. This is a potted specimen of a bladder with thickened bladder wall with trabeculation & diverticula. It is enlarged in a more symmetrical fashion. The median lobe appears prominent . I think this represents a chronic bladder outflow obstruction, most likely due to prostatic enlargement most likely benign. This patient may have presented with clinical features and pathological features.

4 , O( I think this is a carcinoma of the stomach which seemed gastric outlet obstruction & may have metastasi ed to regional !. nodes & may have involved full thickness of stomach. "r Wall of #.$ appears thin. #.$. is dilated. In the lumen solitary, oval shaped white stone. In the region of outflow tract appears to be bulbous & became impacted in outlet tract acute cholecystitis. %erosal surface should normally be smooth & shiny, now appears shaggy could be involved in acute cholecystitis .I think it is a case of cholelithiasis which appears to be complicated by cholecystitis.

INSTR"#ENTS $ DITC% 1. 2. 3. 4. Definition :Identification complete Indication Technique Complication/Contraindication

$% 5ia-nostic

5(+I6S
Therapeutic

OP76 Passive +ctive Passive

C8OS75 +ctive

Penrose ump drain !drains urine Drains peritoneal ca"it#. In retroperitoneal pace. Corri$ate !i.e. a tu%e in tu%e& ! capillar# action on fluid drains do'n inner tu%e drain. put suction 'ithin another tu%e 'ith openin$s. ( ris) of infec*n+ non(porta%le. Chest tu%e

"SE& 1.Drain infected ca"ities

"SE& 1.,esopha$eal atresia

e.$. -reast a%scess

2.Intra(a%dominal a%scesses 3.Post( op acute pancreatitis

C/I: 1. terile areas 2..edullar# ca"it# of %one. 3.Pleural ca"it#

The corru$ated drain is used for draina$e of su%cutaneous ca"ities e$ a%scess. It is placed in dependent position so it drains. / safet# pin should %e added to it to ensure it does not mi$rate.

PICT"RE 'E(O) T*+EN ', #*RIO -"T.RIE $Class 2//4% sho0s an !n1er 0ater seal an1 chest t!2e 0ith trocar. Recall a chest t!2e connecte1 to an !n1er- 0ater seal $0ith s!ction attache1% 2eco3es a close1 acti4e 1rain.

C(OSED DR*INS P*SSI5E N-T c. 2ag *CTI5E .e3o4ac !se1 post& nec) 0 %reast 0 $roin 0 1#mphatic 0 2ac)son Pratt drain ! loo)s li)e a transparent $renade. It is used to pre"ent a collection occurrin$ in closed ca"it# e$ Postmastectom# or post( th#roidectom#. The 3 *s to remem%er %efore remo"al of 2ac)son Pratt drain : ( Stitch remo"al ( Suction discontinuation ( Slo'+ stead# pull

T-T!2e "rinar6 catheter $7 2ag% Passi"e drains 'or) %# capillar# action.

2.

S"'C(*5I*N C*T.ETER "SES&

DI*-NOSTIC 1. .easures C3P !central "enous pressure& 2.To rapidl# $ain I3 access 'hen peripheral "eins are collapsed.

T.ER*PE"TIC 1. /dminister: i. Total parenteral feed. ii. .edication iii. Chemotherap# i". Infuse h#pertonic fluids to pre"ent sclerosis of peripheral "eins ". 4or haemodial#sis

I##EDI*TE C*T.ETER& 1. 2. 3. 4. 6. 7. 8. :. ;.

CO#P(IC*TIONS

O8

S"'C(*5I*N

Pneumothora0 5aemothora0 5emorrha$e 'hen #ou puncture su%cla"ian /. /ir em%olism Catheter em%olism Cardiac arrh#thmias -rachial ple0us in9ur# Ch#lothora0 if infuse fluid and #ou are into l#mphatic ca"it#. 5#drothora0 if infuse fluid and #ou are in pleural ca"it#.

(*TE CO#P(IC*TIONS& 1. 2. 3. 4. Infections econdar# haemorrha$e Throm%osis of "essels /3 malformation

/fter one places the su%cla"ian line+ listen to chest < do C=>.

3.)O"ND DR*INS
#alecot $ 'at0ing% an1 DePe99er $ #!shroo3 &+ there are self (retainin$ catheters! e"idenced %# self retainin$ flan$e&. #aleco an1 Depe99er catheters can %oth %e used for : uprapu%ic c#stostom# ?astrostom# Pel"ic drain INDIC*TIONS & 1. 4ailed transurethral catheteri@ation 2. Continuous irri$ation of %ladder in the a%sence of 3( 'a# catheter. These supra(pu%ic catheters are remo"ed %# insertin$ a metallic st#let. E:a3ples o other 0o!n1 1rains are& Penrose drain Ci$arette A Penrose 'ith $au@e 'ic) Corru$ate drain T( tu%e Disa14antage o open 1rain A .ore suscepti%le to infections *14antages o close1 1rain& 1. Can monitor fluid 2. 1ess ris) of infection

4.T-T"'E
2 trans"erse arms and "ertical arm ( 2 trans"erse arms are inserted pro0imall# into C-D and "ertical arm is passed from duct to the e0ternal en"ironment ! sutured to s)in& -N.'. *R#S *RE TRI##ED TO SI;E (on da# 1 appro0. 6BBml %ile is put out per da# ( / T Tu%e cholan$io$ram is done on 1Bth da# post( op %ecause there is a possi%ilit# of retained stones in %iliar# tree. /lso one 'ants to see the d#e enter the duodenum. 4lo' should %e strai$ht into %o'el. ( It is usuall# remo"ed after 3/62+ %ut %efore remo"al+ clamp T( tu%e for 24 hrs. and loo) for occurrence or recurrence of Charcots Triad !Intermittent fe"er+ Intermittent 9aundice+ intermittent ri$ors&

INDIC*TIONS 8OR P(*CE#ENT O8 T- T"'E 1. Draina$e < Decompression of %iliar# tree ! after %iliar# tree e0ploration& 2. Cna%les cholan$io$ram intra(op and 1Bth da# post( op. /t da# 1B+ fi%rous tracts are formed. 3. Choledoscope to remo"e remainin$ stones. 4. plint for repair in C-D stricture 6. If returned C-D stone+ used for irri$ation facilitate passa$e of stone. c. D/ to

7. ,ccasionall#+ used to form e0ternal %iliar# fistula in C-D o%struction that 'as not amena%le to internal %#pass. E<TR* NOTES& PTC ! Percutaneous transhepatic cholan$io$ram & $i"es most of the information. E It is done o"er C>CP if patient is icteric. In C>CP+ one $oes from distal to o%struction. / side "ie' duodenoscop# F pancreato$raph# can %e done in C>CP. C>CP is used for sphincterotom#. If sphincterotom# a"aila%le ma# not need to use T(tu%e . 2 procedures to drain C-D intra(op 1. Do choledo9e9unostom# to drain C-D. Note& a chole1ocho1!o1enosto36 is not per or3e1 i C'D = 1.2 c3. OR 2. Transduodenal sphincterotom#. phincterotom# A slit open sphincter phincteroplast# A lit open sphincter F stitch open sections. In this procedure can do a more adequate 9o%. T- t!2e can 2e le t in &

1.C-D 2. ?all %ladder ! if C-D is una"aila%le&+ do a Cholec#stostom#. called cholec#stocholan$io$ram. INDIC*TIONS O8 RE#O5*( O8 T >T"'E Dote at 1B da#s the tract is not formed. 'ait further 7 'ee)s for instrumentation. ,ne has the option of usin$ : Choledochoscope Dormi %as)et 4o$ot# catheter T( tu%e is remo"ed after: 1.Do increased draina$e 2.Do si$ns or s#mptoms of cholan$itis then clamp for 24 hrs. and if o%tain a normal cholan$io$ram or C>CP+ then remo"e the tu%eG. CO#P(IC?NS 1.Casier o%struction of C-D lumen %ec. lumen si@e. 2.-loc)ed tu%e %ec. Clots or %iliar# slud$e. T0 A flush c. D/ < 5eparin 3. lippa$e of tu%e 4.-iliar# peritonitis ! if %ile lea)s around a dislocated tu%e. T0 replace tu%e operati"el#

@. "RET.R*( C*T.ETER&

3 Ha# 4ole# catheter 1 end for urine 1 end for s#rin$e ! to inflate the %ul%& 1 end for irri$ation !'ith 'ater& Indications of use of a 3( 'a# catheter: 1.Hhen the patient presents 'ith a clot and urinar# retention and one 'ants to irri$ate the %ladder. Therapeutic uses of 3 'a# catheter: 1. Post( open prostatectom# 2. Post( transurethral resection of prostate !TI>P& to pre"ent clot retention. &(7T)(+8 C+T)7T7(S elf retainin$ retainin$ e.$. 4ole# catheter "SES& 1. Dia$nostic purposes 2. Therapeutic purposes. Don self( e.$. 2a)es catheter

