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Essential Lists for Intercollegiate MRCS

Contents
Foreword Glossary 1 Anaesthetics and ITU 2 General Surgery and Urology 3 Orthopaedics and Neurology 4 Cardiovascular 5 Endocrine and Breast 6 Plastics and ENT 7 Your Lists Bibliography Index page vii ix 1 19 43 57 67 77 85 91 93

Anaesthetics and ITU


(Harmful and excessive response to an insult in the acute phase) Two or more of the following: Tachycardia 9 90 beats minute 1 Tachypnoea 9 20 breaths minute 1 Temperature : 36 C or 9 38 C WCC 9 12 or : 4 103/mm
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SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)

CAUSES OF ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)


(Refractory hypoxia in appropriate clinical setting with bilateral diffuse pulmonary inltrates and a PAWP : 18 mmHg and PaO2/FIO2 : 200) Direct: Aspiration Pulmonary contusion Toxic gas inhalation Near drowning Pneumonia Fat embolus Radiation Indirect: Sepsis DIC Trauma Cardiopulmonary bypass Blood transfusion Pancreatitis Reperfusion injury Burns

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NYHA ASSESSMENT OF CARDIOVASCULAR FUNCTION


I II no limitation of ordinary physical activity slight limitation of ordinary physical activity or ordinary activity result in palpitations, dyspnoea or angina III marked limitation of physical activity. Less than ordinary activity results in palpitations, dyspnoea or angina IV inability to carry out any physical activity without discomfort which may occur at rest

ASA GRADING (+E for Emergency)


I II III IV V healthy individual mild systemic disease severe systemic disease that limits activity but is not incapacitating incapacitating disease that is a constant threat to life moribund not expected to survive with or without an operation

POST MI RISK OF RE-INFARCTION PERI-OPERATIVELY


:3 weeks 3 weeks 3 months 36 months 96 months Peri-operative MI mortality 80% 2030% 515% 14% 50%

(Baseline peri-operative MI rate is 0.2% of which half are silent and most are on the third post-operative day)

BENEFITS OF EPIDURAL POST OP


Improved respiratory function Diaphragmatic splinting DVT Urinary retention Earlier mobilisation Sympathetic stimulation Cardiac workload Vascular resistance ! Splanchnic blood ow

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ENDOCRINE RESPONSE TO STRESS/SURGERY


Catecholamines (adrenal medulla): Inotropic and chronotropic Lipolysis Gluconeogenesis Cortisol (adrenal cortex): Proteolysis Lipolysis Gluconeogenesis Na+ and water retention Water retention
AN A E ST HE TIC S A ND IT U

Aldosterone (adrenal cortex): ADH (posterior pituitary): GH (anterior pituitary): Glucagon (pancreatic G cells):

Gluconeogenesis Insulin resistance Glycogenolysis Gluconeogenesis Insulin secretion

SUXAMETHONIUM SIDE EFFECTS


Muscle pain Bradycardia Bronchospasm Hyperkalaemia Hypo/hypertension Malignant hyperpyrexia

COMPLICATIONS OF GENERAL ANAESTHESIA


Aspiration ! Sputum production Cough reexes Ciliary activity Atelectasis Segmental collapse (V/Q mismatching) ! CO2 ARDS

COMPLICATIONS OF VENTILATION
Barotrauma (pneumomediastinum/thorax, subcutaneous emphysema) Volutrauma Air embolism Cardiac output Nosocomial pneumonia Parenchymal lung damage

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COMPLICATIONS OF INTUBATION
Trauma to teeth or upper airway Procedural hypoxia Aspiration Haemorrhage Blockage Misplacement Cuff puncture/displacement

INDICATIONS FOR INTUBATION


GCS/impaired gag reex High risk of airway obstruction Airway protection Bronchial toilet Hypoxia Metabolic acidosis CO2 retention To counteract ! ICP

PROBLEMS WITH PULSE OXIMETRY


Measures oxygenation not ventilation Inaccurate at O2 saturation :90% Read out is 23 seconds behind real time Interference from abnormal haemoglobin: CO poisoning Smokers Bilirubin Methaemoglobin Interference with signal: Shivering Diathermy Bright light Nail varnish Interference with ow: Hypotension Hypovolaemia Vasoconstriction

