1. Basics of trauma
   Primary survey (ABCDE), secondary survey, resuscitation, shock, triage, ATLS principles.
2. Head trauma
   Classification, GCS, extradural/subdural hematoma, diffuse brain injury, investigations, emergency management.
3. Chest trauma
   Pneumothorax, hemothorax, flail chest, cardiac tamponade, chest-tube indications and management.
4. Brain tumour
   Classification, presentation, diagnosis, raised intracranial pressure, surgery and adjuvant treatment.
5. Brain haemorrhage
   Types: extradural, subdural, subarachnoid, intracerebral and intraventricular hemorrhage; CT features and management.
6. BPH and surgeries
   Symptoms, evaluation, medical treatment, indications for surgery, TURP, open prostatectomy, HoLEP and complications.

1. Trauma basics: ATLS, ABCDE, shock, resuscitation, secondary survey
2. Head trauma: GCS, types of head injury, CT, observation, operative indications
3. Chest trauma: pneumothorax, hemothorax, flail chest, tamponade, intercostal drain
4. Brain tumours: classification, clinical features, diagnosis, surgery, radiotherapy/chemotherapy
5. Brain haemorrhage: extradural, subdural, subarachnoid and intracerebral haemorrhage, CT and management
6. BPH: presentation, investigations, medical management, indications for surgery, TURP, HoLEP and open prostatectomy

1. General trauma and ATLS approach
2. Head injury
3. Chest trauma
4. Brain tumours
5. Intracranial haemorrhage and its types
6. Benign prostatic hyperplasia and surgical treatment

1. Basics of trauma
   Primary survey (ABCDE), secondary survey, resuscitation, shock, triage, ATLS principles.
2. Head trauma
   Classification, GCS, extradural/subdural hematoma, diffuse brain injury, investigations, emergency management.
3. Chest trauma
   Pneumothorax, hemothorax, flail chest, cardiac tamponade, chest-tube indications and management.
4. Brain tumour
   Classification, presentation, diagnosis, raised intracranial pressure, surgery and adjuvant treatment.
5. Brain haemorrhage
   Types: extradural, subdural, subarachnoid, intracerebral and intraventricular hemorrhage; CT features and management.
6. BPH and surgeries
   Symptoms, evaluation, medical treatment, indications for surgery, TURP, open prostatectomy, HoLEP and complications.

1. Trauma basics: ATLS, ABCDE, shock, resuscitation, secondary survey
2. Head trauma: GCS, types of head injury, CT, observation, operative indications
3. Chest trauma: pneumothorax, hemothorax, flail chest, tamponade, intercostal drain
4. Brain tumours: classification, clinical features, diagnosis, surgery, radiotherapy/chemotherapy
5. Brain haemorrhage: extradural, subdural, subarachnoid and intracerebral haemorrhage, CT and management
6. BPH: presentation, investigations, medical management, indications for surgery, TURP, HoLEP and open prostatectomy

1. General trauma and ATLS approach
2. Head injury
3. Chest trauma
4. Brain tumours
5. Intracranial haemorrhage and its types
6. Benign prostatic hyperplasia and surgical treatment

1. Basic trauma and ATLS approach
2. Head trauma
3. Chest trauma
4. Brain tumour
5. Brain haemorrhage: types and management
6. BPH: all surgical management

1. Basic Trauma Management - Long Answer Question

Definition

Initial assessment and resuscitation

Preparation

• Ensure personal safety and use PPE.
• Activate trauma team.
• Obtain brief history: mechanism, time of injury, allergies, drugs, past illness, last meal, events surrounding injury.
• Assume cervical-spine injury in blunt trauma until excluded.

Primary survey: ABCDE with simultaneous resuscitation

A - Airway maintenance with cervical-spine protection

• Ability to speak
• Stridor, gurgling, snoring
• Facial injury, blood or vomitus
• Foreign body
• Expanding neck hematoma

• Manual in-line cervical stabilization
• Suction and remove visible foreign body
• Jaw thrust, airway adjuncts if appropriate
• Definitive airway by cuffed endotracheal intubation when airway is threatened, GCS is 8 or less, severe respiratory failure, or anticipated deterioration
• Surgical airway if unable to intubate and unable to oxygenate

B - Breathing and ventilation

• Respiratory rate, effort, chest symmetry
• Oxygen saturation
• Tracheal position
• Breath sounds and percussion note
• Open chest wound, flail segment, subcutaneous emphysema