DI*-NOSTIC "SES O8 A*+ES C*T.ETER $ re1 colo!re1%& 1. Cmpt# the %ladder %efore doin$ a pel"ic procedure 2. . .easure post( "oid residual "olume ! usuall# B& in normal health# adult %ut 1BB(16B mls accepta%le &. 3.4aDoin$ a micturatin$ c#stourethro$ram ! .CI?& Thus facilitates c#sto$ram and urethro$ram 4 6. ,%tain urine for C F . DI*-NOSTIC "SES O8 SE(8- RET*ININ- C*T.ETER 1. .onitorin$ urine output 4or urine output+ for adult need B.6 1.B cc/ )$/ hr. 4or child need 1.B cc/ )$/ hr. Irine output is a reflection of intra"ascular "olume and renal perfusion. 2. .aintains an empt# %ladder. T.ER*PE"TIC& 1.>elie"e acute/Chronic Irinar# retention (painful (%ladder irri$ation (Post( sur$ical Procedures of %ladder < prostate for draina$e. 2.Instillation of dru$s esp. %ladder Ca i.e. immunotherap# "ia intra"esical -C? or chemotherap#.

3.To protect anastomosis in e0tensi"e post( pel"ic 0. Pel"ic operator to e0posure F pre"ent %ladder in9ur#. 4.Pre"ent strictures. Providin- that any contraindications" pass lubricated catheter percutaneously under aseptic conditions% I9 unable " one can do a suprapubic cystoscopy% Dote if the patient had urinar# retention one should record the "olume.

B."RET.R*( 'O"-IE
C0ample: it has 14 4 tip c. 1: 4 shaft ( It is made of metal ( to %e used %# urolo$ist (2TT r 4rench A circumference in 4rench !2r& TT A circumference in 4rench or diameter!3& A si@e in 4rench To con"ert from 1ister to 4rench: !2 0 numerator& 2 is formula used to con"ert from 1ister to 4rench 4iliform %ou$ies are used in I. ./ can allo' someone to ne$otiate a stricture. It is not used in 2amaica.

'O"-IES

3I,1ID 5/PCD -/ C C$. Cloutton -ou$ie

1I TC> !c. rounded end& c.

Don*t start 'ith smallest %ecause it can penetrate+start middle. Contrain1ications& Irethral rupture Irine stasis INDIC?NS& 1. Dilate urethral strictures secondar# to infections.

2. Cali%rate urethra e$. If $oin$ to do a lar$e procedure to use the resectoscope + pass a num%er of %ou$ies to ensure the urethra can accommodate the si@e of the instrument e"entuall# #ou 'ant to use the resectoscope. 3. Can identif# 'here the stricture is + i.e. can pass a sound and it 'ill a%ut the stricture. #ou 'ould )no' 'here to ma)e the incision.

)hat are so3e o the ca!ses o strict!resC

Pre"ious instrumentation strictureJ (meatus ( %ul% (mem%ranous urethra

1. Trauma

/ccidental: e$ )ic) in perineum+ fall off a %ic#cle. In a motor "ehicle accident + the mem%ranous urethra is affected. Pu%oprostatic li$ament can tear mem%ranous urethral in9ur# Complete/ partial tear of .em%ranous urethra. .em%ranous prostatic in9ur# can %e felt per rectal e0amination as a hi$h ridin$ prostate ! due to complete transaction of mem%ranous urethra&

2. ?onococcal and chlam#dial infections.

"RET.R*( STRICT"RES

CON-ENIT*( EPosterior !rethral 4al4e strict!re

*CD"IRED EIn ections

Post ?onococcal urethral strictures affect the %ul%ar urethra: ( ?onococcus has affinit# for areas 'ith $lands !most commonl#&. NS" $ Non- speci ic !rethritis% Chlam#dia+ .#coplasma+ T- !in some places of the 'orld&. Iatro$enic Trauma( Post( Instrumentation .em%ranous urethra .eatus ! C0ternal meatus& &eatal stenosis Trauma ! C0ternal & ( .em%ranous urethra could %e in9ured in pel"ic Ks. can $et: L%ld. /t meatus Lhi$h ridin$ prostate on D>C ! L crotal F perineal ecch#mosis di$ital rectal e0amination&

 /cquired e.$. %ul%ar urethral stricture: esp. in a paraple$ic c. lon$ d'ellin$ I/ Catheter. /lso+ %ul%ar urethra can %e in9ured from a fall from: -ic#cle 5orse( %ac) ridin$ .ost strictures are ho'e"er idiopathic. Passin$ a stone local irritation >0: 1. Dilatation 2. ,ptical internal urethrotom# 3. Irethroplast# In4estigation o choice F *scen1ing G Retrogra1e !rethrogra3 PROCED"RE O8 DOIN- * 'O"-IN*-E& (-efore passin$ this instrument the %ladder is emptied. (Pass $entl# until reach perineal urethra F turn it 1:B F pass it into the %ladder smaller K is for tip lar$er K is for %ase. Dote 3B mins later+ pt. Could %e in septic shoc). i.e. his %.p. is 7B/4B : T A 36 .

CO#P(IC*TIONS O8 'O"-IN*-E& 1. epticemia can occur if patient is not under proph#lactic anti%iotic co"era$e. ?ram "e %acteremia can manifests in 2B mins. If septicemia manifests+ can resuscitate patient ! /-C& <culture 6cc %lood.

,ther complications:
2. 3. 4. 6. 4alse passa$e Irethral %leedin$ Perforate %ladder peritonitis Create fistula %et'een rectum and urethra ! rectourethral fistula&

D.-. 5e$ar dilator is used to dilate female urethra. >etro$rade dilator for cer"ical incompetence.

H.* '*R'IT*-E F

rese32les a 3agni ie1 4ersion o a 1ropperI%

It is !se1 to irrigate the 2la11er 0ith nor3al saline so that a t!r2!lence is create1 in the !rine in the 2la11er an1 aspirate1 l!i1 is sent to c6tolog6.

J.DO"'(E A- STENT

LL a' dou%le 2( stent ! can %e used in h#dronephrosis&. Its main use is to decompress a )idne#. Its main use is to relie"e ureteric o%struction from 'hate"er cause. PROCED"RE& To pass a stent + do c#stoscop#. Introduce $uide 'ire !one end is flopp# and the other end is thic)&. Ise flopp# end %ecause it does less dama$e. It is done under =( ra# controlled + confirmed. >ail( road i.e. pass stent o"er $uide 'ire into ureteric orifice. 1 end curls and is retained in the )idne# and the other end is in the ureteric orifice ! at tri$one of %ladder&. Ireteric catheter use A retro$rade p#elo$ram ! outlines pel"i( cal#ceal s#stem&+ introduced at time of c#stoscop#. 1st mar)in$ at 6cm /t 1B cm+ 2 mar)in$sM.. C . I5" 0hich gi4es an anterogra1e 4is!alisation o !rinar6 tract. 'e ore rea1 an I5P nee1 a KSCO"T il3 I rea1 an I5P il3 0hich sho0e1 an e:tensi4e staghorn calc!li & opacities in Rt. Renal area. / Depe@@er catheter used in supapu%ic c#stoscop# %ecause it does not ha"e a lon$ nec) + a"oids spasms.

L.

C,STOSCOPE

8(E<I'(E 1./. adequate

RI-ID ?./. needed

Str!ct!re& Trocar 5C/T5: Pro0. Cnd( 3 parts Distal end( %ehe"elled Parts : 1.1i$ht source 2.4luid 3.Instrumentation "SE& Direct "isualisation for %ladder < urethra

INDIC*TIONS O8 C,STOSCOP,&

1. DI/?D, TIC In"esti$ation of haematuria ! to d0 %ladder Ca or p#uria& -ladder calculi -ladder di"erticuli -ladder -0 Can pass ureteric catheter thr. it.

T5C>/PCITIC 4ul$aration of %ladder C/ Pro$nostic for %ladder

Chemotherap# for treatment of squamous cell carcinoma. -C? A immunot0 in mali$nant melanoma

Can pass stent ! c#lindrical mesh& thr. c#stoscope into ureter to relie"e urinar# o%struction due to oedema+ trauma or pressure from the )idne# stones or a tumour outside the ureter. >etro$rade p#elo$ram stud#

L. *('*RR*N DE8(ECTIN- #EC.*NIS#&

.as 2 parts 2 irrigation channels #i11le part is or telescope $ or&

3/ lens or H/ lens

1/.

