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🩸 STOP THE BLEEDING — Complete Exam Guide

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🔑 THE BIG PICTURE — Why It Matters

Uncontrolled hemorrhage is the #1 preventable cause of death from trauma. The core rule: Control bleeding BEFORE airway if there is exsanguinating (massive) external hemorrhage. (Bailey & Love's Surgery, 28th Ed., p. 376)

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🧠 MEMORIZE THIS FRAMEWORK — "3-P Rule"

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📌 THE 3 MAIN TECHNIQUES (Core of Every Exam)

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1️⃣ DIRECT PRESSURE

• Use a clean cloth, gauze, or dressing
• Place directly over the wound
• Press HARD and CONTINUOUSLY — do not lift to check
• Hold for at least 10 minutes (arterial bleeds can take longer)
• If soaked through → add more gauze on top, do NOT remove the first layer

⚠️ Key exam point: Removing the dressing disturbs the clot. Always add on top!

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2️⃣ WOUND PACKING

1. Pack gauze INTO the wound cavity — use finger-over-finger technique
2. Fill the entire cavity tightly
3. Apply firm direct pressure on top of the packed gauze
4. Hold for 3–5 minutes minimum

• Contains agents that augment local coagulation (speed up clotting)
• Used in military and civilian trauma
• Preferred over plain gauze for deep wounds

⚠️ Key exam point: Wound packing + hemostatic gauze is THE method for junctional wounds where tourniquets cannot be applied.

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3️⃣ TOURNIQUET

1. Apply 2–3 inches (5–7 cm) ABOVE the wound (proximal to injury, not on a joint)
2. Tighten until bleeding STOPS (not just slows)
3. Note the TIME of application — write it on the patient's skin or tourniquet
4. Do NOT remove in the field
5. Get the patient to surgical care URGENTLY

⚠️ Critical exam points:

• Once applied → limb becomes ischemic — time is tissue!
• Maximum recommended time before tissue damage: ~2 hours
• Always record application time
• Never apply over a joint
• Improvised tourniquets (belt, cloth) can be used if no commercial TQ available

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📦 TYPES OF DRESSINGS — Know These

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🗺️ WOUND LOCATION → CHOOSE YOUR TECHNIQUE

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🔢 STEP-BY-STEP OSCE/TOAC APPROACH

1. ENSURE SCENE SAFETY — protect yourself (gloves if available)
2. CALL FOR HELP — activate EMS / shout for assistance
3. IDENTIFY the source of bleeding
4. CHOOSE your technique:
     → Surface wound? → DIRECT PRESSURE
     → Deep/junctional? → WOUND PACKING
     → Limb spurting/uncontrolled? → TOURNIQUET
5. APPLY and HOLD firmly
6. RECORD time (for tourniquet)
7. MONITOR — watch for continued bleeding
8. DO NOT REMOVE dressings — add on top if soaked
9. REASSURE the patient
10. TRANSPORT urgently to surgical care

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⚡ RECOGNITION — Types of Bleeding (Exam Classic)

Trick: "Arteries = bright red + pulse. Veins = dark + drain."

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⚠️ KEY RULES TO NEVER FORGET (Exam Red Flags)

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🧲 MEMORY ANCHORS — Quick Recall

• "ABC" in trauma = C-ABC → Catastrophic hemorrhage comes before Airway
• "Pack it, press it, don't peel it" → wound packing rule
• "2-3 above, time it, don't remove" → tourniquet rule
• Hemostatic gauze = chemical clotting booster in a bandage
• Junctional wounds = tourniquet can't go there → pack it

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📷 Training Simulators Used in Stop-the-Bleed Stations

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📝 QUICK EXAM CHEAT SHEET

BLEEDING TYPES:    Arterial (bright/spurt) | Venous (dark/flow) | Capillary (ooze)
3 TECHNIQUES:      Direct Pressure → Wound Packing → Tourniquet
TOURNIQUET RULES:  2-3in above wound | Tighten till stopped | Write time | Max ~2hrs
WOUND PACKING:     For deep/junctional | Finger-over-finger | Hemostatic gauze preferred
DIRECT PRESSURE:   10+ min | Don't lift | Add on top if soaked
REMEMBER C-ABC:    Catastrophic bleed controlled BEFORE airway

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✏️ SURGICAL INCISION MARKINGS — Complete Exam Guide

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🔑 WHY INCISION MARKING MATTERS