• Tension pneumothorax: immediate needle/finger thoracostomy followed by intercostal chest drain
• Open pneumothorax: three-sided occlusive dressing followed by chest drain away from the wound
• Massive hemothorax: chest drain and resuscitation
• Flail chest/pulmonary contusion: oxygen, analgesia, ventilatory support if needed
• Cardiac tamponade: urgent resuscitation and operative/pericardial intervention depending on setting

C - Circulation with haemorrhage control

• Pulse, blood pressure, capillary refill, skin temperature
• Level of consciousness
• External bleeding
• Pelvic and long-bone injuries

• Direct pressure, hemostatic dressing, tourniquet for catastrophic limb bleeding
• Two large-bore IV cannulas or intraosseous access
• Send blood for grouping, cross-match, hemogram, coagulation profile, lactate/ABG
• Warmed balanced blood-product resuscitation for major haemorrhage
• Activate massive transfusion protocol when indicated
• Tranexamic acid as early as possible in significant traumatic bleeding, ideally within 3 hours
• Avoid excessive crystalloid infusion
• Pelvic binder over greater trochanters for suspected unstable pelvic fracture
• Urgent damage-control surgery or angioembolization for ongoing bleeding

D - Disability: neurological assessment

• Glasgow Coma Scale
• Pupillary size and reaction
• Limb movement and focal neurological deficits
• Blood glucose
• Look for lateralizing signs and seizures

E - Exposure and environmental control

• Completely expose the patient and examine front and back.
• Log-roll with spinal precautions.
• Prevent hypothermia with warm blankets, warmed fluids, and ambient temperature control.

Adjuncts to primary survey

• ECG
• Pulse oximetry and capnography
• Arterial blood gas and lactate
• Portable chest and pelvic X-ray where useful
• FAST or eFAST ultrasound for intraperitoneal, pericardial, or pleural fluid/air
• Urinary catheter if no suspected urethral injury
• Gastric tube if indicated

Secondary survey

• Head and face
• Neck and cervical spine
• Chest
• Abdomen
• Perineum and rectum when indicated
• Pelvis
• Limbs, pulses, sensory and motor function
• Spine and back

• A: Allergies
• M: Medications
• P: Past illnesses/pregnancy
• L: Last meal
• E: Events/environment related to injury

Definitive care

• CT trauma imaging in stable patients where appropriate
• Emergency operation for uncontrolled bleeding, peritonitis, perforation, tamponade, etc.
• Neurosurgical, orthopedic, vascular, urologic, or thoracic referral as needed
• Tetanus prophylaxis and antibiotics for contaminated/open wounds

Important principles

1. Treat the greatest threat to life first.
2. Reassess ABCDE repeatedly.
3. Do not delay treatment for investigations.
4. Prevent hypoxia, hypotension, hypothermia, acidosis, and coagulopathy.
5. Definitive surgery may be delayed until physiology is restored in severely unstable patients.

2. Head Trauma - Long Answer Question

Definition

Classification

According to severity by Glasgow Coma Scale

According to type

1. Closed head injury
2. Open or penetrating head injury
3. Primary brain injury
4. Secondary brain injury

Primary brain injuries

• Scalp injury
• Skull fracture
• Cerebral concussion
• Cerebral contusion
• Diffuse axonal injury
• Extradural hematoma
• Acute subdural hematoma
• Traumatic subarachnoid hemorrhage
• Intracerebral hematoma

Secondary brain injury

• Hypoxia
• Hypotension
• Hypercapnia or severe hypocapnia
• Cerebral edema
• Raised intracranial pressure
• Seizures
• Fever
• Hypoglycemia or hyperglycemia
• Anemia
• Infection

Clinical assessment

History

• Mechanism and time of injury
• Loss of consciousness
• Vomiting, seizures, headache
• Amnesia
• Alcohol/drug use
• Anticoagulant or antiplatelet use
• Previous neurological disease

Examination

• ABCDE trauma assessment first
• GCS and serial neurological observations
• Pupils: size, equality, reactivity
• Focal deficit: weakness, aphasia, cranial nerve palsy
• Signs of skull-base fracture:
  • Periorbital ecchymosis
  • Mastoid bruising
  • CSF rhinorrhea/otorrhea
  • Hemotympanum
• Scalp wounds and depressed skull fracture
• Examine cervical spine

