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🏥 General Surgery - Physiotherapy Exam Notes

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PART A: MAJOR TOPICS

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1. SHOCK

Classification (6 Types - Blalock's + Modern)

Clinical Features

• Hypotension (SBP <90 mmHg)
• Tachycardia
• Cool, clammy skin (except septic - warm in early phase)
• Decreased urine output (<0.5 mL/kg/hr)
• Altered consciousness

Stages of Hemorrhagic Shock (ATLS Classification)

Management

• Hemorrhagic: Volume resuscitation with blood products; control bleeding (damage control surgery)
• Septic: IV fluids, appropriate antibiotics, source control (drain abscesses, debride necrotic tissue)
• Cardiogenic: Inotropes (dobutamine), treat underlying cause
• Neurogenic: IV fluids, vasopressors
• Key triad to prevent in hemorrhagic shock: Hypothermia + Acidosis + Coagulopathy (lethal triad)

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2. BURNS

Classification by Depth

• Tintinalli's Emergency Medicine

Estimation of Burn Size - Rule of Nines

Lund-Browder chart is more accurate, especially in children (larger heads, smaller legs).

Fluid Resuscitation - Parkland Formula

• 4 mL × kg body weight × % TBSA burned
• Half given in first 8 hours (from time of injury)
• Remaining half over next 16 hours
• Fluid of choice: Lactated Ringer's solution

American Burn Association - Major Burn Criteria

• Partial thickness burns >25% TBSA
• Full thickness burns >10% TBSA
• Burns of face, hands, feet, genitalia, major joints
• Circumferential burns
• Chemical/electrical burns
• Inhalation injury

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3. ABDOMINAL INCISIONS

Layers Cut in Midline Incision (from outside in):

1. Skin
2. Subcutaneous fat (Camper's + Scarpa's fascia)
3. Linea alba
4. Transversalis fascia
5. Extraperitoneal fat
6. Peritoneum

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4. MINIMALLY INVASIVE SURGERY (MIS) / LAPAROSCOPY

Physiological Basis - CO₂ Pneumoperitoneum

• CO₂ is insufflated into the abdomen at 12-15 mmHg pressure
• Causes diaphragmatic elevation → reduces lung compliance
• CO₂ absorption → hypercapnia (hypercarbia)
• Reverse Trendelenburg for upper abdominal surgery; Trendelenburg for pelvic surgery
• Reduces venous return (preload) due to increased IAP

Advantages of Laparoscopy over Open Surgery

Common Laparoscopic Procedures

• Cholecystectomy (most common) - 4 ports
• Appendicectomy
• Fundoplication (GERD)
• Colectomy
• Hernia repair (TEP/TAPP)
• Hysterectomy, myomectomy

Contraindications

• Previous extensive abdominal surgery (relative)
• Cardiopulmonary compromise
• Uncorrectable coagulopathy
• Massive bowel distension

Physiotherapy Relevance Post-Laparoscopy

• Referred shoulder pain (diaphragmatic irritation from CO₂) - position: lying down, heat
• Deep breathing exercises day 1 post-op
• Earlier ambulation vs. open surgery
• Abdominal binder support

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5. WOUND & MANAGEMENT

Types of Wound Healing

Phases of Wound Healing

1. Hemostasis (0-24 hrs): Vasoconstriction, platelet plug, clot formation (fibrin mesh)
2. Inflammatory phase (1-4 days): Neutrophils arrive (days 1-2), then macrophages; clean debris, release growth factors
3. Proliferative phase (4-21 days): Fibroblasts produce collagen; angiogenesis; granulation tissue forms; wound contracts
4. Remodeling/Maturation phase (21 days - 2 years): Type III collagen replaced by Type I; tensile strength increases to max 80% of original

Factors Affecting Wound Healing

Wound Classification

• Clean: Elective, no infection, no bowel entry (1-2% infection)
• Clean-contaminated: Controlled bowel entry (5-10%)
• Contaminated: Inflamed tissue, fresh trauma (15-20%)
• Dirty/Infected: Perforated viscus, pus (>30%)

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6. BLOOD TRANSFUSION

Types of Blood Products

Indications for Blood Transfusion

• Hb <7 g/dL in stable patients
• Hb <8 g/dL in cardiac disease or peri-operative
• Active hemorrhage with hemodynamic instability
• Class III/IV hemorrhagic shock

Complications of Blood Transfusion

Massive Transfusion Protocol

• Definition: >10 units PRBC in 24 hours
• Balanced ratio: PRBC : FFP : Platelets = 1:1:1
• Monitor for: hypothermia, hypocalcemia (calcium chelation by citrate), hyperkalemia

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7. TUMORS

Classification

Nomenclature

• Epithelial benign: Adenoma, papilloma
• Epithelial malignant: Carcinoma (squamous, adeno, transitional)
• Connective tissue benign: Fibroma, lipoma, chondroma, osteoma
• Connective tissue malignant: Fibrosarcoma, liposarcoma, osteosarcoma
• Mixed: Teratoma
• Lymphoid: Lymphoma, Hodgkin's disease

TNM Staging

Tumor Markers (Key ones)

• PSA - Prostate cancer
• AFP - Hepatocellular carcinoma, teratoma
• CEA - Colorectal, breast cancer
• CA-125 - Ovarian cancer
• CA 19-9 - Pancreatic cancer
• beta-hCG - Choriocarcinoma, testicular germ cell tumors

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8. ULCER

Classification by Cause

Parts of an Ulcer (Examination)

• Base: Floor of the ulcer (may be granulating, sloughy, necrotic)
• Edge: Sloping (healing), undermined (TB), punched out (arterial/trophic), everted (malignant), raised (BCC)
• Surrounding tissue: Induration, pigmentation, edema

Pressure Ulcer Staging (NPUAP)

• Stage I: Non-blanchable erythema
• Stage II: Partial thickness skin loss (shallow open wound)
• Stage III: Full thickness skin loss (but not through fascia)
• Stage IV: Full thickness, involves muscle/bone
• Unstageable: Base covered by slough or eschar