8O-*RT, E#'O(ECTO#, C*T.ETER

C0traction of arterial em%oli in acute arterial occlusion 7 Ps A pallor+ pulselessness+ pain+ paral#sed + paraesthetic+ perishin$l# cold. Dote 7hrs. 'indo' period for acute arterial disease. ta)en to theatre. 5ollo' plia%le catheter It is $raduated + thus can )no' 'hat "essel one has entered. /t pro0imal end+ the s#rin$e fittin$ pro"ides means for fluid e0chan$e into %alloon at distal tip. Inserted as far as possi%le into acutel# occluded "essel. -alloon then inflated and 'ithdra'n in inflated position. -alloon maintains uniform area contained in "essel 'all as it passes throu$h areas of narro'in$. Depth mar)in$s on catheter indicate distance of %alloon from arteriotom#. ur$eon manipulates s#rin$e < catheter durin$ 'ithdra'al so can inflate < deflate as necessar# to pass thru. Darro' areas. Initial approach is "ia common femoral /. re$ardless of anatomic location.

Dote: Hon*t $et "enous em%oli %ecause one is on arterial side. 4or sepsis+ $entamicin < amo0#cillin or < 3rd $eneration cephalosporin. N.'. Non- 2alloon catheter e:ists.

11. #O"SSE*"- '*R'IN T"'E

Pro0imal end: funnel shaped ! oran$e coloured in dia$ram %elo'& Distal end: fenestrated for insertion N rat tail PICTI>C -C1,H 5,H : oesopha$uscope+ li$ht source Chest tu%e 'ith trocar + %iops# forceps+ %ronchoscope ! note 2 holes at distal end for "entilation&+ mediastinoscope ! loo)s li)e a handle+ and .ousseau -ar%in tu%e ! oran$e tu%e&.

"SES O8 #O"SSE*" '*R'IN T"'E&

( in pts. Hith non( resecta%le oesopha$eal o%struction ,ptimal for palliation in d#spha$ia in selected cases of oesopha$eal C/ esp. lo'er 1/3& It is contraindicated in upper 1/3 oesopha$eal Ca %ecause it 'ill press on air'a#. -ut it is no' replaced %# stents. PROCED"RE&

1. Informed consent 2. Pre-op -ld. tudies >adiolo$ical studies CC? Dutrition 3. Intra-op ?eneral anaesthesia < proph#lactic anti%iotics 1aparotom# < ?astrostom# openin$ made on stomach Cannulate the oesopha$us 'ith the D?T. /ttach sil) strin$s to .osseau( -ar%in tu%e and anaesthesist pulls %ac) up D?T. ur$eon 'hile holdin$ its strin$+ pulls tu%e until it sits in poc)et of Ca. In( situ+ the funnel shaped pro0imal end is secured a%o"e Ca and 0s. Tu%e distall# is cut off. /nchor to ant. tomach 'all c. 2 o !secondar#& )nots of non(a%s.+ s#nthetic suture.

CO6SI57(+TIO6S# Pts. /re allo'ed to consume onl# liquids. Do solid food %ecause the cone of the tu%e is narro'. Don compliance %loc)a$e of tu%e. COMP8IC+TIO6S#

I##EDI*TE /naesthesia 0 (haemorrha$e

E*R(, 1. Hound infec*n 2. Ischemia 3. ?an$rene

(*TE 1. Prolapse 2. >etraction 3. Parasternal ("iscera dama$e herniation 4. )in e0coriation 6. tomal stenosis 7. Diarrhoea 8.Peri( stomal a%scess :. Depression < social discomfort

A'A(%T)(TI* I'%T+,&('T%

$2% 6G T&:7
CONTR*INDIC*TIONS& 1. K Cri%iform plate 2. ,esopha$eal anastomosis INDIC?NS

DI*-NOSTIC 1.Colour of aspirate !coffee $round I?I-& 2. .onitor fluid "olume from stomach

T.ER*PE"TIC 1.Decompression of stomach PRE-OP Cmpt# stomach for anesthesia POST-OP( Paral#tic ileus+ %o'el o%s.+ cholec#stitis+ pancreatitis

3. Oualit# of $astric contents 4.Poisonin$ !Penta$astrin ./,/ -/,& test

2.Cnteral feedin$( coma+ ". ill (premature infants 3.Pre"ent further "omitin$ 4..edication 6.1a"a$e for in$estion 7.T0 acute $astric dilatation secondar# to %urns.

13.OROP.*R,N-E*( *IR)*,
P!rpose& Creates a patent air passa$e %et'een ton$ue and post. Phar#n$eal 'all. H5PE 1oss of upper air'a# muscle tone! e.$. $enio$lossus in anaesthesised/ comatosed pts& ((Q ton$ue/ epi$lottis fallin$ a$ainst posterior 'all. ,f note: / nasophar#n$eal air'a# ! %etter used for li$ht anaesthesia & 1CD?T5 C TI./TI,D: Distance %et'een tip of nose and ear( lo%e. Insertion& Placed in mouth ! after remo"al of dentures& Hhen in( situ+ rotated 1:B , to correct position. ,ther'ise it forces the ton$ue further posteriorl#.

14.8*CE #*S+& STR"CT"RE& RI#( Contoured < Conformin$ to "ariet# of facial features 'OD, if transparent+ can o%ser"e e0haled humidified $as < immediate reco$nition of "omitin$. ORI8ICE:( 22mm /ttaches to ,2 /-reathin$ circuit direct throu$h ri$ht an$le connector. -reathin$ hoo)s( can attach to head stirrup so that mas) need not %e continuall# held. *I#& Deli"er# of ,2 / anaesthetic $as from %reathin$ circuit %# creatin$ an airti$ht seal ! alon$ patent air'a# essential for effecti"e "entilation& PROCED"RE& Isuall# orophar#n$eal air'a# is in( situ 5old mas) in left hand : ri$ht hand to squee@e %ac) !<"e Pressure& .as) held 'ith do'n'ard pressure "ia thum% and inde0 fin$er ,ther fin$er $rasps the mandi%le( e0tend atlanto(occipital 9oint ! it pre"ents ton$ue from slippin$ %ac)'ards& D.-. -on# mandi%le + not soft tissue&

1@. S"CTION C*T.ETER

tructure : Pro0. Cnd: 2 parts 1 part attachment for suction apparatus other part ( for occlusion 'ith fin$er Distal end: -e"elled 'ith 2 holes !.urph#*s e#e&

1@.ENDOTR*C.E*( T"'E& ! i@e : -a0ter CTT&

Type -orte. (TT 4eatures:

Cur"ed tu%e of internal diameter 0 mm. Deed diameter of little fin$er. Inflata%le cuff to pro"ide an air(ti$ht seal. Pilot %alloon attached to CTT %# an inflatin$ tu%e ! "al"e pre"ents air loss&. -e"elled tip aids direct "isuali@ation and insertion throu$h "ocal cords. .urph#*s e#e to ris) of complete tu%al occlusion. Connector ! connects to "entilator or air%a$& >adio(opaque line to allo' direct "isuali@ation on C=>. Cuff is inflata%le %ecause: 1. To pre"ent lea)a$e of anaesthetic a$ent !$as&. 2. Pre"ents aspiration of secretions. Note& In children uncuffed CTT required ! su%$lottic re$ion is the narro'est portion of lar#n0. /dults do not ha"e a narro'in$ of lar#n0.

*D5*NT*-ES O8 "SIN- TR*C.EOSTO#, T"'E& 1.CTT facilitates positi"e pressure "entilation. Can %e left in for lon$ periods( life 2. .ore B2 can %e deli"ered F quic)er. 3.It reduces the dead space %# half. ! Dormall# dead space A 16B ml& 4.Can %e used in procedures 'ith upper air'a# o%struction

a. R*

lar#n$eal o%struction

%. R* impaired lar#n$eal refle0. Care o the t!2e& 1. Intermittent suction F proper humidification F relie"in$ pressure of cuff i.e. inflate 1 cuff F deflate other cuff I CTT. 3arious si@es Internal diameter : .en :.B( ;.B mm Homen 8.6( :.6 mm 1CD?T5: .en: 22 24 cm Homen 2B 22 cm ETT is !se1 c. #acIntosh 2la1e.

1. Clinicall# chec) if equal %ilateral air entr# into lun$s 'ith stethoscope. 2. Definiti"e means of confirmation of CTT placement is %# capno$raph#. In1ications& 1. Pts at ris) for aspiration !to secure and protect their air'a# F pre"ent .endelson s#ndrome& Inconscious/ emer$enc# pts. Pre$nant 'omen. Pts. Hith a%sent $a$ refle0 Comatosed pts.