Danger signs requiring urgent CT brain/neurosurgical opinion

• GCS below 13 initially, or persistent GCS below 15
• Declining GCS
• Focal neurological deficit
• Unequal or fixed dilated pupils
• Post-traumatic seizure
• Repeated vomiting
• Suspected open or depressed skull fracture
• Signs of basal skull fracture
• Anticoagulant use or bleeding disorder
• Significant mechanism of injury
• Persistent severe headache or altered behavior

Investigations

1. Non-contrast CT brain: investigation of choice in acute head injury.
2. CT cervical spine when indicated.
3. Skull X-ray has little role in acute evaluation.
4. CBC, blood group/cross-match, coagulation profile, electrolytes, glucose, ABG.
5. MRI is useful later for diffuse axonal injury, brainstem injury, and subtle lesions.

Management

Initial management

• Follow ABCDE.
• Maintain cervical-spine immobilization until cleared.
• Avoid hypoxia and hypotension.
• Intubate and ventilate if GCS 8 or less, airway compromise, or respiratory failure.
• Elevate head end about 30 degrees and maintain neutral neck alignment.
• Adequate analgesia, sedation where ventilated, temperature control.
• Correct coagulopathy urgently.
• Avoid routine corticosteroids in traumatic brain injury.

Management of raised intracranial pressure

• Worsening consciousness
• Headache, vomiting
• Bradycardia, hypertension, irregular respiration: Cushing response
• Unequal/fixed pupils
• Posturing

• Head elevation and neutral alignment
• Oxygenation and normocapnia
• Sedation/analgesia in ventilated patient
• Hypertonic saline or mannitol in suspected raised ICP/herniation, with hemodynamic monitoring
• Short-term controlled hyperventilation only as a bridge in impending herniation
• Seizure treatment
• Neurosurgical decompression or hematoma evacuation when indicated

Specific lesions

Concussion

• Observation
• Analgesia
• Written head-injury advice
• Return immediately for vomiting, worsening headache, confusion, weakness, seizure, or drowsiness

Cerebral contusion

• Observation with serial GCS and CT
• Control raised ICP
• Surgery if large lesion, mass effect, or deterioration

Depressed skull fracture

• Antibiotics and tetanus prophylaxis for compound injury
• Surgical elevation/debridement when open, contaminated, significantly depressed, associated with CSF leak, dural tear, hematoma, or neurological deficit

Extradural hematoma

• Brief loss of consciousness
• Lucid interval may occur
• Rapid deterioration, ipsilateral dilated pupil, contralateral weakness

Acute subdural hematoma

• Resuscitation and correction of coagulopathy
• Urgent craniotomy/craniectomy and evacuation in appropriate patients with significant clot, midline shift, or deterioration

Complications

• Raised intracranial pressure and brain herniation
• Seizures
• CSF leak and meningitis
• Post-traumatic epilepsy
• Cognitive, behavioral, speech, and motor disability
• Hydrocephalus
• Persistent post-concussion symptoms

3. Chest Trauma - Long Answer Question

Definition

Causes

• Road traffic collision
• Fall from height
• Crush injury
• Assault
• Stab wound
• Gunshot injury
• Iatrogenic injury

Classification

Chest-wall injuries

• Rib fractures
• Flail chest
• Sternal fracture
• Scapular/clavicular fracture

Pleural and pulmonary injuries

• Pneumothorax
• Tension pneumothorax
• Hemothorax
• Massive hemothorax
• Hemopneumothorax
• Pulmonary contusion
• Tracheobronchial injury

Mediastinal injuries

• Cardiac tamponade
• Myocardial contusion
• Great-vessel injury
• Traumatic aortic injury
• Esophageal rupture
• Diaphragmatic rupture

Initial assessment

• Respiratory rate and SpO₂
• Chest movement
• Tracheal position
• Percussion note
• Breath sounds
• External wounds
• Subcutaneous emphysema
• Jugular venous pressure
• Pulse and BP

Immediately life-threatening chest injuries

1. Tension pneumothorax

• Severe respiratory distress
• Hypoxia
• Unilateral absent breath sounds
• Hyperresonance
• Hypotension
• Distended neck veins may occur
• Tracheal deviation is a late sign

• Clinical diagnosis: do not wait for X-ray.
• Immediate needle decompression or finger thoracostomy.
• Insert intercostal chest drain subsequently.