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9. HEMORRHAGE

Classification

• Arterial: Bright red, spurts with heartbeat
• Venous: Dark red, steady flow
• Capillary: Oozing

• Primary hemorrhage: At time of surgery/injury
• Reactionary hemorrhage: Within 24 hours (clot displacement as BP rises)
• Secondary hemorrhage: 7-14 days post-op (due to infection, vessel erosion)

• External: Visible blood loss
• Internal: Hidden in body cavities (hemothorax, hemoperitoneum)

Consequences of Blood Loss

• Hypovolemia → decreased preload → decreased CO
• Compensatory tachycardia, peripheral vasoconstriction

• 30% loss: Class III shock (see above)

• 40% loss: Life-threatening

Management

• Direct pressure (first aid)
• Tourniquet (limb hemorrhage)
• Surgical ligation, endovascular embolization
• Blood transfusion
• Treat coagulopathy (FFP, platelets, cryoprecipitate)
• Tranexamic acid (within 3 hours of injury - CRASH-2 trial)

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10. ANAESTHESIA

Types of Anaesthesia

Stages of General Anaesthesia (Guedel's Stages)

1. Analgesia - awake, analgesic, amnesic
2. Excitement (Delirium) - unconscious, excited, irregular breathing, risk of vomiting/laryngospasm
3. Surgical anaesthesia - regular breathing, muscle relaxation; surgery performed
4. Medullary depression - respiratory/cardiovascular collapse; DANGER

Pre-operative Assessment

• ASA Classification:

Complications of Anaesthesia

• Aspiration (Mendelson's syndrome) - reason for NPO (nil by mouth)
• Malignant hyperthermia - rare genetic complication; treat with dantrolene
• Laryngospasm, bronchospasm
• Hypotension, arrhythmia
• Post-operative nausea & vomiting (PONV)
• Awareness under anaesthesia

Physiotherapy Considerations Post-Anaesthesia

• Residual muscle relaxants impair respiratory function
• Encourage deep breathing exercises, incentive spirometry
• Early ambulation to prevent DVT

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11. ASSESSMENT OF A TRAUMA PATIENT

ATLS Framework: Primary + Secondary + Tertiary Survey

• Full history: AMPLE (Allergies, Medications, Past history, Last meal, Events)
• Head: scalp lacerations, skull fractures
• Eyes: visual acuity, raccoon eyes (base of skull fracture)
• Ears: Battle's sign (mastoid bruising - base of skull fracture), haemotympanum
• Neck: tracheal deviation, venous distension, C-spine tenderness
• Chest: rib fractures, auscultate
• Abdomen: tenderness, rigidity, FAST ultrasound
• Pelvis: instability, urethral blood (do NOT catheterize)
• Extremities: fractures, dislocations, vascular status
• Neurological: complete neuro exam

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12. SURGICAL SITE INFECTIONS (SSI)

CDC Classification of SSI

1. Superficial incisional SSI - involves skin and subcutaneous tissue only
2. Deep incisional SSI - involves fascia and muscle layers
3. Organ/Space SSI - involves organ or space opened during surgery (e.g., intra-abdominal abscess)

Common Organisms

• Staphylococcus aureus (most common, including MRSA)
• E. coli, Klebsiella
• Enterococcus
• Pseudomonas aeruginosa

Risk Factors

Prevention

• Antibiotic prophylaxis: Single dose IV 30-60 min before incision (e.g., cefazolin)
• Proper skin preparation (chlorhexidine-alcohol)
• Hair removal with clippers (not razors)
• Maintain intraoperative normothermia
• Maintain normoglycemia (<200 mg/dL)
• Strict aseptic technique
• Appropriate wound closure

Signs of SSI

• Rubor (redness)
• Calor (warmth)
• Dolor (pain)
• Tumor (swelling)
• Discharge (pus/serous)
• Fever >38°C after 48 hours post-op

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PART B: SHORT 5-MARK TOPICS

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1. PRIMARY & SECONDARY SURVEY IN TRAUMA

A = Airway (+ C-spine protection)
B = Breathing (+ ventilation)
C = Circulation (+ hemorrhage control)
D = Disability (neurological status)
E = Exposure / Environmental control

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2. FIBROADENOMA

Features

• Age: Young women, 15-35 years
• Hormonal dependence: Estrogen-sensitive; grows in pregnancy, involutes post-menopause
• Consistency: Firm, rubbery, smooth
• Mobility: Highly mobile ("breast mouse")
• Size: Typically 1-3 cm; giant fibroadenoma >5 cm (especially in adolescents)
• Pain: Usually painless
• Skin changes: None

Histology

• Consists of compressed, elongated duct-like structures in a fibrous stroma
• Two patterns: Intracanalicular (fibrous tissue compresses ducts into slit-like spaces) and Pericanalicular (fibrous tissue grows around ducts)

Investigations

• Triple assessment: Clinical examination + Ultrasound/Mammography + FNAC/Biopsy
• Ultrasound: Well-defined, smooth, hypoechoic lesion
• FNAC: Clusters of epithelial cells + bare nuclei + fibrous stromal fragments

Management

• Observation if confirmed by triple assessment (in young women, lesion <3 cm)
• Excision if: rapid growth, >3 cm, uncertain diagnosis, patient preference
• Giant fibroadenoma: Surgical excision

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3. HEMANGIOMA

Types

Infantile (Strawberry) Hemangioma

• Most common benign tumor of infancy
• Appears at 2-4 weeks of life
• Rapid growth phase for 6-12 months, then spontaneous involution
• 50% involute by age 5; 70% by age 7
• Treatment: observation; propranolol for threatening lesions (near eye, airway)

Cavernous Hemangioma (Liver)

• Most common benign liver tumor
• Usually asymptomatic; found incidentally
• MRI: "Peripheral nodular enhancement" pattern
• Treatment: no treatment if <5 cm; resection if symptomatic or >10 cm

Kasabach-Merritt Syndrome

• Large hemangioma trapping platelets → thrombocytopenia + DIC
• Occurs in giant kaposiform hemangioendothelioma