• ✅ Maximum access to the target organ
• ✅ Minimum damage to nerves, vessels, and muscles
• ✅ Good healing and minimal scarring
• ✅ Best cosmetic outcome
• ✅ Ability to extend the incision if needed

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📐 PART 1 — SKIN TENSION LINES (The Foundation of All Incision Marking)

🔴 Langer's Lines

• Represent the orientation of dermal collagen fibres
• Originally mapped on cadavers
• Historically used to guide incision placement
• Clinical relevance has been questioned by modern surgeons

🟢 Relaxed Skin Tension Lines (RSTLs) — The Modern Standard

• Follow the creases formed when skin is pinched and relaxed
• More clinically useful, especially in head and neck surgery
• Incisions placed parallel to RSTLs → less tension on suture line → better healing → less visible scar
• Natural body creases and wrinkles are the best guide

Trick to remember: "Langer = old cadaver lines. RSTLs = live skin creases. USE THE CREASE."

Langer's Lines on the Face:

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📏 PART 2 — PRINCIPLES OF A GOOD SURGICAL INCISION

The "ACCESS" Mnemonic:

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🗺️ PART 3 — CLASSIFICATION OF SURGICAL INCISIONS

By Direction:

By Location:

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🧠 PART 4 — ALL MAJOR NAMED INCISIONS (The Exam Core)

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1️⃣ MIDLINE INCISION (Median Laparotomy)

• Landmark: From xiphisternum → umbilicus → pubic symphysis (or any segment)
• Layers cut: Skin → subcutaneous fat → linea alba → peritoneum
• Key point: Cuts through the avascular linea alba — no muscles or major vessels cut
• Advantages:
  • Fastest to open and close
  • Best access to the entire abdomen
  • Easily extended upward or downward
• Uses: Emergency laparotomy, bowel surgery, aortic surgery, trauma

🏆 Gold standard for emergency abdominal surgery

Trick: "Midline = fastest, most versatile. Goes through linea alba — no bleeding."

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2️⃣ PARAMEDIAN INCISION

• Landmark: 2–3 cm lateral to midline, vertical
• Layers cut: Skin → anterior rectus sheath → rectus muscle (retracted laterally, NOT cut) → posterior rectus sheath → peritoneum
• Advantage: Muscle-sparing (retracted, not divided) → stronger closure, less hernia risk
• Disadvantage: Slower than midline; denervation risk if too lateral
• Uses: Elective abdominal surgery (now largely replaced by midline)

Trick: "Para = beside. 2–3 cm beside the midline. Muscle moves aside, not cut."

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3️⃣ KOCHER'S SUBCOSTAL INCISION

• Landmark: Parallel to and 2–5 cm below the costal margin (right side = biliary surgery, left side = splenectomy)
• Layers: Skin → external oblique → internal oblique → rectus muscle (cut) → peritoneum
• Right Kocher's: Used for open cholecystectomy, liver surgery
• Left Kocher's: Used for splenectomy
• Bilateral Kocher's (Chevron / Rooftop incision): Used for liver transplantation, total gastrectomy

Trick: "Kocher = under the ribs. Right = liver/gallbladder. Left = spleen. Both = transplant."

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4️⃣ KOCHER'S COLLAR INCISION (Neck)

• Landmark: Transverse, 2–3 cm above the suprasternal notch, in a natural skin crease
• Use: Thyroidectomy, parathyroidectomy
• Follows RSTL → excellent cosmesis

Trick: "Collar = necklace shaped. 2 fingers above the notch. For thyroid."

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5️⃣ PFANNENSTIEL INCISION

• Landmark: Transverse curved incision just above the pubic symphysis (~3 cm above), within the pubic hairline
• Layers: Skin (curved) → anterior rectus sheath (transverse) → rectus muscles separated in midline → peritoneum (vertical)
• Key point: Skin incision = horizontal/curved, but peritoneum entered vertically
• Uses: Caesarean section, hysterectomy, bladder surgery, pelvic surgery
• Advantage: Excellent cosmesis (scar hidden in hairline)

Trick: "Pfannenstiel = bikini cut. Just above pubis. Scar hidden. For C-section."