2. Open pneumothorax

• Three-sided occlusive dressing
• Oxygen
• Chest drain placed away from wound
• Surgical closure after stabilization

3. Massive hemothorax

• Shock
• Respiratory distress
• Reduced breath sounds
• Dull percussion note
• Flat neck veins due to hypovolemia

• Large-bore chest drain
• Blood transfusion and massive haemorrhage protocol if needed
• Thoracotomy if immediate drainage is about 1.5 L, ongoing bleeding is roughly more than 200 mL/hour for 2-4 hours, or persistent hemodynamic instability

4. Flail chest with pulmonary contusion

• Paradoxical inward movement on inspiration
• Severe pain
• Respiratory distress
• Underlying pulmonary contusion is often the major cause of hypoxia

• Oxygen and aggressive multimodal analgesia
• Chest physiotherapy and pulmonary toilet
• Treat associated pneumothorax/hemothorax
• Non-invasive or invasive ventilation if respiratory failure
• Consider surgical stabilization of rib fractures in selected patients

5. Cardiac tamponade

• Hypotension
• Raised JVP
• Muffled heart sounds: Beck triad
• Tachycardia, pulsus paradoxus
• Positive FAST/eFAST pericardial fluid

• Urgent surgical exploration/pericardial drainage in trauma setting
• Pericardiocentesis may be a temporary measure if surgery is not immediately available

Potentially life-threatening chest injuries

Simple pneumothorax

• Oxygen and observation if small/stable
• Chest drain if large, symptomatic, ventilated, or progressing

Rib fractures

• Good analgesia, including regional methods where appropriate
• Incentive spirometry/chest physiotherapy
• Early mobilization
• Treat associated complications such as pneumonia and pneumothorax

Pulmonary contusion

• Hypoxia and increasing respiratory distress, sometimes delayed
• Patchy infiltrates on imaging

• Oxygen, analgesia, pulmonary hygiene
• Avoid fluid overload
• Ventilatory support if required

Myocardial contusion

• ECG
• Troponin
• Echocardiography if abnormal ECG, raised troponin, or instability

Traumatic aortic injury

• CT angiography
• Blood-pressure/heart-rate control
• Urgent endovascular repair in appropriate cases

Diaphragmatic rupture

• Respiratory distress
• Bowel sounds in chest
• Herniation of abdominal viscera on X-ray/CT

Investigations

• eFAST ultrasound
• Portable chest X-ray
• CT chest with contrast in stable patients
• ECG, ABG, CBC, blood grouping/cross-match
• Echocardiography for suspected cardiac injury

Chest-drain principles

• Usually inserted in the safe triangle.
• Connect to underwater-seal drainage.
• Document air leak and amount/nature of drainage.
• Obtain post-procedure imaging when feasible.
• Never clamp a bubbling drain in a patient with pneumothorax unless specifically directed by a thoracic specialist.

4. Brain Tumour - Long Answer Question

Definition

Classification

According to origin

Primary brain tumours

• Gliomas:
  • Astrocytoma
  • Oligodendroglioma
  • Glioblastoma
  • Ependymoma
• Meningioma
• Pituitary adenoma
• Schwannoma, especially vestibular schwannoma
• Craniopharyngioma
• Medulloblastoma
• Primary CNS lymphoma
• Pineal tumours
• Germ-cell tumours

Secondary brain tumours

• Lung
• Breast
• Melanoma
• Kidney
• Colorectal cancer

According to behavior

• Benign or low-grade
• Malignant/high-grade
• WHO classification also incorporates histology and molecular features in modern practice.

Clinical features

Features due to raised intracranial pressure

• Headache, often worse in morning
• Vomiting, sometimes projectile
• Papilledema
• Drowsiness and altered consciousness
• Diplopia due to sixth-nerve palsy
• Bradycardia and hypertension late in disease

Focal neurological features

• Frontal lobe: personality change, disinhibition, weakness
• Parietal lobe: sensory loss, visuospatial dysfunction
• Temporal lobe: memory disturbance, aphasia, seizures
• Occipital lobe: visual field defect
• Cerebellum: ataxia, nystagmus, dysmetria
• Brainstem: cranial-nerve palsies, long-tract signs
• Pituitary region: visual-field defect, endocrine disorder

Other features

• New-onset focal seizure
• Progressive neurological deficit
• Cognitive or behavioral change
• Endocrine abnormalities
• Hydrocephalus

Investigations

Imaging

1. MRI brain with contrast is the investigation of choice.
2. CT brain is useful in emergencies, hemorrhage, calcification, hydrocephalus, or when MRI is unavailable.
3. CT chest/abdomen/pelvis or PET-CT when metastasis is suspected.
4. Angiography may be required for highly vascular lesions or preoperative embolization.