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4. BURKITT TUMOR (Burkitt Lymphoma)

Types

Pathology

• Translocation: t(8;14) in 80% - MYC oncogene overexpression
• Alternative: t(2;8) or t(8;22)
• Histology: Starry sky pattern - sheets of medium-sized lymphocytes interrupted by pale macrophages containing apoptotic debris

Clinical Features

• Endemic type: massive jaw swelling, orbital involvement
• Sporadic type: abdominal mass, bowel obstruction, ascites
• B symptoms: fever, night sweats, weight loss
• Serum LDH markedly elevated (marker of tumor burden)

Treatment

• Intensive short-duration chemotherapy (CODOX-M/IVAC protocol)
• Rituximab (anti-CD20)
• High cure rate (~90%) with early treatment

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5. SUBDURAL HAEMATOMA

Classification by Timing

Mechanism

• Bridging veins (cortical veins bridging the cortex to dural sinuses) tear
• More susceptible in elderly (brain atrophy = longer bridging veins under tension)
• Minor trauma can cause it in elderly/alcoholics

Clinical Features

• Acute: Deteriorating consciousness after head injury; lucid interval possible
• Chronic: Gradual headache, confusion, cognitive decline, focal deficits; may present weeks after trivial injury (can be forgotten)
• Raised ICP: headache, vomiting, papilledema

Investigations

• CT scan (non-contrast) - investigation of choice
• Crescent-shaped collection, concave medially, convex laterally (crosses suture lines - unlike EDH)
• Midline shift if large

Management

• Acute/symptomatic: Surgical evacuation (craniotomy or burr-hole drainage)
• Chronic small SDH: Conservative (observation, steroids, reverse anticoagulation)
• Chronic large symptomatic: Burr-hole drainage

Note: Subdural vs Extradural - SDH crosses suture lines (crescent), EDH does NOT cross suture lines (biconvex/lens-shaped, usually from middle meningeal artery)

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6. CARDIAC TAMPONADE

Causes

• Trauma (penetrating chest injury - most common surgical cause)
• Pericarditis (viral, bacterial, TB)
• Malignancy
• Post-cardiac surgery
• Aortic dissection
• Uremia

Classic Signs - Beck's Triad

1. Hypotension (reduced cardiac output)
2. Elevated JVP / distended neck veins (impaired venous return)
3. Muffled/distant heart sounds (fluid insulates sounds)

Additional Signs

• Pulsus paradoxus: >10 mmHg drop in SBP during inspiration (key sign)
• Tachycardia
• Kussmaul's sign: JVP rises on inspiration (instead of falling)

ECG Findings

• Sinus tachycardia
• Low voltage QRS complexes
• Electrical alternans (alternating QRS height) - pathognomonic

Investigations

• Bedside ECHO/e-FAST: Gold standard - pericardial fluid + diastolic collapse of right ventricle
• CXR: Enlarged globular "water-bottle" shaped cardiac silhouette (if >250 mL)

Management

• Pericardiocentesis (needle aspiration from subxiphoid route) - immediate relief
• Pericardial window (surgical drainage) - definitive
• IV fluids to maintain preload while preparing for drainage
• Do NOT: Give diuretics or vasodilators (will worsen hypotension)

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7. PNEUMOTHORAX & TENSION PNEUMOTHORAX

Types

Tension Pneumothorax - EMERGENCY

1. Tracheal deviation to contralateral side
2. Absent breath sounds on ipsilateral side
3. Hyperresonance on percussion of ipsilateral side
4. Distended neck veins
5. Hypotension + tachycardia

⚠️ CLINICAL DIAGNOSIS - Do NOT wait for chest X-ray. Treat immediately!

Management

Physiotherapy Management Post-Chest Drain

• Breathing exercises (deep inspiration, huffing)
• Monitor drain for swinging (confirms position), bubbling (active air leak), drainage
• Encourage early ambulation
• Remove drain when lung fully expanded, no air leak

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QUICK REFERENCE - KEY NUMBERS TO REMEMBER

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🏥 GENERAL SURGERY - PHYSIOTHERAPY EXAM

COMPLETE NOTES | 15-MARK & 5-MARK FORMAT

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PART A - MAJOR TOPICS (15 MARKS EACH)

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1. SHOCK (15 Marks)

Definition

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Classification

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Pathophysiology

1. Compensated Phase: Body compensates via neuroendocrine response (catecholamines, ADH, RAAS activation) - tachycardia, vasoconstriction, fluid conservation. BP may be maintained.
2. Decompensated Phase: Compensation fails. Cellular hypoxia worsens. Anaerobic metabolism → lactic acidosis. Microcirculatory dysfunction. Organ dysfunction begins.
3. Irreversible Phase: Extensive parenchymal + microvascular injury. Volume resuscitation fails to reverse. MODS (Multi-Organ Dysfunction Syndrome) → death.

• Reduced O₂ delivery → mitochondrial dysfunction
• Switch to anaerobic glycolysis → lactate production
• Cell membrane Na/K-ATPase fails → cellular edema
• Release of DAMPs (damage-associated molecular patterns) → systemic inflammation

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ATLS Classification of Hemorrhagic Shock (4 Classes)

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Clinical Features

• Hypotension (SBP <90 mmHg)
• Tachycardia
• Oliguria (<0.5 mL/kg/hr)
• Altered consciousness
• Metabolic acidosis (lactic acidosis)

• Septic shock: Initially warm, flushed skin (early distributive); then cold, clammy (late)
• Cardiogenic: Raised JVP, pulmonary edema, S3 gallop
• Neurogenic: Bradycardia + hypotension (paradox - no tachycardia due to loss of sympathetics)
• Obstructive (tamponade): Beck's triad; tension pneumothorax: absent breath sounds + tracheal deviation