2. 4or ?/ ! .a9or sur$ical procedures( head < nec)< %od# ca"ities& 3. >esp. upport ! Dote :NOT S"IT*'(E for lon$ term use& 4. /dmin. of medic*n E

PROCED"RE& CO#P(IC*TIONS D!ring Insertion& /ir'a# trauma (tooth (ton$ue (sore throat (dislocated mandi%le ( haemorrha$e .alposition (oesopha$eal (*TE Irritate "ocal cord 4istula formation

(endo%ronchial

17. (*R,N-OSCOPE

CI>3CD
.cIntosh

T>/I?5T (.a$ill

Each lar6ngoscope consists o & (5andle ! contains $rip and po'er handle source& and ( -lade !li$ht source and $roo"e& Diagra3 2elo0 sho0s 2 1i erent si9e1 han1les

DI*-R*# S.O)IN- #cIntosh 2la1esM lar6ngoscope han1lesM an1 #c-ill 2la1es $ 1escription or3 le t to right%

PICT"RE 'E(O) S.O)S * (*R,N-OSCOPE )IT. * #*-I(( '(*DE. #agill 2la1e1 lar6ngoscope is !se1 in neonates or chil1ren 2eca!se the anato36 o phar6n:.

5o'e"er in e0am+ #ou 'ill more li)el# see a lar#n$oscope 'ith a .cIntosh %lade ! used for adults&.

POSITIONIN-& (.oderate head ele"ation (C0tension of atlanto( occipital 9oint Clear mouth of dentures+ forei$n o%9ects 'ith $lo"ed hand.

1H. #EDI*STINOSCOPE

.ediastinoscope is similar to lar#n$oscope. Dote slit on side differentiates it from a lar#n$oscope. .ediastinoscope is important for instrumentation. 5o'E Dissect 1 fin$er %reath superior to sternal notch. Dissect to trachea. ?o to pre( tracheal fascia. -efore %iops# + aspirate 1stG In mediastinoscop#+ incise o"er 2nd costal cartila$e F $et to /nt. .ediastinum.

CONTR*INDIC*TIONS TO #EDI*STINOSCOP,: >C1/TI3C 1. /neur#sm 2. 3C ,%struction /- ,1ITC 1. Pre"ious mediastinal 0. 2. Pre"ious tracheostom#

1H $2% T,PES O8 'IOPS, 1. 8N*' (4orm of e0foliati"e c#tolo$# (S 2B $au$e needle is used. (Cells sent from : I. putum

II. -ronchial 'ashin$s III. Pleural fluid I3. ?astric 'ashin$s 3. /scitic fluid 3I. Cer"ical smear e.$. Pap smear 2.INCISION*( 3.E<CISION*(

1J. 'RONC.OSCOPE
1en$th in adults Paed Internal diameter: 8(: mm in adults 3 mm in paed. 5as ;B+ and B "ie'in$ portes. Can con"ert fle0i%le %ronchoscope throu$h the ri$id instrument. 4B cm E2Bcm

,ne can differentiate a ri$id %ronchoscope from oesopha$oscope. It has 2 holes at tip of %ronchoscope to allo' air so can "entilate the patientG 8le:i2le 2ronchoscope co3pose1 o & 'ronchoscope (ight carrier itting in 2ronchoscope (ight ca2le (ight so!rce The i2reoptic technolog6 has 1 light so!rce can le: 1J/ /. Can go J/ posteriorl6 to looN !p at Right !pper lo2e 2ronch!s !nliNe rigi1. 'iops6 orceps that 0orNs 0ith rigi1 2ronchoscope is larger 2iops6 hole than le:i2le. 'iops6 is connecte1 to s!ction. i pt. .as :s. .ae3opt6sisM 1o rigi1 2ronchoscop6. One 2iopsies the no1e re4eale1 ro3 CT Scan 8acilitates 1rag 7 therape!tic inter4ention at 4th or @th or1er 2ronchial le4el. /d"anta$es: 1. Can e"aluate pts. HithEE c( spine d/o Contraindications: mall air'a#s. e"ere medical pro%lems contraindicatin$ anaesthesia.

:(O6C)OSCOP7 I65IC+TIO6S

DI/?D, TIC DI*-NOSTIC 1. 2. 3. 4. 6. 7. 8. :. ;.

T5C>/PCITIC

5aemopt#sis Ine0plained < "e sputum. Pulmonar# mass on C=> esp. children. >ecurrent/ Inresol"ed pneumonia Persistent atelectasis Diffuse lun$ disease uspicion of forei$n %od# .ali$nant pleural effusion -rochioal"eolar la"a$e

T.ER*PE"TIC 1. 2. 3. 4. 6. 7. 4orei$n %od# remo"al Difficult intu%ation 1o%ar atelectasis tricture dilation 1un$ a%scess Therap#: (1aser (Photo (Cr#o (Immuno

CO#P(IC*TIONS P>C.CD: </D/C T5C I/ 1. 2. 3. 4. 6. >espirator# depression/ /rrest Transient h#potension ei@ures #ncop# 1ar#$ospasm

TCC5DIC/1 ( >espirator# components ! %ronchospasm& ( 5aemorrha$e ( 1ar#n$ospasm -I,P P (5aemorha$e (Perforation (/ir em%olism

Dote: .ediastinoscop# sho's middle/ parasternal structure.

(Paratracheal 1. nodes The purpose of sta$in$ is confirm that an# D2 nodes. If in"ol"ed+ cannot operate or e0cise the tumour.

1L. Oesophag!scope
4or direct e"aluation of interior of oesopha$us. Clecti"el# should %e proceeded %# -arium s'allo'.

OESOP.*-"SCOPE 41C=I-1C ("aries in diameter (permits passa$e of "ariet# of instruments: 4orceps !male& Irri$ation catheters >I?ID 46cm !female& 6B cm

tips %e"elled< %lunted

.o"ement of distal :cm manuall# controlled %# 'heels near e#e(piece

1i$ht source Done under ?/ usuall#

De'er ones permit "ideo recordin$ till photo$raph# Introduce alon$ the %ase of ton$ue past phar#n0 F intu%ate esopha$us as the pt. 'allo's.

INDIC*TIONS O8 OESOP.*-OSCOP,& DI/?D, TIC: 1.D#spha$ia 2.,d#nopha$ia 3.,ccult %ld loss 4.5aematemesis C,D4I>. tructure 5iatal hernia Di"erticula 3arices T5C>/PCITIC Dilatation < -0 structures >emo"e forei$n %odies clerotherap# Cndoluminal prosthesis

6.?C> 7./t#pical chest pain

C0trinsic Compression Tumour recurrence

8./ssess: (,esopha$itis (-arret*s oesopha$us (Caustic In9ur# (Tumour ! in pro0. 1/3 F middle 1/3 &

2/. I; <8&I5S
Cr6stalloi1s CO((OIDS

5#pertonicIsotonic PDT5CTIC

5#potonic D/TI>/1

6T D/ 1/> 6TD/H 6BTD D/ De0tran 4B:8B

-ld Pac)ed cells P1Ts /l%umin Plasma

?elafusin '%c

@O DG) In 6T D/H 1BB ml of 6TD/H contains 6$ de0trose. in 6BBml+ 26$ de0trose. 26$ de0troseA 1BBUcal >ecall 1$ C5, A 4 Ucal 26$ C5, A 1BBUcal Caloric "alue is minimal + thus not used for sur$ical nutrition. &S7S# 1. Dia%etic pt. Pre(op To minimi@e "e D2 %alance Prefer to %e sli$htl# h#per$l#cemic than h#po.+ %ecause easier to correct and it pre"ents the ad"erse effects of h#po$l#cemia such as comaM. 2. -urns pt. Prot. parin$ %# $i"in$ C52, Pre"ent "e D2 %alance. 3.4luid admin.

( .aintenance: for insensi%le losses (,n$oin$ losses: T CONTR*INDIC*TIONS& 1. 2. 3. 4. 6. +Cl 2BT UCl sol*n or Q 4BmCq / 16 mls for I3 fluid administration Consi1erations& Cnsure pt. 5as adequate urine output. INDIC*TIONS: 1. U< deficienc# (0s "omitin$ (diarrhoea ()etoacidotic pt ! T0 c.1BI insulin<E 16.eq UCl& 2. DP, Pt. ! usuall# needed for Q 7 da#s& B.6(1 mCq/ U$ in 24hrs. Dote: 1$ of U 4,> DCDT/1 1, 1$ of U for 11 acid ! $astric contents& 5ead Trauma hoc) 5aemorrha$e /cute lun$ %urns

D*I(, RED"IRE#ENTS& Da< U< 8Bmmol/da# 7Bmmol/da#

?eneral rate of fluid administration: 126ml/ hr/da#+ i.e. 2( 31 /da#.