SHIFTS O2/SATURATION CURVE RIGHT (decreases afnity of Hb for p aO2


p aO2 ! H+ ! 2,3 DPG
Pyrexia Haemoglobin F (fetal) Altitude

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RESPIRATORY FAILURE
Type I: paO2: 8 kPa and paCO2 : 6.7 kPa) Acute asthma ARDS COPD/emphysema PE Pneumonia Pulmonary brosis Atelectasis Haemo/pneumothorax Type II: paO2: 8 kPa and paCO2 : 6.7 kPa) Severe asthma Spinal injury Severe COPD/emphysema Head injury Bronchiectasis ! ICP Kyphoscoliosis Coma Chest wall trauma Opioids Abdominal distension Muscular dystrophy Phrenic nerve injury Myasthenia gravis Sleep apnoea GuillianBarre syndrome

ACID BASE DISORDERS


Respiratory acidosis: CVA CNS tumour Encephalitis Sedation/opioids ! ICP Neuromuscular disease Trauma/surgery Ankylosing spondylitis COPD Pneumonia Respiratory alkalosis: CVA PE Encephalitis Hypoxia in COPD Hyperventilation/panic attack Exercise Altitude Salicyclate (early in poisoning) Amphetamine Pulmonary oedema

Metabolic acidosis Metabolic alkalosis: Ketoacidosis Vomiting Acute renal failure Chronic renal failure Lactic acidosis (see below) Hyperaldosteronism Methanol/ethanol Iatrogenic, eg diuretics Fistulae/diarrhoea Alkali abuse TPN Salicylate (late in poisoning)

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CAUSES OF LACTIC ACIDOSIS


Shock (see below) Pancreatitis Liver impairment/failure Renal impairment/failure Excessive exercise Leukaemia Biguanides

POST OP HYPOXIA
Pneumonia Atelectasis Bronchospasm Pneumothorax Diaphragmatic splinting Poor analgesia Opioids ARDS/ALI PE Pulmonary oedema Tracheal compression

IV FLUIDS
Crystalloids: Na+ Cl mmol/l mmol/l 154 154 0 0 30 30 131 111 147 156 Dextrose g/l 0 50 40 0 0 K+ Osmolality mmol/l mosm/l 0 308 0 252 0 286 5 279 4 273

Normal saline Dextrose 1/5 Normal saline Hartmanns Ringers lactate Colloids: Albumin Gelofusine Dextrans (40,70) Penta/Hetastarch

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TYPES OF SHOCK
Hypovolaemic Septic Cardiogenic Anaphylactic Neurogenic Temp. / !/ / !/ CVP BP TPR ! !

CLASSES OF SHOCK
AN A E ST HE TIC S A ND IT U

Class Vol loss Pulse rate BP Pulse pressure Urine output Resp rate Consciousness Fluid Skin Class Vol loss Pulse rate BP Pulse pressure Urine output Resp rate Consciousness Fluid Skin

I 1015% (0.75 L) :100 930 :20 Restless Crystalloid Normal III 3040% (:2 L) 120

II 3040% (1.5 L) 9100 920 :30 Anxious Cry/colloid Clammy IV 940% (92 L) 9140

95 :40 Confused Colloid/blood Cap. rell

0 940 Lethargic/coma Colloid/blood Pale/cold

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INDICATIONS FOR SWAN GANZ CATHETER (ie CVP " LA pressure)


Valvular heart disease LVF and interstitial pulmonary oedema Chronic severe lung disease Assessing hemodynamic response to therapies Diagnosis and assessment of pulmonary hypertension Diagnosis and assessment of shock states Diagnosis and assessment of ARDS/MODS Instability after cardiac surgery

CAUSES OF RAISED CVP


CCF MI with RVF Overload Cardiac contusion SVC obstruction Tension pneumothorax Pericardial effusion Cardiac tamponade TR