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Investigations

• Lactate (>2 mmol/L = hypoperfusion; >4 mmol/L = severe shock)
• ABG: metabolic acidosis, base deficit
• FBC: Hb, WBC, platelets
• Coagulation (PT, APTT) - coagulopathy in hemorrhagic
• Blood cultures (septic shock)
• ECG, troponin (cardiogenic)
• Echocardiography / bedside FAST
• Serum electrolytes, creatinine (organ function)

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Management

• Two large-bore IV cannulae (16G or larger)
• Oxygen supplementation
• Continuous monitoring: pulse, BP, SpO₂, urine output, ECG
• Treat the underlying cause

• Control hemorrhage - direct pressure, tourniquet, surgery
• Blood product resuscitation: PRBC, FFP, platelets (1:1:1 ratio in massive hemorrhage)
• Avoid "lethal triad": hypothermia + acidosis + coagulopathy
• Permissive hypotension: SBP 80-90 until hemorrhage controlled
• Tranexamic acid within 3 hours (CRASH-2 trial evidence)

• IV broad-spectrum antibiotics within 1 hour
• 30 mL/kg IV crystalloid within 3 hours
• Source control (drain pus, remove infected hardware, debridement)
• Vasopressors: Norepinephrine is first-line if fluid-unresponsive
• Target MAP ≥65 mmHg, urine output ≥0.5 mL/kg/hr

• Inotropes: Dobutamine, milrinone
• Treat arrhythmias, reperfusion for MI (PCI)
• Do NOT give excessive IV fluids

• IV fluids (limited) + vasopressors (norepinephrine)
• Spinal immobilization

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Physiotherapy Relevance in Shock Recovery

• Patients post-shock have prolonged ICU stays; early physiotherapy reduces muscle wasting
• Respiratory physiotherapy (suction, positioning, NIV weaning)
• Progressive mobilization once hemodynamically stable
• Management of complications: pressure sores, DVT prevention, ICU-acquired weakness

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2. BURNS (15 Marks)

Definition

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Classification by Depth

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Estimation of Burn Surface Area

Note: In children - head is larger (18%) and legs are smaller. Use Lund-Browder chart for accurate pediatric assessment. Palm method: Patient's own palm = 1% BSA (useful for scattered burns)

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Pathophysiology of Burns - Jackson's Zones

1. Zone of Coagulation (central) - maximum damage, irreversible cell death
2. Zone of Stasis (middle) - ischemic but potentially viable; management aim is to prevent conversion to zone of coagulation
3. Zone of Hyperemia (periphery) - increased perfusion, full recovery expected

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Systemic Effects (Major Burns >20% TBSA)

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American Burn Association - Major Burn Classification (Requires Hospital Transfer)

• Partial thickness >25% TBSA (adult), >20% (elderly/child)
• Full thickness >10% TBSA
• Burns of face, hands, feet, genitalia, perineum, or major joints
• Circumferential extremity or chest burns
• Inhalation injury
• Chemical or electrical burns
• Burns + major trauma

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Management

• Stop burning process (cool with running water 10-20 min; do NOT use ice)
• Remove jewellery, non-adherent clothing
• Cover with clean dressing
• ABC assessment

4 mL × body weight (kg) × % TBSA burned

• Give half in the first 8 hours (from time of burn, not arrival)
• Give remaining half over next 16 hours
• Fluid: Lactated Ringer's solution
• Monitor: urine output target 0.5-1 mL/kg/hr (adults), 1 mL/kg/hr (children)
• Note: only 2nd and 3rd degree burns are counted; 1st degree excluded

• Debride blisters (or leave intact - controversial)
• Topical agents: Silver sulfadiazine (most common), mafenide acetate, silver nitrate
• Synthetic dressings (e.g., Biobrane) for partial thickness

• Escharotomy: For circumferential full-thickness burns → compartment syndrome → incise eschar along full length of limb
• Fasciotomy: If compartment syndrome persists
• Early excision and skin grafting: Within 3-5 days for deep partial/full thickness
  • Split-thickness skin graft (STSG): from thigh, buttock (donor site)
  • Full-thickness skin graft (FTSG): for face, hands

• 100% O₂ via non-rebreather mask (carbon monoxide poisoning)
• Early intubation if: stridor, hoarseness, facial burns, singed nasal hair, carbonaceous sputum
• Bronchoscopy to assess airway

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Physiotherapy in Burns

• Positioning: Anti-contracture positioning from day 1 (neck extension, shoulder abduction, elbow extension, hip extension, knee extension, ankle dorsiflexion)
• Splinting: Custom splints to prevent contracture
• Exercises: Active/passive ROM, progressive strengthening
• Scar management: Pressure garments (worn 23 hrs/day for 1-2 years), silicone sheets, massage
• Ambulation: Early walking prevents complications
• Respiratory physio: Breathing exercises, suctioning, chest physio for inhalation injury patients

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3. WOUND & MANAGEMENT (15 Marks)

Definition

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Classification of Wounds

• Incised: Clean cut by sharp instrument
• Laceration: Irregular tear
• Abrasion: Superficial scraping
• Puncture/Stab: Deep narrow wound
• Contusion: Closed, bruised tissue
• Avulsion: Skin/tissue torn away
• Bite wound: Animal/human; high infection risk

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Types of Wound Healing

1. Primary intention (First intention): Clean wound with approximated edges (sutured). Minimal scarring. Surgical incisions.
2. Secondary intention: Wound left open; heals by granulation tissue formation, contraction, epithelialization. Larger scar. Used for infected wounds, pressure ulcers, abscess cavities.
3. Tertiary intention (Delayed primary closure): Wound cleaned and left open 4-5 days, then sutured. Used for contaminated traumatic wounds.