/0. / proctoscope is a "er# short instrument to loo) at the

rectum. >ectum /nus a ri$id F fle0i%le A 13 16 cm len$th A4 cm len$th si$moidoscope A 2B cm si$moidoscope A up to 76 cm A 17B 176 cm

a colonoscope

SI-#OIDOSCOPE

8(E<I'(E 4B( 7B cm lon$ children

RI-ID 2Bcm lon$ in !C0tra 1B cm for instrumentation& 26(3B lon$ in adults

>ectum is 4 cm from anal "er$e >ectum A 1B 12cm D,TC: 13(16 cm A distance of rectosi$moid 9unction from anal $roo"e. Thus can see 12 cm ! 6 inches& into si$moid.

STR"CT"RE& 1.Introducer ! Trocar& !,%turator& 2. Cali%rated sheath (part for attachment of li$ht source. "SES O8 PROCTOSI-#OIDOSCOPE&

DI*-NOSTIC

T.ER*PE"TIC

 In"esti$ate P> %leed. ! %ut recall still ha"e to in"0 for metatchronous lesions i.e. lesions else'here in rest of colon G& Incidence s#nchronous lesion A 6T Direct "isuali@ation of anal canal+ rectum+ F distal si$moid colon. 4acilitates %iops# of lesion in rectum F si$moid 1i)el# lesions (pol#ps (ulcers (carcinoma (di"erticular disease (Inflammator# %o'el disease ( 5aemorrhoids

Rn of si$moid "ol"ulus

PROCED"RE& (Pt. Is hea"il# sedated ! either Pethidine or 3alium& (Pt is placed in the left lateral position )nee to chest. (D>C 1st done to ensure a%sent loadin$ F rela0 sphincters. ( Inspect mucosa for colour+ inflammation + %lood ( i$moidoscope is lu%ricated. Introducer is pulled out of si$moidoscope. ( i$moidoscope is passed 'ith adequate li$ht and "isuali@ation. ( /ir source is attached to distend %o'el 'ith air.

Note & >ectosi$moid 9unction is 12(16cm from anal canal F it ma# %e difficult to ne$otiate. Complications of passa$e of this scope: 1. Trauma to surroundin$ structures 2. 5aemorrha$e/ -leedin$ 3. >is) of perforation ! pel"ic floor F recto( si$moid 9unction& CO#P(IC*TIONS& 1. >upture 2. /ir em%olism

22.CO(OSTO#,& is defined as an openin$ of colon onto

a%d. urface. 4unction as an outlet of feces 'hen distal colon or rectum is remo"ed CO(OSTO#,F a ist!la

TC.P,>/>P

PC>./DCDT

Isuall# end( colostom# 1oop Dou%le %arrel 5artman*s

Defunctionin$ e.$.Temporar# Cnd colostom# "s!all6 ollo0ing *P resection o rectal t!3o!rs

CO(OSTO#,

8"NCTION*( To: ( 1i4ert e$ perforated di"erticulitits F do not 'ant feces distall#.

*N*TO#IC*(

1,,P

Dou%le %arrell

! Don*t resect %o'el& (Deco3press

Indications: 1.Inprepared %o'el 2. e"ere infection

-ENER*( INDIC*TIONS 8OR CO(OSTO#,& 1.The presence of a factor that contra( indicates a primar# repair of %o'el. 2.To direct fecal stream . 3.Decompress a more distal colonic o%struction < ser"es as a "ent. 4.Temporaril# di"ert fecal stream from a patholo$ical process.

D,TC: The process of e0teriorisation of redundant si$moid colon A Paul .ic)elit@ procedure. One can 1o colosto36 on 3o2ile 2o0el areas $ i.e. areas 0here 3esenter6 is attache1%& Trans4erse colon Sig3oi1 colon Distal colon Can 1o a contrast st!16 to ens!re patenc6. leaNage & goo1

I all is 0ellM close it.

/ 1e !nctioning colosto36 pro0imal to anastomosis allo's most of the %o'el to heal can later close it . / defunctionin$ colostom# is made at a point to pre"ent somethin$ from $oin$ to distal %o'el. >easons : the di"erticular mass can anastomosis healin$.

In loop colostom# + studies sho'ed that fecal contents do not enter the other. There is no resection of %o'el. -rin$ out the loop of one %o'el and anchor it to fascia. /ll one sees is mucosa and not serosa.

In end colostom# %rin$ out one end to the e0terior. Permanent colostom# is usuall# an end colostom#+ 2!t /n end colostom# is not al'a#s a permanent colostom#. Can ha"e a temporar# end colostom# e.$. 5artman*s procedure. .art3an?s proce1!re is an en1 colosto36 o pro:i3al 2o0el an1 clos!re o the 1istal 2o0el.

PROCED"RE 8OR .*RT#*N?S CO(OSTO#,& It is impt. To use a si$moidoscope in 5artmann*s procedure to det. If occlusion distall#. i$moid resection c. o"erse'in$ or disuse of distal rectal pouch. Thus formed an end colostom# and closed rectal stump. Ideall# the stoma is located in 1eft iliac fossa comin$ throu$h the rectosi$moid sheath to decrease the ris) of peristomal ele"ation -/4 remo"in$+ do radio$raphic or endoscopic e"aluation F %o'el prep. 1( da# prior to sur$er#+ do %o'el prep. ,ne 'ill perform a V Hhole $ut irri$ationW + i.e. pass D?T F $et lar$e amt. of D/ F allo' it to run thr. Intil colostom# is clear of particulate matter. 11 of D/ is run in o"er 16 2B mins. Deed 4(7 1 of D/ for a"$. person. OR -olus cathartics .$ ,4 ! 26T& 1BT mannitol ! 6BBml & Cth#lene $l#col Docola0 OR 4 1a6 preparation&

4rom da# 4+ 4rom da# 3+ cathartics < enema. 4rom da# 2+ enema.

1o' residue diet. lo' residue diet < fluid diet < cathartics <

4rom da# 1+ A da# prior to 0+ anti%iotics 1$ Deom#cin p.o. F 1$ Cr#throm#cin p.o. e"er# 4 hrs.

PROCED"RE 8OR DO"'(E '*RRE((ED CO(OSTO#,& 1./septic procedure !Done in ,.T& 2..a)e an openin$ in loop of %o'el throu$h taenia. 3. -rin$ out 2 loops of %o'el throu$h the same hole so that #ou 'on*t ha"e to search for the other end ne0t time.

CO#P(IC*TIONS O8 CO(OSTO#, 1. 2. 3. 4. Prolapse >etract 4orm hernias /%scess

The su%mucosa is the stron$est la#er+ impt. in %o'el repair. CO#P(IC*TIONS O8 CO(OSTO#,&

I..CDI/TC 1. -leedin$

C/>1P 1. Diarrhoea !Infecti"e Cnteritis&

1/TC 1. tomal stenosis 2. tomal necrosis 2o to ischemia 3.Periosto mal hernia 4.Internal hernia 6.Perforati on

23.

NEED(E DRI5ER & 8ORCEPS

DI*-R*# 'E(O) S.O)S *DSON PIC+"P 8ORCEPS an1 NEED(E DRI5ER

23 $c%. *((IS 8ORCEPS 5as teeth and ta)es out %reast lump ( has fenestrations to relie"e press.

23. $1% +OC+ER 8ORCEPS -i$ and stron$ 'ith teeth Hill hold fascia 'ith this.

23 $e% '*'COC+ 8ORCEPS $ atra!3aticM enestrate1 instr!3ent% Ised to handle %o'el+ appendi0.

23. !f& 1ein*s tissue forceps fenestrated on either sides. 23. !$& mall >ei$ retractor to e0pose tissue. 23. !h& .a$ill*s forceps !1on$ cur"ed handle ( continous an$le F o%tuse an$le&. Iesd to introduce endotracheal tu%e for "isualisation for passa$e of endotracheal tu%e. ,r $rasps ton$ue to remo"e ton$ue a'a# e.$. tonsillectom#. ,r remo"al of forei$n %odies. .osquito 23. $i% *. 8ORCEPS Cr#le/ haemostat ! occludes %ld. 3essel& Can hold "essels/ tissue 'hile li$ate. >o%erts forceps A lar$er than Cr#le F its purpose A Crushin$ /occludin$ %ld. 3essel

24.#*-I((?S 8ORCEPS .a$ill*s forceps 'ith continous an$le F o%tuse an$le assists the introduction of endotracheal tu%e+ ,> it ma# %e used to $rasp the ton$ue F mo"es the ton$ue a'a# e$ tonsillectom#. OR for remo"al of forei$n %odies

1on$ cur"e( dissectin$ scissors A suture scissors 23. $P% SCISSORS uture scissors A suture scissors Tissue scissorsA .cIndou/ .endelson %and A almost same as suture scissors.