Other tests

• Visual-field testing for pituitary lesions
• Endocrine profile for sellar/suprasellar lesions
• Histopathology and molecular testing after biopsy/resection

Principles of management

General supportive treatment

• Dexamethasone for symptomatic vasogenic edema around many tumours, especially metastases
• Antiseizure drug after a seizure. Routine prophylaxis in seizure-naive patients is not universal.
• Analgesia and antiemetics
• Management of hydrocephalus: external ventricular drain, endoscopic third ventriculostomy, or VP shunt where appropriate
• Rehabilitation, neuropsychology, and palliative care support

Definitive treatment

1. Observation

• Small asymptomatic meningiomas
• Incidental low-risk lesions
• Frail patients with slow-growing tumours

2. Surgery

• Obtain tissue diagnosis
• Maximal safe resection
• Reduce mass effect and raised ICP
• Control seizures
• Relieve hydrocephalus

• Craniotomy and excision
• Stereotactic biopsy for deep, multiple, diffuse, or unresectable lesions
• Endoscopic biopsy for ventricular lesions

3. Radiotherapy

• External-beam radiotherapy
• Stereotactic radiosurgery for selected small tumours/metastases
• Fractionated radiotherapy for high-grade glioma or residual disease

4. Chemotherapy/systemic therapy

• Temozolomide is commonly used with radiotherapy for glioblastoma
• High-dose methotrexate-based therapy for primary CNS lymphoma
• Targeted therapy or immunotherapy for selected metastatic tumours

Management according to common tumour type

Glioblastoma

• Maximal safe surgical resection where feasible
• Radiotherapy with concurrent and adjuvant temozolomide
• Steroids for edema
• Prognosis is generally poor despite treatment

Meningioma

• Observation if small/asymptomatic
• Surgical excision where symptomatic, enlarging, or causing mass effect
• Radiosurgery/radiotherapy for residual, recurrent, or inaccessible tumour

Solitary brain metastasis

• Surgery or stereotactic radiosurgery for suitable accessible lesions
• Whole-brain radiotherapy is used selectively
• Treat primary cancer systemically where appropriate

Pituitary adenoma

• Endocrine evaluation
• Dopamine agonist for prolactinoma
• Transsphenoidal surgery for visual compromise, hormone hypersecretion not controlled medically, or mass effect

Complications

• Seizures
• Herniation
• Hydrocephalus
• Endocrine dysfunction
• Neurological deficits after surgery
• Tumour recurrence
• Radiation necrosis
• Cognitive decline

5. Brain Haemorrhage: Types and Management - Long Answer Question

Definition

Types

General clinical presentation

• Sudden severe headache
• Vomiting
• Altered consciousness
• Focal neurological deficit
• Seizure
• Neck stiffness in subarachnoid hemorrhage
• Signs of raised intracranial pressure
• Pupillary asymmetry or coma in major traumatic hematoma

Investigations

1. Urgent non-contrast CT brain: first-line test.
2. CT angiography or MR angiography for aneurysm, AVM, or vascular cause.
3. Digital subtraction angiography when needed.
4. CBC, electrolytes, renal/liver function, blood glucose.
5. PT/INR, aPTT, platelet count, drug history.
6. ECG and cardiac evaluation in spontaneous hemorrhage.
7. Lumbar puncture only if subarachnoid hemorrhage remains suspected after negative CT and imaging strategy permits it. Never perform if raised ICP/mass lesion is suspected.

A. Extradural Hematoma

Etiology

• Temporal/parietal skull fracture
• Laceration of middle meningeal artery
• Less commonly venous bleeding

Clinical features

• Loss of consciousness followed by lucid interval in some patients
• Headache, vomiting
• Rapid fall in GCS
• Ipsilateral fixed dilated pupil
• Contralateral hemiparesis

CT appearance

• Biconvex/lens-shaped hyperdense collection
• Usually does not cross suture lines

Management

• ABCDE and prevention of hypoxia/hypotension
• Urgent neurosurgical referral
• Craniotomy/craniectomy and evacuation if significant size, mass effect, neurological deficit, declining consciousness, or pupillary changes
• Small stable hematomas may be observed in a neurosurgical setting with serial CT and examination