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Phases of Wound Healing

• Vasoconstriction (immediate, 5-10 min)
• Platelet activation and aggregation
• Coagulation cascade → fibrin clot
• Clot acts as scaffold and reservoir for growth factors

• Vasodilation + increased permeability (mediated by histamine, prostaglandins)
• Neutrophils (peak day 1-2): phagocytosis of bacteria and debris; release of proteases and ROS
• Macrophages (peak day 2-3): the master regulators; phagocytosis + release of key growth factors (PDGF, TGF-β, VEGF, EGF, FGF)
• T-lymphocytes arrive at day 5-7; bridge inflammation to proliferation
• Signs: Redness, warmth, swelling, pain (cardinal signs)

• Fibroblasts (recruited by PDGF): proliferate, synthesize extracellular matrix
• Collagen synthesis: Type III collagen first (provisional), later replaced by Type I
• Requires: Vitamin C (for hydroxylation of proline/lysine), oxygen, zinc
• Angiogenesis: New capillaries form (VEGF-driven); granulation tissue = fibroblasts + capillaries + matrix
• Wound contraction: Myofibroblasts (differentiated fibroblasts) pull wound edges together; reduces wound size by up to 40-80%
• Re-epithelialization: Keratinocytes migrate from wound edges

• Type III collagen replaced by Type I collagen (stronger, organized)
• Cross-linking of collagen fibers
• Tensile strength increases progressively: 50% at 6 weeks; maximum 80% of original tissue at 1-2 years (never 100%)
• Scar initially red and raised → becomes pale and flat over months

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Macrophage Activities in Wound Healing (Critical)

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Factors Affecting Wound Healing

• Infection (most common cause of delayed healing)
• Poor blood supply (ischemia, pressure, radiation)
• Foreign body / dead space
• Wound tension / edema
• Hematoma formation
• Denervation (e.g., neuropathic ulcers)

• Diabetes mellitus (hyperglycemia impairs neutrophil function, reduces growth factors, microvascular disease)
• Malnutrition (low protein = poor collagen; Vitamin C deficiency = impaired hydroxylation; Zinc deficiency)
• Age (slower cell turnover, reduced growth factors)
• Steroids / immunosuppressants (suppress inflammation and proliferation)
• Anemia (reduced oxygen delivery)
• Jaundice / uremia (toxic metabolites impair healing)
• Smoking (vasoconstriction, reduced O₂, impairs angiogenesis)
• Obesity (poor vascularity of fat, increased tension)
• Malignancy / radiotherapy

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Wound Complications

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Wound Dressings and Management

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4. BLOOD TRANSFUSION (15 Marks)

Definition

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Blood Group Systems

• ABO system: A, B, AB, O (determined by antigens on RBC)
  • O negative = Universal donor
  • AB positive = Universal recipient
• Rhesus (Rh) system: Most important after ABO; Rh-D antigen
  • Rh-negative women of childbearing age should receive Rh-negative blood

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Pre-Transfusion Testing

1. ABO and Rh typing
2. Antibody screen (indirect Coombs test)
3. Cross-matching: Mix donor RBCs with recipient serum; detects incompatibility
   • Electronic crossmatch
   • Immediate spin crossmatch
   • Full serological crossmatch (takes 45-60 min; most thorough)

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Blood Products and Indications

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Transfusion Triggers (Evidence-Based)

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Complications of Blood Transfusion

• Delayed hemolytic reaction (3-10 days): Minor blood group antibody boosting
• Post-transfusion purpura: 5-10 days; thrombocytopenia
• Alloimmunization: Development of new RBC, HLA, platelet antibodies
• Transfusion-transmitted infections: HIV, HCV, HBV, malaria, CMV, variant CJD
• Iron overload: After >20 transfusions; use desferrioxamine
• Graft-versus-host disease (TA-GvHD): Immunocompromised patients; prevent with irradiated blood

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Massive Transfusion Protocol (MTP)

• Definition: ≥10 units PRBC in 24 hours (or ≥4 units in 1 hour)
• Balanced resuscitation ratio: PRBC : FFP : Platelets = 1:1:1
• Monitor for:
  • Hypothermia (use blood warmers)
  • Hypocalcemia (citrate chelates calcium → give 10 mL 10% calcium gluconate per 4 units)
  • Hyperkalemia (older blood releases K⁺)
  • Dilutional coagulopathy
  • Metabolic alkalosis (citrate converted to bicarbonate)

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5. MINIMALLY INVASIVE SURGERY (MIS) / LAPAROSCOPY (15 Marks)

Definition

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Types of MIS

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Physiological Basis of CO₂ Pneumoperitoneum

• Diaphragm pushed cephalad → reduced FRC, reduced lung compliance
• Ventilation-perfusion mismatch
• CO₂ absorption from peritoneum → hypercapnia (hypercarbia)
• Requires increased minute ventilation during anaesthesia

• Increased intra-abdominal pressure → decreased venous return (preload)
• Compression of IVC → decreased cardiac output
• Reflex sympathetic activation → increased HR and SVR
• Reverse Trendelenburg (head up) worsens venous return

• Reduced renal perfusion → decreased urine output during procedure
• Risk of CO₂ embolism (rare but life-threatening)
• Hypothermia (cold dry CO₂ gas)

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Steps of Laparoscopic Cholecystectomy (Standard Procedure)

1. General anaesthesia + endotracheal intubation
2. Veress needle inserted (umbilicus) OR Hasson technique (open) for initial access
3. CO₂ insufflation to 12-15 mmHg
4. 10 mm camera port at umbilicus
5. 3 working ports (5 mm) - epigastric, right flank, right hypochondrium
6. Patient tilted: head up (reverse Trendelenburg) + left tilt
7. Gallbladder retracted; Calot's triangle dissected
8. Critical view of safety: cystic duct and cystic artery identified
9. Clip and divide cystic duct and artery
10. Gallbladder dissected off liver bed using electrocautery
11. Specimen extracted through umbilical port (via endoscopy bag)
12. Deflation and port closure

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Advantages vs Open Surgery

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Disadvantages / Complications of Laparoscopy

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Physiotherapy Post-Laparoscopy

• Shoulder tip pain: Lying flat, local heat, gentle shoulder movements; caused by diaphragmatic irritation from residual CO₂
• Deep breathing exercises: Day 1 post-op (incentive spirometry)
• Early ambulation: 4-6 hours post-operatively
• Core stability: Avoid strenuous core exercises for 2 weeks
• Port site care: Observe for hernia signs when exercises increase intra-abdominal pressure
• DVT prophylaxis: Compression stockings + early mobilization