1ap pac) has a loop at the end 'hen put in %ell# has to %e attached c. clip on outside the %od# to ensure it 'ould not %e o"erloo)ed.

24. en$ ta)en Tu%e ! E -la)e tu%e&

( it is a multi( lumen tu%e (1 lumen drains $astric contents (1 lumen connects to %alloon F puts pressure on "arices.

( 1 lumen fills in the oesopha$us to tamponade preliminar# control.

2@. C5P (INE If haemo/ pneumothora0+ place the C3P line on the same side %ecause if complications de"elop+ 'ill occur on the same side. -asilic 3ein /0. 3. su%cla"ian 3. I C : 1. .easures central "enous pressure. 2. C3P A >eflection of "enous "olume+ ri$ht atrial pressure. ! cf. 'an@ ?at@ 'hich measures left atrial pressure.! pulm. /. press.& 3. The 'an@( ?at@ catheter is passed li)e a C3P thr. "ein ri$ht "entricle lun$ field to the peripheral lun$ "essel. 2B. D*CRON -R*8T - !se1 to repair aortic ane!r6s3s - there are 2 t6pes & 1. +nitte1 $ F 3ore per3ea2le%. Dia3eter F 2c3 0hich is nor3al 1ia3eter o aorta *ne!r6s3 F 2< nor3al 1ia3eter I ane!r6s3 is 4c3 or C @c3 M or get Q C /.@ c3 in BG12M repair. 4c3 ane!r6s3 has 14@ risN o r!pt!re F lo0 2L. 1st -ENER*TION N*I( & +"NTSC.ER N*I( $+- nail %

De inition: /n intramedullar# nail 'hich is hollo' and of clo"er leaf section . #O*& 3 point fi0ation

STR"CT"RE& Its structure allo's the nail to ne$otiate canal 'hen %een put in. 1Bmm!'idest& 0 3: mm ! lon$& ta%ilit# is $ained %# 3 points of U( nail in contact 'ith femur. .o0e4er there is no rotational control or sta2ilit6 o +- nailM th!s not !se1 R lo0er 1G3 e3!r S 2eca!se e3!r R 1istal 1G3 lares. LCnsure the hole is at the top 'hen U( nail is placed %ecause it is for remo"alG Put the hoo) there F %ash it out G "SE& Internal fi0ation of K of lon$ %ones particularl# shaft of femur ! pro0imal and middle 1/3&+ti%ia+ humerus+ F ulna. +- Nail !nctions to 3aintain length & align3ent. CONTR*INDIC*TIONS & 1. Co33in!te1 S 2. O2liT!e S 3. (o0er 1G3 e3!r S

P*SS*-E O8 N*I(& (1ateral incision made o"er trochanteric re$ion K site ( 1on$ $uide 'ire is introduced ( >eam the dip of $reater trochanter. ( Pass do'n the shaft impt. To chec) The intramedullar# nail is then threaded o"er the $uide( 'ire . F reduce K F hammer nail F lea"e 1 cm nail stic)in$ out F close 'ound. ( ( Hh# does it ha"e a hole at one endE o that a hoo) can %e used to pull it out. ( >emo"al aided %# rectan$ular hole at upper end.

Description& (1i$ht+ hollo' Clo"er leaf + cross( section (>ectan$ular openin$ at one end placed pro0imall# ! aids remo"al 'hen K site unite& ( hape pre"ents rotation+ more sta%le. /1. 2nd G767(+TIO6 6+I8 # +O 6+I8 imilar to U( nail %ut is cur"ed. The /, nail addressed the pro%lem of the cur"ature of the femur /lso has a 3 point( fi0ation. Can %e loc)ed at the top + hollo'+ clo"er leaf in cross section. .o0e4erM it cannot pre"ent rotation F maintain lim% len$th. 2J. 3RD -ENER*TION N*I(& *O (OC+ED N*I(

It has holes for scre's at the top F %ottom. Pass $uide 'ire from top F ream o"er $uide 'ire until hit corte0. achie"e certain si@e ! recall : In canal+ cancellous %one+ 'ant to erode medullar# %one &. Can loc) it J top F %ottom+ loc)ed nail. It maintains lim% len$th F rotational control. I C: It can %e used for : femur shaft K 1o'er 1/3 femur K /d".: Don*t ha"e to open K site + thus pre"ents ris) of infection.

2L.*"STIN > #OORE PROST.ESIS F he3i- arthroplast6 ( It is used for displaced intracapsular K ( >emo"e head of femur F put it into shaft F it 'ill articulate 'ith aceta%ulum. ( Its head is "er# shin# to reduce friction. ( The holes in it are for %one $raftin$+ %one 'ill heal onto either side of pro0imal femur. ( The hoo) J top is for remo"al F %ash it out. Pro2le3s: 1.Hill $et 'earin$ of hip 9t. Csp. of aceta%ulum+ $ood for the elderl# 'ith mo"ement. Dot $ood for 7B #ear old unless mo"ement is "er# limited. 3. oc)et 9t. Dislocation.

4. Can ha"e r0n of metal. / portion of the transition @one distal to metal portion is 'ea)ened+ li)el# to K distall# if fall. 32.D.S $ 16na3ic hip scre0% Pass a $uide 'ire up nec) of femur to head. >eam o"er 'ire F create core. Pass scre' o"er $uide 'ire into head of femur until it fits alon$side %one. Hhen collapse o"er K site+ slidin$ mechanism pre"ents scre' from enterin$ pel"is. slidin$ A safet# de"ice 34. TOT*( .IP *RT.ROP(*ST, Total hip arthroplast# is used for : arthritis $osteoM rhe!3atoi1%. 5er6 acti4e pt. 0ith intracaps!lar NO8 S Total hip arthroplast# lasts 1B 16 #ears I1 1+ I1 7 stimulates osteoclastic acti"it# loosenin$ of %one

'0% (&S) (O5 ( loo/s li/e a hoo/ ) Intra(medullar# de"ice. Ised in .0 of K of forearm %ones i.e. !radius+ !lna& < humerus < E filula& 5as a hole at one end. ,nl# maintains ali$nment of K+ pre"ent displacement . 4or simple trans"erse K

Dot $ood for unsta%le K e$. ,%lique K Does not $i"e rotational sta%ilit#. Do need to use rush rod %# itself. Does not $i"e sta%ilit# to %e used on its o'n. Deeds cast. 5oo) lies su%cutaneousl# + facilitates remo"al.

31. +- )IRE $ +ERSC.NER )IRE% Ised in reduction of -ennet*s K !K at %ase of 1st metacarpal 'ith in"ol"ement of carpometacarpal 9oint. It can occur from a direct "iolent force as in %o0in$&. 1oo)s li)e a lon$+ slim teinmann pin %ut 'ith 2 pointed ends

'2% ST7I6M+66 PI6 4mm diameter steel pin 2 pointed ends ! or 1 pointed/ 1 %lunted end& Threaded or unthreadedE The choice depends on : ur$eon*s preference Densit# of %one 4orce to %e applied Threaded $ood draina$e

)here site1C Distal e3!r Pro:i3al 1G3 ti2ia Distal ti2ia Calcaneo!s- occasionall6 P"RPOSE& /pplication of s)eletal traction ! alon$ 'ith de"ices -ohter -rain frame& Thomas splint 5amilton >ussel traction Dote : Deed for counter( traction !ele"ate the foot of the %ed& IDDIC/TI,D : 1. Primaril# the lon$ %one K of the lo'er lim% 2. Particularl# %eneficial for: Insta%le K Comminuted K I4C H5PE Pro"ides %oth lon$itudinal force and pro"ides rotational sta%ilit#. K .ana$ement (Pain relief ! muscle spasm& (,"ercome 0s. .. tone & (*n of K ( ta%ilisation of reduction.!promotes healin$ Pre"ents soft tissue dama$e& P(*CE#ENT&