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6️⃣ McBURNEY'S INCISION (Gridiron Incision)

• Landmark: McBurney's Point = junction of lateral 1/3 and medial 2/3 of the line from ASIS to umbilicus
• The incision is made perpendicular to this line at McBurney's point
• Layers (split, not cut): Skin → external oblique (split in direction of fibres) → internal oblique (split) → transversus abdominis (split) → peritoneum
• Use: Open appendicectomy
• Key point: Muscles are split along their fibre direction (gridiron = grid pattern of muscle splitting)

Trick: "McBurney = 1/3 from ASIS. Gridiron = muscles split like a grid. Appendix only."

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7️⃣ LANZ INCISION

• Landmark: Same region as McBurney's but the incision is transverse (horizontal), within skin crease
• Advantage over McBurney's: Better cosmesis
• Uses: Open appendicectomy (preferred cosmetically, especially in women)

Trick: "Lanz = Lanz horizontal = better scar than McBurney's. Same area, just sideways."

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8️⃣ STERNOTOMY (Median Sternotomy)

• Landmark: Midline of the sternum, from suprasternal notch to xiphisternum
• Use: Cardiac surgery (CABG, valve surgery), mediastinal surgery
• Key point: Sternum split with an oscillating saw

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9️⃣ THORACOTOMY

• Lateral Thoracotomy: Along intercostal space (e.g., 5th or 6th) — for lung, esophagus surgery
• Clamshell (Bilateral Thoracotomy): Transverse across both sides of chest — for bilateral lung transplant, trauma
• Landmarking: Along specific rib space counted from top

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🔟 PERIAREOLAR INCISION

• Landmark: Along the edge of the areola
• Use: Breast lumpectomy, breast augmentation, gynaecomastia
• Advantage: Scar hidden at pigmented border

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1️⃣1️⃣ INFRAMAMMARY INCISION

• Landmark: In the fold below the breast
• Use: Breast augmentation, breast reconstruction
• Advantage: Scar hidden in natural fold

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1️⃣2️⃣ INGUINAL INCISION

• Landmark: Parallel to the inguinal ligament, from ASIS toward pubic tubercle
• Use: Inguinal hernia repair, femoral artery access, orchidopexy

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1️⃣3️⃣ PERIUMBILICAL / TRANSVERSE INCISION

• Used for access to suprarenal aorta or umbilical hernia
• Just above or around the umbilicus

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1️⃣4️⃣ THORACOABDOMINAL INCISION

• Combines thoracotomy + laparotomy → used for oesophagectomy, proximal gastric surgery, thoracoabdominal aorta

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🖼️ Laparoscopic Incision Marking (Port Placement)

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🧩 PART 5 — HOW TO MARK AN INCISION (TOAC Station Steps)

STEP 1 — IDENTIFY the target organ and what access you need
STEP 2 — IDENTIFY key bony/surface landmarks (ASIS, umbilicus, costal margin, pubic symphysis)
STEP 3 — CHECK skin tension lines / natural creases in the region
STEP 4 — MARK the incision with a skin marker BEFORE draping
STEP 5 — CONFIRM:
          ✔ Adequate access?
          ✔ Avoids major nerves/vessels?
          ✔ Can be extended?
          ✔ Follows skin crease where possible?
STEP 6 — PROCEED with incision along the marking

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📊 PART 6 — MASTER COMPARISON TABLE

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⚡ PART 7 — QUICK ANATOMY FOR MARKING (Know These Landmarks)

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🧲 PART 8 — MEMORY TRICKS SUMMARY

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📝 RAPID-FIRE EXAM CHEAT SHEET

SKIN TENSION LINES:    Langer's (collagen, old) vs RSTLs (live skin creases — USE THESE)
RULE:                  Incisions PARALLEL to tension lines = less scar, better healing

MIDLINE:               Linea alba, avascular, fastest, best access, emergency
PARAMEDIAN:            2-3cm lateral, muscle retracted NOT cut
KOCHER SUBCOSTAL:      R=cholecystectomy, L=splenectomy, both=transplant
KOCHER COLLAR:         Thyroid, 2-3cm above sternal notch, skin crease
PFANNENSTIEL:          Bikini, 3cm above pubis, C-section/hysterectomy
McBURNEY'S:            1/3 ASIS-umbilicus, gridiron split, appendix
LANZ:                  Horizontal McBurney's, same place, better cosmesis
STERNOTOMY:            Midsternal, cardiac surgery
INGUINAL:              Parallel to inguinal ligament, hernia repair

McBURNEY'S POINT:      1/3 from ASIS along line to umbilicus
LINEA ALBA:            Midline, avascular fusion of aponeuroses → midline incision uses this

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