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6. ABDOMINAL INCISIONS (15 Marks)

Definition

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Principles of a Good Incision

• Adequate exposure of operative field
• Minimal nerve and muscle damage
• Good cosmetic result
• Low risk of hernia
• Extensible if needed
• Secure closure

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Layers of Abdominal Wall (from outside to inside)

1. Skin
2. Subcutaneous fat (Camper's fascia superficial, Scarpa's fascia deep)
3. External oblique aponeurosis
4. Internal oblique
5. Transversus abdominis
6. Transversalis fascia
7. Extraperitoneal fat (preperitoneal)
8. Peritoneum (parietal)

Midline incision goes through: Skin → Fat → Linea alba → Transversalis fascia → Peritoneum (no muscle cutting)

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Classification and Types of Incisions

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Wound Closure - Principles

• Absorbable: Vicryl, PDS, Monocryl (fascial closure, internal layers)
• Non-absorbable: Prolene, nylon, silk (skin, vessels)

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Complications of Incisions

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Physiotherapy Post-Laparotomy

• Respiratory: Risk of basal atelectasis (splinting due to pain); teach diaphragmatic breathing and huffing from day 1
• Abdominal support: Pillow or binder when coughing (reduces pain)
• Early mobilization: Sitting up day 1, walking day 1-2 (reduces ileus, DVT, pneumonia)
• Core exercises: Delayed 4-6 weeks; avoid increasing IAP (no Valsalva)
• Incentive spirometry: Every 1-2 hours while awake for first 48-72 hrs

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7. SURGICAL SITE INFECTIONS (SSI) (15 Marks)

Definition (CDC)

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Classification (CDC - 3 Types)

1. Superficial Incisional SSI
   • Involves skin and subcutaneous tissue only
   • Signs: redness, warmth, purulent drainage, pain at wound
   • Diagnosed clinically within 30 days
2. Deep Incisional SSI
   • Involves deep soft tissues (fascia and muscle layers)
   • Signs: wound opens spontaneously, purulent drainage from deep layer, fever
   • May require re-exploration
3. Organ/Space SSI
   • Involves any organ or space opened/manipulated during surgery
   • Examples: intra-abdominal abscess, empyema, osteomyelitis of sternum
   • Diagnosed by culture or imaging

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Microbiology - Common Organisms

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Risk Factors

• Diabetes mellitus (hyperglycemia impairs neutrophils)
• Obesity (poor vascularization of fat, wound tension)
• Malnutrition (poor immune function and healing)
• Immunosuppression (steroids, chemotherapy, HIV)
• Smoking (vasoconstriction, impaired healing)
• Age extremes
• Remote infection at time of surgery (skin, UTI)
• ASA class ≥3

• Wound class (contaminated > clean-contaminated > clean)
• Duration of surgery (>2 hours = higher risk)
• Emergency surgery
• Inadequate skin preparation
• Hair removal with razor (vs. clipper)
• Hypothermia intraoperatively
• Hyperglycemia intraoperatively
• Inadequate antibiotic prophylaxis
• Poor surgical technique (excessive tissue trauma, dead space, haematoma)
• Drains left in >48 hrs

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Prevention Bundle (WHO / CDC Guidelines)

• Identify and treat remote infections before elective surgery
• Nasal decolonization for MRSA carriers (mupirocin nasal ointment)
• Nutritional optimization
• Skin preparation: Chlorhexidine-alcohol (superior to povidone-iodine)
• Hair removal: Clippers on day of surgery (NOT razors - razors increase risk)
• Shower with antiseptic soap night before

• Antibiotic prophylaxis: IV cefazolin given within 60 minutes before incision (or 120 min for vancomycin)
• Redose antibiotics if surgery >4 hours (for cefazolin, t½ = 2 hrs → redose at 4 hrs)
• Maintain normothermia (body temp 36-37°C) - warming blankets, warm IV fluids
• Maintain normoglycemia (BGL <200 mg/dL; ideally <180 mg/dL)
• Maintain adequate tissue oxygenation
• Careful tissue handling; minimize dead space
• Sterile technique throughout

• Wound closed with sterile dressing for 48 hours
• Do not disturb wound unnecessarily in first 48 hrs
• Proper hand hygiene before wound care
• Prophylactic drains removed early when safe

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Diagnosis

• Rubor (redness/erythema)
• Calor (warmth)
• Dolor (pain/tenderness)
• Tumor (swelling)
• Functio laesa (loss of function)
• Purulent discharge from wound
• Fever >38°C after 48-72 hours post-op
• Elevated WBC and CRP

• Wound swab for culture and sensitivity
• Blood cultures if systemic sepsis
• Ultrasound / CT scan for deep/organ space SSI

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Treatment

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8. HEMORRHAGE (15 Marks)

Definition

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Classification

• Hematemesis: Vomiting blood (upper GI source)
• Melena: Black tarry stools (upper GI >60 mL)
• Hematochezia: Bright red rectal bleeding (lower GI or massive upper GI)
• Hemoptysis: Coughing blood (respiratory tract)
• Epistaxis: Nasal bleeding

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Physiological Response to Hemorrhage

1. Baroreceptor activation → sympathetic surge
2. Catecholamine release → tachycardia + vasoconstriction
3. ADH (vasopressin) release → water retention
4. RAAS activation → aldosterone → Na+ and water retention
5. Fluid shift from interstitial to intravascular
6. Increased RBC production (EPO)

• Class III-IV shock develops (see Shock section)
• Lethal triad: hypothermia + coagulopathy + acidosis

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Management

• Direct pressure (most effective first aid)
• Elevation of limb
• Tourniquet for limb hemorrhage uncontrolled by pressure
• Wound packing with haemostatic gauze (e.g., Combat Gauze)
• Pressure points (brachial, femoral)
• Wound closure (suturing, stapling)