FEATURES OF TENSION PNEUMOTHORAX


Respiratory distress ! JVP EMD arrest Tracheal deviation away from side Ipsilateral decreased breath sounds Ipsilateral hyper-resonance

FEATURES OF CARDIAC TAMPONADE


! JVP Mufed heart sounds BP Kussmauls sign EMD arrest (First three are known as Becks triad)

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CARDIAC SUPPORT (INOTROPES)


1 2 1 2

Dopamine Dobutamine Adrenaline Noradrenaline Isoprenaline

++ ++ +++

+ ++ ++

++ +++ +++ +++ +++

++ + +++ + +++

D1 +++

D2 ++

INDICATIONS FOR RENAL REPLACEMENT THERAPY IN RENAL FAILURE


Persistent hyperkalaemia 9 6.0 Acidosis pH : 7.2 Pulmonary oedema Fluid overload despite diuresis Drug clearance, eg sedatives Uraemic complications, eg pericarditis, tamponade
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RENAL FAILURE
Pre-renal: Hypovolaemic shock Septic shock Cardiogenic shock Anaphylactic shock ATN Hypertension Diabetic disease Glomerulonephritis Infection/pyelonephritis Renal artery trauma/embolus Renal artery stenosis Compartment/crush syndrome Vasculitis Interstitial nephritis Goodpastures syndrome Renal vein thrombosis/embolism

Renal:

Post-renal: Bladder outlet obstruction Stricture Stones Retroperitoneal brosis Blocked catheter Neoplasm Infection

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CHILDS CLASSIFICATION OF SEVERITY IN CHRONIC LIVER DISEASE


Bilirubin ( mol/l) Albumin (g/l) Ascites Encephalopathy Nutrition/prothrombin time (seconds prolonged) 1 :35 935 None None Good/ 94 s 2 3 3550 950 3035 :30 Mild Marked Mild Advanced Moderate/ Poor/ 46 s 96 s

* Patient is grouped from A to C where A is :7, B 79 and C 99

(Original classication used nutrition but later modied to prothrombin time increase)

SURGICAL PROBLEMS ASSOCIATED WITH OBESITY


DM IHD Atelectasis ! Risk of aspiration Difcult intubation More wound infections ! DVT/PE ! Dissection/tissue trauma Longer duration of surgery Larger wounds

FEED TYPES
Enteral (EN): Oral NG PEG NJ Jejunostomy Peripheral line PICC Central line

Parenteral (TPN):

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ADVANTAGES OF EN OVER TPN


Cheaper Increased gut blood ow Decreased gut translocation Decreased stress ulceration Maintains gall bladder function More effective energy usage by portal system Fewer infections Less line associated complications

Vitamin A epithelial cell proliferation and differentiation Vitamin B6 collagen cross-linkage Vitamin C collagen cross-linkage and transport Vitamin D calcium and phosphate metabolism Carbohydrate prevents ketosis during a stress response Proteins extracellular matrix Zinc RNA/DNA synthesis, metalloproteases, antibacterial Copper collagen and elastin cross-linkage Selenium anti-oxidant

COMPLICATIONS OF EN
Tube related: Feed related: Misplacement Displacement Diarrhoea Bloating/colic Refeeding syndrome Leakage Blockage Nausea/vomiting Drug interactions

AN A E ST HE TIC S A ND IT U

FUNCTIONS OF ELEMENTS IN FEEDS

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COMPLICATIONS OF TPN
Line related: Sepsis/infective endocarditis Thrombophlebitis Pneumothorax Haemothorax Nerve injury Vascular injury/haematoma Feed related: ! Glucose, Na+, K+, H+ ! Ca++, CL Folate, Zn, PO4, Mg++ Fluid overload Thoracic duct injury Chylothorax Embolism Lost guide wire Arrhythmia Perforated right atrium Fatty liver Abnormal LFTs Gall bladder stasis Refeeding syndrome

STEROID EQUIVALENCE
Hydrocortisone Prednisolone Methylprednisolone 20 mg 5 mg 4 mg Triamcinalone 4 mg Betamethasone 0.75 mg Dexamethasone 0.75 mg