C0plain procedure to patient /septic technique 1ocal anaesthesia soft tissue (((Q periosteum Pro0imal ti%ia insertion :( 2.6 cm distal and posterior to ti%ial tu%erosit#& CO#P(IC*TION& 1. Common peroneal D. in9ur#. 2. Infection 33. P(*STER O8 P*RIS& 5emi( h#drated calcium sulphate P>,PC>TIC : /ddition of 52, ((Q Particles of 'ater incorporated into cr#stalline lattice of Ca ,4.1/2 52,. Its immersion in 52, is ceased 'hen there are no more %u%%lin$+ i.e. until all air spaces are saturated. RES"(T& Po'der ((Q olid ! roc) hard mass& D-. C0othermic r0n + process re"ersi%le ! de$rade plaster %# soa)in$ it in 52,& *D5& 1o' cost C0cellent mouldin$ radiolucenc# .ultiple uses DIS*D5. ( Poor 52, resistance ( Poor ( 5ea"#

 3. lo' aller$enicit# hospitali@ation

( >is) of %urns

In ne'%orn+ +main concern is that it must %e 'ell padded to pre"ent pressure necrosis. Dischar$e instructions to mother: 1. Ueep cast dr# 2. 1oo) out for si$ns of ischemia such as: inconsola%le child+ child stampin$ lim%+ or squee@in$ lim%. "SES& 1. K < dislocations of %ones / 9oints. 2. Correction of con$enital //cquired deformities 3. In9uries of ..+ tendons+ fascias+ li$aments. 4. Protection of "ascular or D. repairs. @. /pplication around amputation stump ! speeds up stump maturation < earl# prosthesis& B. >eplica for 'hich prosthesis can %e fashioned H. Pre"ention of pro$ressi"e deformit#! e.$. cere%ral pals#& CO#P(IC*TIONS 'oneGAt. SNin 5essel ,steoporosis ( Plaster %urns 2oint stiffness ( Contact dermatitis ( Pressure sores *D5ISE Pt.& 1. Cle"ate lim% Ner4es D. pals# /. in9ur# e.$. Common peroneal D.

2. .o"e toes/ fin$ers frequentl# 3. /"oid 52, 4. /"oid scratchin$ SEE+ #EDIC*( *TTENTION I8& 1. Pain is not reduced %# anal$esia 2. Chan$e in colour of di$its 3. Ti$htness / loss of sensation CO#P(IC*TIONS& I..CDI/TC 1. /ller$# C/>1P 1/TC 1. Compt. #ndrome 1. Diffuse 2. -urns ,steoporosis 2. Pruritus 2. tiff 9ts. 3. Primar# necrosis 4. >ash /e0coriatio n of s)in 6. D. dama$e 7. .. atroph#

NOTE& (ateral con16le o e3!r pre4ents lateral 1isplace3ent o patella.

< > R*,S Dame /$e Date Institution -on# ali$nment oft tissue ali$nment

<- R*, S 1& Tension pneumothora0 'ith haemothora0 from %lunt or pentratin$ chest in9ur#. Dote : Tension pneumothora0 is a clinical 1iagnosis : Complaints: d#spnea < pleuritic chest pain ,n e0amination: ( 23P (tracheal shift a'a# from affected side (5#per(resonance on affected side (Inilateral or a%sent %reath sounds. Immediatel# dia$nosin$ a tension pneumothora0+ immediate needle thoracotom# is mandator# is 2nd intercostals space mid(

a0illar# line follo'ed %# tu%e thoracostom# in 6th intercostals space anterior to mid( a0illar# line. (east i3portant& ,n C=>: sa' si$ns of tension pneumothora0 i.e. displaced trachea+ 'ith si$ns of pneumothora0 ! e"idenced %# no lun$ mar)in$&. 5aemothora0 is e"idenced %# an area of opacification in lun$ field+ more specificall# one sees a fluid le"elG The patient 'ould present in h#po"olemic choc) %ecause )in)in$ of $reat "essels. ST"D, S &Erect chest :- ra6 0ith air !n1er right he3i1iaphrag3 pne!3o-peritone!3. )hat are so3e ca!ses o pne!3o- peritone!3C 1. 2. 3. 4. Perforated "iscus u%phrenic a%scess /ir em%olism from sur$ical procedure Pneumotosis intestinalis

I patient is !na2le to 1o an erect chest :- ra6M 0hat is the other 0a6 one can 1etect a pne!3operitone!3C A 1et patient lie on his side and ta)e 0( ra# and see free air under a%dominal 'all. ST"D, S & *P *21o3inopel4ic :- ra6 sho0ing open 2ooN ract!re o pel4is.

T0A /-C < place/ tie a sheet around pel"is F call orthopaedics. <- R*, S a' a supine a%dominal 0( ra# 'ith 3assi4el6 dilated lar$e %o'el 'ith air in rectum ! impl#in$ incomplete intestinal o%struction&. The supine a%d. =( ra# $i"es a %etter picture of distri%ution of $as 'ithin %o'el+ i.e. can deetermine if %o'el is distended or not. /lso one can %etter assess the %o'el architecture+ if it is small or lar$e %o'el. Differential dia$nosis of massi"el# dilated lar$e %o'el: 1. i$moid "ol"ulus ! althou$h one did not see the classical ome$a si$n& 2. To0ic me$acolon. >I U: Patient is at ris) for ischemic %o'el+ i.e. in uncomplicated cases can do a si$moidoscop# to treat the si$moid "ol"ulus ?ush of air <faeces >elie"ed distension

D,TC: if there 'as a trans"erse colon "ol"ulus+ there 'ould %e no air in distal %o'el. <- R*, S 3& Isin$ a%dominal 0( ra# ! /=>&+ ho' can #ou determine the difference %et'een paral#tic ileus and mechanical o%structionE If %oth small and lar$e %o'el are dilated to the rectum+ then paral#tic ileus or pseudo( o%struction. The lot of distension is from $aseous distension from fermentation of $as+ %ut fluid in %o'el alsoG Treatment of intestinal o%struction A laparotom# %ut some fe' e0ceptions 'hich are: !i& Intestinal o%struction due to adhesions !ii& Incomplete 1ar$e %o'el o%struction %ecause can $i"e it a chance to settle %ut can in"esti$ate 'ith -arium F do electi"e 0. ST"D, S & Plain a21o3inal :- ra6 sho0ing 3 ra1io- opaT!e stones : 'hich are either $all %ladder or renal stones. Deed to do a lateral film to differentiate %et'een $all stones "s. renal. ?all stones are more anterior compared to renal stones. ST"D, S 4& Intra4eno!s p6elogra3 $ I5P%

The I3P sho'ed %iphid ureters A con$enital a%normalit# (Pt . is mostl# as#mptomatic ( ris) of infections. (Can $et h#dronephrosis %ecause "esico( ureteric reflu0 especiall# if %oth open independentl#. Treatment: Can remo"e the part that is causin$ the reflu0.

ST"D,S @& I5P sho0ing illing 1e ect o 2la11er D,TC: Peristalisis ma# %e occurrin$ ma# not see contrast I n distal ureter. ST"D, S H& <- R*, sho0ing illing 1e ect in oesophag!s a dia$nosis of oesopha$eal carcinoma. This patient 'ill present 'ith pro$ressi"e d#spha$ia 'ith constitutional s#mptoms. In"esti$ation A ,esopha$oscop# < %iops# 2BT patients presents 'ith potential curati"e oesopha$eal carcinoma+ T0 A oesopha$ectom# < re( esta%lish continuit# 'ith 9e9unum or trans"erse colon. Palliati"e T0 A chemo(radiation < palliati"e resection or stentin$. Hhat are causes of stricturesE

1. 2. 3. 4. 6.

In$estion of causati"e a$ents >adiation Crohn*s disease -ullous pemphi$us cleroderma

ST"D, S & C.O(EC,STOSTO#, C.O(*N-IO-R*# Indication A patient is unfit for sur$er#. ST"D, S & Perc!taneo!s transhepatic cholangiogra3 $ PTC% Common hepatic duct stone A uncommon .ost common cause of common hepatic duct o%struction A cholan$iocarcinoma. Cholan$iocarcinoma A adenocarcinoma of %ile ducts A mali$nanc# of e0trahepatic or intahepatic ducts A primar# %ile duct cancer T#pical patient Y 76#ears old and presents 'ith s#mptoms and si$ns of o%structi"e 9aundice such as icterus+ pruritus+ dar) urine and cla# coloured stools. >is) factors of cholan$iocarcinoma: ( choledochal c#sts ( ulcerati"e colitis ( sclerosin$ cholan$itis ( li"er flu)es In"esti$ations: ( ultrasound ( CT scan of a%domen ( C>CP/ PTC 'ith %iops#/ %rushin$s for c#tolo$#.