• Ligation of bleeding vessel
• Suture-ligation for vessel in wound bed
• Diathermy/electrocautery (mono or bipolar)
• Haemostatic clips (e.g., laparoscopic surgery)
• Endovascular embolization (interventional radiology) - for solid organ, pelvic fractures
• Damage control surgery: Temporary packing and return for definitive repair after resuscitation

• Tranexamic acid (TXA): Antifibrinolytic; 1g IV given within 3 hours of injury (CRASH-2 trial showed reduced mortality)
• Desmopressin (DDAVP): For platelet dysfunction, von Willebrand disease
• Vitamin K: For warfarin reversal
• Protamine sulfate: For heparin reversal
• Prothrombin Complex Concentrate (PCC): For warfarin/DOAC reversal

• Class I-II: Crystalloids (normal saline, Hartmann's)
• Class III-IV: Blood products + crystalloids (see Blood Transfusion)

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Physiotherapy in Hemorrhage Management

• Position patient: flat (or slight Trendelenburg for limb bleeding) to maximise cerebral perfusion
• Do NOT elevate head in active hemorrhagic shock
• Compression bandaging and immobilization of fractures reduces blood loss
• Post-hemorrhage rehab: Graded exercise for fatigue/deconditioning; Hb monitoring before exercise prescription; orthostatic hypotension management

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9. ANAESTHESIA (15 Marks)

Definition

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Components of General Anaesthesia (Triad)

1. Analgesia - absence of pain
2. Unconsciousness (Hypnosis) - loss of awareness
3. Muscle relaxation - surgical access and airway management

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Types of Anaesthesia

• Patient is completely unconscious and paralysed
• Induction: IV agents - Propofol (most common), ketamine, thiopentone
• Maintenance: Volatile inhalation agents (sevoflurane, isoflurane, desflurane) + IV (TIVA with propofol)
• Muscle relaxation: Neuromuscular blocking agents
  • Depolarizing: Succinylcholine (suxamethonium) - rapid onset, short duration; causes fasciculations; risk of hyperkalemia
  • Non-depolarizing: Rocuronium, vecuronium, atracurium - reversed by neostigmine (or sugammadex for rocuronium)
• Airway: Endotracheal tube (ETT), laryngeal mask airway (LMA), facemask
• Reversal: Neostigmine + atropine (or sugammadex)

• Infiltration of LA agent directly into tissue
• Agents: Lignocaine (max 3-4 mg/kg; 7 mg/kg with adrenaline), bupivacaine (long-acting), ropivacaine
• Mechanism: Block Na⁺ channels → prevent depolarization

• IV sedation with maintained verbal contact
• Propofol, midazolam, fentanyl
• Used for endoscopy, minor procedures, pain procedures

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Stages of General Anaesthesia (Guedel's Classification)

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Pre-anaesthetic Assessment

• Clear fluids: 2 hours before
• Breast milk: 4 hours before
• Light meal/non-human milk: 6 hours before
• Full meal: 8 hours before

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Complications of Anaesthesia

• Aspiration (Mendelson's syndrome): Stomach contents aspirated; chemical pneumonitis → ARDS. Reason for strict NPO.
• Failed intubation: Difficult airway algorithm; can't intubate/can't oxygenate = surgical airway (cricothyroidotomy)
• Laryngospasm, bronchospasm

• Hypotension (vasodilation from induction agents)
• Arrhythmias (volatile agents sensitize myocardium to catecholamines)
• Cardiac arrest

• Hypoventilation, atelectasis
• Post-op respiratory depression (opioids, residual relaxants)

• Malignant hyperthermia (MH): Rare; autosomal dominant; triggered by halogenated agents or succinylcholine; uncontrolled Ca²⁺ release → hyperthermia, muscle rigidity, acidosis, rhabdomyolysis. Treatment: Dantrolene (direct acting muscle relaxant)

• PONV (Post-operative nausea and vomiting): Most common complaint; treat with ondansetron, dexamethasone, droperidol
• Post-operative delirium: Common in elderly; prevention with orientation, early mobilization
• Pain: VAS/NRS score guided multimodal analgesia

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Physiotherapy Considerations

• Residual neuromuscular blockade → impaired cough, respiratory weakness
• Opioid analgesia → respiratory depression, reduced mobility
• Spinal anaesthesia → lower limb sensory/motor block (resolves in 2-4 hrs); assist early ambulation
• Epidural analgesia: maintains good pain control → better cooperation with breathing exercises; monitor for hypotension and epidural haematoma
• Post-GA: incentive spirometry + deep breathing from recovery room

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10. ASSESSMENT OF A TRAUMA PATIENT (15 Marks)

Concept

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PRIMARY SURVEY - ABCDE

• Assess: Is the patient talking? (Patent airway if yes)
• Look for: stridor, gurgling, foreign bodies, maxillofacial injury, tracheal deviation
• All blunt trauma patients - assume C-spine injury until excluded
• Apply hard cervical collar + sandbags + tape (NOT soft collar)
• Airway manoeuvres: chin lift, jaw thrust
• Simple adjuncts: nasopharyngeal airway (NPA), oropharyngeal airway (OPA/Guedel)
• Definitive airway: Rapid Sequence Intubation (RSI) with in-line stabilization
• Cannot intubate: surgical airway (cricothyroidotomy)

• Inspect, palpate, percuss, auscultate the chest
• Life-threatening conditions - identify and treat IMMEDIATELY:

• Assess: HR, BP, skin color/temperature/perfusion, pulse quality, capillary refill
• Control external bleeding: direct pressure, tourniquet
• IV access: 2 large-bore peripheral IVs (16G or larger)
• Fluid resuscitation: Warmed crystalloid + blood products
• Life-threatening conditions - treat immediately:

• GCS (Glasgow Coma Scale):

• GCS ≤8 = severe brain injury; intubate
• Pupil size and reactivity: unilateral fixed dilated pupil = herniation ipsilateral; bilateral fixed = brainstem
• Blood glucose (hypoglycemia mimics brain injury; treat with IV dextrose)
• AVPU scale (rapid): Alert / Voice / Pain / Unresponsive