TRANSPLANT REJECTIONS
Hyperacute preformed antibody (hours) Accelerated acute secondary antibody response (days) Acute cytotoxic T-cell mediated (weeks) Chronic antibody-mediated vascular damage (months controversial)

AUTOIMMUNE DISEASE
Hashimotos thyroiditis Thyroglobulin + microsome Graves disease TSH receptor Atrophic gastritis Parietal cells Pernicious anaemia Intrinsic factor Goodpastures syndrome Basement membrane Myasthenia Gravis Acetylcholine receptor Systemic Lupus erythematosis DNA smooth muscle Rheumatoid Arthritis IgM Scleroderma Centromere

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Primary biliary cirrhosis Mitochondria Insulin-dependent DM Pancreatic islet cells GuillianBarre syndrome Peripheral nerve myelin

CAUSES OF IMMUNOSUPPRESSION
Congenital: Agammaglobulinaemia Hypogammaglobulinaemia IgA deciency Common variable immunodeciency Selective antibody deciency Acquired: Infectious HIV, systemic infection Iatrogenic Splenectomy, transfusion, radiotherapy, chemotherapy, steroids Neoplastic Leukaemia, lymphoma, myeloproliferative diseases, advanced solid tumours Other Hypoxia, DM, alcoholism, poor nutrition, trauma/surgery

CAUSES OF POST-OPERATIVE PYREXIA


Physiological response Drug-induced DVT/PE Anastomotic leak Abscess Respiratory tract infection Urinary tract infection Wound infection Cannula site infection

RISK FACTORS FOR WOUND INFECTION


Operative factors: Emergency surgery Extended pre-op admission Site of incision, eg peri-anal Excessive tension Poor tissue handling Pre-op shaving Necrotic tissue Tissue ischaemia Faecal peritonitis Intra-abdominal abscess

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Patient factors: Extremes of age Poor nutritional status Obesity DM Alcoholism

Immunosuppression (see above) Cardiac failure Renal failure Hepatic failure Respiratory failure

ANTIBIOTICS
Bacteriocidal: -lactams Aminoglycosides Vancomycin Chloramphenicol Tetracycline Erythromycin Clindamycin

Bacteriostatic:

STERILISATION (kills everything including viruses and spores)


Autoclave Ethylene oxide Irradiation Dry heat Low temperature steam with formaldehyde

DISINFECTION (kills everything except some viruses and spores)


Boiling water Low temperature steam Formaldehyde Iodophors/iodine Alcohol Hydrogen peroxide

NORMAL COMMENSAL ORGANISMS


Skin Nasal Oral staph, strep, corynebacteria, Propionibacter staph staph, strep, Neisseria, Haemophilus, corynebacteria, anaerobes

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Upper GIT staph, strep, Neisseria, Haemophilus, corynebacteria, clostridium, yeasts Lower GIT Enterobacteriaceae, enterococci, bacteroides, clostridium, yeasts GU Enterobacteriaceae, enterococci, bacteroides, clostridium, yeasts, staph, strep, lactobacilli, corynebacteria

CLASSIFICATION OF WOUND
uninammed tissue with no GU/GI tract entry (:2% infection rate) Clean-contaminated entry to hollow viscus other than colon with minimal contamination. (810% infection rate) Contaminated spillage from hollow viscus, eg colon, open fractures or bites (1220% infection rate) Dirty frank pus, perforated viscus, traumatic wound (925% infection rate) Clean

TUMOURS IN HIV
Lymphoma non-Hodgkins lymphoma Squamous cell carcinoma skin, cervix, larynx Kaposis sarcoma Squamous cell papilloma

ACUTE ABDOMEN IN HIV


Bacterial enteritis Megacolon 2 to CMV Haemorrhage 2 to GI involvement by Kaposis sarcoma, lymphoma Pancreatitis 2 to anti-retroviral therapy Tuberculous disease of the GI tract Normal surgical disease in HIV +ve patient

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TOXINS
Bacteria Source Structure Effect Vaccine Heat stable Exotoxin Gram +ve and ve Intracellular Polypeptide Variable Yes No Endotoxin Gram ve Cell wall Lipopolysaccharide Septic shock No Yes