#anage3ent o pro:i3al 2ile 1!ct cholangiocarcino3a

A resection 'ith >ou0( en P hepatico9e9unostom# !anastomose %ile ducts to 9e9unum& )hat is the 3anage3ent o 1istal co33on 2ile 1!ct$C'D% cholangiocarcino3a C A Hhipple procedure

)hipple proce1!re F
LPancreatico1!o1enecto36 ! remo"e head of pancreas and duodenum& 7 Chole1ochoPeP!nosto36 ! anastomose C-D to 9e9unum& 7 PancraticoPeP!nosto36 ! anastomosis of distal pancreas remnant to 9e9unum& 7 -astroPeP!nosto36 ! anastomosis of stomach to 9e9unum&

ST"D, S & *NE"R,S#

*RTERIO-R*#

S.O)IN-

8*(SE

-riefl# the procedure of doin$ an arterio$ram is %# threadin$ up the femoral arter# and d#e is in9ected. Possi%le complication A aller$ic reaction.

ST"D,S & sho0ing spiral S o le t h!3er!s.

This is at ris) for malunion.

Thus T0 A ,>I4 ! open reduction and internal fi0ation&.

-a meal( this is 1 film of a series in -a meal.

ECor pulmonale Pencil point mar)in$s suddenl#. ECoarctation of aorta( Dotchin$ of %order of lo'er ri%. E4al!ate these res!lts IN peripheral arterial 1isease& Pulse Pallor Paral#sis Perishin$l# cold Paraesthesia Pain /D/T,.P -elo' sup. .esenteric /. A 3rd part of duodenum

POTS& Pot S 1& #ecNel?s 1i4ertic!l!3 $ note co!l1 also see persistence o other re3nants s!ch as !rach!s%.

>I1C ,4 2* : 1..ec)el*s di"erticulum is 2 feet pro0imal to terminal ileum. 2. In .ec)el*s di"erticulum+ there are 2 t#pes of mucosa: ( ?astric ( Pancreatic 3. It occurs in 2T of population 3. It is 2 inches lon$ Hhat are the possi%le complications of .ec)el*s di"erticulumE 1. The %and to the um%ilicus can under$o torsion. 2. Intusseception can occur %ecause of peristalisis. 3. Can ha"e $astric or pancreatic or intestinal tissue in it thus implies acid production. 4. Pain li)e acute appendicitis. 6. Perforation. POTS 2& Pot sho0ing colon cancerIIIIIIIIIIIIIIIIIII .ost colon cancer arise from pre( e0istin$ pol#ps V adenoma carcinoma sequenceW. 3illous adenoma is most associated 'ith colon cancer. The V 4rond( li)e W appearance of $lands on histolo$# occurs.

In /P> ! /%domino( Perineal resection&+ one remo"es si$moid colon < rectum < anus /nal cancer can %e treated radiolo$icall#. POT S 3& Sho0e1 ter3inal ileitis F Crohn?s 1isease Presentation: -lood# diarrhea / altered %o'el ha%it. -e conser"ati"e in resection %ecause the entire ?IT is at ris) %ut %e a$$ressi"e in #ou mana$ement . The medical mana$ement of Crohn*s disease is : A?old < sulphasala@ine < c#closporin < .ethotre0ate CO#P(IC*TIONS O8 CRO.N?S DISE*SE& 1. tricture 2. Intestinal o%struction 3. 4istulation %et'een %o'el and ad9acent structures such as s)in+ or other a%dominal or$ans e$. -ladder+ "a$ina + thus the patient presents 'ith pneumouria ! air in urine& or feculuria ! feces in urine&. 4. Protracted %leedin$ 6. /%dominal pain CO#P(IC*TIONS O8 "(CER*TI5E CO(ITIS ,"er 1B #ears of acti"e ulcerati"e colitis can lead to : 1. Pancolitis

2. 4ailure to thri"e 3. Protracti"e %leedin$ *(( *'O5E 3 *RE E(ECTI5E INDIC*TIONS O8 S"R-ER,. 4. e"ere lo'er $astrointestinal %leedin$ 6. To0ic .e$acolon T.E *'O5E 2 *RE E#ER-ENC, INDIC*TIONS 8OR S"RE-ER, IN "(CER*TI5E CO(ITIS. POT S 4& C*EC*( C*NCER Presentation& 1. Iron deficienc# anemia 2. Constitutional s#mptoms ! 't. 1oss+ loss of appetite+ lethar$#& 3. /%dominal mass 4. .a# present 'ith a%dominal pain li)e an acute appendicitis especiall# in elderl#. #anage3ent is 26& i. Clinical dia$nosis ii. Confirmation C"er# patient 'ith iron deficienc# anemia must %e in"esti$ated especiall# a proctosi$moidoscop# 'ith either a %arium enema or colonoscop#.

/lso must send feces for faecal occult %lood test and %e careful to ad"ise the patient not to eat %eet or li"er %efore the testG

POT S @ & PO(,POSIS CO(I POT >ecall : ?ardener*s s#ndrome Tourquot*s s#ndrome 4/P ! 4amilial adenomatous pol#posis coli& s#ndrome

PRESENT*TION& 1. Diarrhoea 2. 5#po)alemia %ecause e0cessi"e mucus is %een produced 3. .ali$nanc# related to the side of colon >i$ht 1eft side colon anemia side colon o%struction

Patient is as#mptomatic and adematous pol#ps are found on sur"eillance. ./D/?C.CDT : >esect the entire colon and do ileoanal anastomosis.

econd option: /%domino( perineal resection < ileostom#

(e t Colon Cancer presents 0ith & 1. Chan$e in %o'el ha%it 2. P> -leedin$ 3. >ecurrent %out of intestinal o%struction 4. purious diarrhea. POT S B& S*-ITT*( SECTION O8 5ERTE'R*( CO("#N S.O)IN- CO((*PSE O8 ("#'*R 5ETE'R*E Differential dia$nosis: 1. Pott*s disease 2. .etastatic tumour e$ from cancer midline paired structures e$ th#roid+ parath#roid+ %reast+ lun$+ adrenals+ )idne#+ prostate. PRESENT*TION& Collapse of a disc on 1 side 'ill lead to spinal root lesion thus leadin$ to lo'er motor neuron s#mptoms and si$ns. 5ence the patient 'ill complain of motor+ sensor# and autonomic complaints. .otor complaints: 1. e"ere muscle 'ea)ness 2. 1o'er %ac) pain 3. Pain in the distri%ution of ner"e root ! V >adicular painW& ensor# complaints:

/utonomic complaints: ii. iii. i". Irinar# retention Constipation e0ual d#sfunction/ impotence

E<*#IN*TION& On inspection the follo'in$ are present: 1. 4asiculations 2. e"ere muscle 'astin$ On palpation& 1. 5#potonia 2. e"ere muscle 'ea)ness / decreased muscle po'er RE8(E<ES& 5#porefle0ia P(*N& 1. /dmit patient and in"esti$ate him. 2. Treatment of metastatic tumour of "erte%ral column is radiotherap#. POT S H& * potte1 speci3en o renal cell carcino3a >enal cell carcinoma ma# present 'ith:

1. Painless haematuria 2. >ecurrent urinar# tract infection ! ITI& In4estigations& 1.Complete %lood count 2.Irine microscop# 3. /%dominal ultrasound com%ined 'ith Intra"enous uro$ram 4. Contrast C can of a%domen to sho' function andf e0tent of mass DON?T 'IOPS, M #*+E * DI*-NOSIS O8 REN*( CE(( C*RCINO#* *ND -O TO T.E*TRE I P>C/D: 1. 1ocal 2. 5aemato$enous : spread in %lood "ia renal "ein+ inferior "ena ca"a ! I3C& to the ri$ht atrium. 3. 1#mphatic : spread to lun$+ li"er and %one. If it occurs on the left side in man+ patient can present 'ith a "aricocoele. Patient ma# complain of a dra$$in$ sensation in scrotum. It is also associated 'ith defecti"e spermato$enesis+ and patient is often su%(fertile. ,n e0amination in standin$ position+ the "aricose "eins 'ithin the scrotum feel li)e a V %a$ of 'ormsW+ %ut there ma# %e little to feel 'hen the patient lies do'n. 3aricocele is a condition of "aricosities of the pampiniform ple0us of "eins. It usuall# occurs on the left+ and manifests first in adolescence. It is present in 1BT males.

Its ori$in is due to the draina$e of the left testicular "ein at ri$ht an$les into the left renal "ein+ unli)e the ri$ht testicular "ein 'hich drains o%liquel# into inferior "ena ca"a !I3C&. Patients 'ith "aricoceles ha"e a%sent or incompetent "al"es at the 9unction 'ith the left renal "ein. ,ccasionall# a "aricocele can %e secondar# to a tumour or other patholo$ical process %loc)in$ the testicular "ein. The %est )no'n e0ample of this is a tumour of the )idne# in"ol"in$ the renal "ein and o%structin$ the draina$e of the left testicular "ein.