• Fully undress patient to detect all injuries
• Logroll (4 people + team leader for head) to examine posterior
• Check: spine, buttocks, perineum, posterior wounds
• Prevent hypothermia: warm blankets, warm IV fluids, warm room

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Concurrent RESUSCITATION (runs with primary survey)

• 2 large-bore IVs + IV fluids
• High-flow O₂ (15L/min via NRM)
• Cardiac monitor, pulse oximetry, capnography
• Urinary catheter (NOT if urethral injury suspected: blood at meatus, scrotal haematoma, high-riding prostate)
• Nasogastric tube (NOT if basal skull fracture: Battle's sign, raccoon eyes, haemotympanum, CSF leak - use oral-gastric instead)

• Pericardial space (tamponade)
• Right upper quadrant (hepatorenal space - Morrison's pouch)
• Left upper quadrant (splenorenal)
• Pelvis (free fluid)
• E-FAST adds lung scan (pneumothorax, hemothorax)

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SECONDARY SURVEY (Head-to-Toe)

• Allergies
• Medications
• Past medical history
• Last meal (fasting status)
• Events/mechanism of injury

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TERTIARY SURVEY

• Repeated head-to-toe exam at 24-72 hours
• Once sedation/paralysis reversed and patient cooperative
• Reviews all imaging
• Aims to catch missed injuries (commonly: small pneumothorax, hairline fractures, ligamentous injuries)

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Physiotherapy in Trauma Assessment

• Physiotherapists are key members of the trauma rehabilitation team
• Early respiratory physiotherapy prevents atelectasis and pneumonia (especially with rib fractures)
• Rib fractures: incentive spirometry, IPPB, epidural analgesia facilitates deep breathing
• Spinal injury: logroll technique; positioning; bed mobility
• Limb fractures: elevation, cryotherapy, early joint mobilization once stable
• Traumatic brain injury: level of consciousness guides therapy approach; sensory stimulation, positioning

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11. ULCER (15 Marks)

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12. TUMORS (15 Marks)

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PART B - SHORT TOPICS (5 MARKS EACH)

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1. PRIMARY & SECONDARY SURVEY IN TRAUMA (5 Marks)

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2. FIBROADENOMA (5 Marks)

• Most common benign breast tumor in young women (15-35 yrs)
• "Breast mouse" - firm, rubbery, well-defined, highly mobile, non-tender
• Estrogen-sensitive - grows in pregnancy; involutes post-menopause
• Histology: fibrous stroma + compressed epithelial ducts; intracanalicular or pericanalicular pattern
• Diagnosis: Triple assessment (Clinical + USS + FNAC)
• Management: Observation if <3 cm, confirmed benign; excision if >3 cm, rapid growth, or uncertain diagnosis
• Giant fibroadenoma (>5 cm): Excision; common in adolescents

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3. HEMANGIOMA (5 Marks)

• Benign vascular tumor/hamartoma
• Types:
  • Capillary (Strawberry nevus): Most common tumor of infancy; appears 2-4 weeks; rapid growth 6-12 months; spontaneously involutes by age 7; treat with propranolol if threatening
  • Cavernous: Large dilated channels; most common benign liver tumor; does NOT involute; incidental finding; MRI shows peripheral nodular enhancement
  • Port wine stain: Congenital capillary malformation; does not involute; associated with Sturge-Weber syndrome
• Kasabach-Merritt syndrome: Large hemangioma → platelet trapping → thrombocytopenia + DIC

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4. BURKITT TUMOR / LYMPHOMA (5 Marks)

• Highly aggressive B-cell non-Hodgkin's lymphoma; fastest doubling time of any human cancer
• Types: Endemic (African) - jaw/facial bones, 100% EBV+; Sporadic - ileocecal region; Immunodeficiency-related (HIV)
• Translocation: t(8;14) → MYC oncogene overexpression (80%)
• Histology: "Starry sky" pattern - sheets of lymphocytes with scattered pale macrophages
• Features: Rapidly growing mass, B symptoms (fever, weight loss, night sweats), very high LDH
• Treatment: Intensive chemotherapy (CODOX-M/IVAC) + Rituximab; ~90% cure rate with early treatment

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5. SUBDURAL HAEMATOMA (5 Marks)

• Blood collection between dura and arachnoid from bridging vein rupture
• Types:

• Crescent-shaped collection crosses suture lines (unlike EDH which is biconvex)
• Acute: Head injury, deteriorating GCS → craniotomy
• Chronic: Elderly, alcoholics; minor/forgotten trauma → headache, confusion, cognitive decline → burr-hole drainage
• Investigation of choice: Non-contrast CT scan

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6. CARDIAC TAMPONADE (5 Marks)

• Blood/fluid in pericardial space → increased intrapericardial pressure → impaired cardiac filling → decreased CO
• Beck's Triad: Hypotension + Raised JVP + Muffled heart sounds
• Additional signs: Pulsus paradoxus (>10 mmHg SBP drop on inspiration); tachycardia; Kussmaul's sign
• ECG: Sinus tachycardia + low voltage + electrical alternans (pathognomonic)
• Diagnosis: Bedside ECHO/e-FAST (gold standard - pericardial fluid + RV diastolic collapse)
• Treatment: IV fluids (maintain preload) → pericardiocentesis (subxiphoid route) → pericardial window if recurs
• Common cause in trauma: Penetrating chest injury

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7. PNEUMOTHORAX & TENSION PNEUMOTHORAX (5 Marks)

• Air in pleural space → lung collapse
• Tension pneumothorax: One-way valve mechanism → progressive air accumulation → mediastinal shift → contralateral lung compression + IVC kinking → obstructive shock → DEATH

1. Tracheal deviation (away from affected side)
2. Absent breath sounds (ipsilateral)
3. Hyperresonance on percussion (ipsilateral)
4. Distended neck veins
5. Hypotension + tachycardia

⚠️ CLINICAL DIAGNOSIS - Do NOT wait for X-ray. Treat immediately!

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🔑 MASTER CHEAT SHEET - KEY NUMBERS

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