B. Acute Subdural Hematoma

Etiology

• Tearing of bridging veins after acceleration-deceleration injury
• Common in severe head injury
• Risk increased in elderly people, alcohol misuse, cerebral atrophy, anticoagulation

Clinical features

• Headache and altered sensorium
• Focal neurological deficit
• Rapid deterioration in acute cases
• May have associated contusions and diffuse brain injury

CT appearance

• Crescent-shaped hyperdense collection
• Can cross suture lines but not dural reflections
• Midline shift may be present

Management

• Resuscitation and correction of coagulopathy
• Urgent neurosurgical assessment
• Craniotomy/craniectomy and clot evacuation for significant hematoma, mass effect, low GCS/deterioration, or raised ICP
• ICU care and ICP control

Chronic subdural hematoma

• Weeks after minor trauma, especially in elderly persons
• Headache, cognitive decline, gait disturbance, hemiparesis, fluctuating consciousness

• Hypodense or mixed-density crescentic collection

• Burr-hole drainage with closed drainage system for symptomatic/significant hematoma
• Correct anticoagulation where possible

C. Subarachnoid Hemorrhage

Causes

• Ruptured berry aneurysm
• Arteriovenous malformation
• Trauma
• Less often coagulopathy or other vascular lesions

Clinical features

• Sudden severe “thunderclap” headache
• Neck stiffness and photophobia
• Vomiting
• Collapse or coma
• Seizure
• Focal deficit if associated vasospasm, hematoma, or hydrocephalus

Investigations

• Urgent non-contrast CT brain
• CT angiography to detect aneurysm
• Lumbar puncture in selected patients with continued suspicion after negative imaging, based on local protocol
• Digital subtraction angiography if needed

Management

• ICU/neurosurgical management
• Control pain, vomiting, fever, glucose, and BP carefully
• Nimodipine to reduce delayed ischemic neurological deficit from vasospasm
• Secure aneurysm early by endovascular coiling or surgical clipping
• External ventricular drainage for hydrocephalus
• Treat vasospasm and delayed cerebral ischemia in specialist neurocritical care

• Rebleeding
• Vasospasm and cerebral infarction
• Hydrocephalus
• Hyponatremia
• Seizures
• Cardiac arrhythmias

D. Intracerebral Hemorrhage

Causes

• Chronic hypertension: deep ganglia, thalamus, pons, cerebellum
• Cerebral amyloid angiopathy: lobar hemorrhage in elderly people
• Anticoagulants/thrombolysis
• AVM/aneurysm
• Tumour
• Coagulopathy
• Illicit sympathomimetic drugs

Clinical features

• Sudden focal deficit
• Headache, vomiting
• Reduced consciousness depending on size/site
• Seizures, particularly lobar hematoma

Management

• ABCDE and neurocritical care
• Rapid CT scan
• Controlled BP reduction according to stroke protocol
• Stop and reverse anticoagulation where indicated
• Treat raised ICP
• Neurosurgical evacuation for selected cerebellar hemorrhage, hydrocephalus, deterioration, or selected accessible lobar hematomas
• External ventricular drain for obstructive hydrocephalus/intraventricular hemorrhage
• Rehabilitation: physiotherapy, speech therapy, occupational therapy, secondary prevention

E. Intraventricular Hemorrhage

• Acute obstructive hydrocephalus
• Raised intracranial pressure
• Reduced consciousness

• Neurocritical care
• Correct coagulopathy
• External ventricular drainage if hydrocephalus or reduced consciousness
• Treat underlying cause

General principles in all intracranial hemorrhages

1. Stabilize airway, oxygenation, circulation, and glucose.
2. Urgent CT brain.
3. Repeated GCS and pupil examination.
4. Stop/reverse anticoagulants where indicated.
5. Avoid hypotension, fever, hypoxia, and hyperglycemia.
6. Manage raised ICP.
7. Obtain early neurosurgical or stroke-team input.
8. Start rehabilitation and secondary prevention early.

6. Benign Prostatic Hyperplasia and Surgical Management - Long Answer Question

Definition

Etiology and pathogenesis

• Increasing age
• Androgen-dependent process
• Dihydrotestosterone stimulates prostatic growth
• Enlargement in transition zone compresses prostatic urethra
• Dynamic obstruction is due to increased smooth-muscle tone mediated by alpha-1 adrenergic receptors
• Static obstruction is due to enlarged prostate tissue

Clinical features

Voiding symptoms

• Poor stream
• Hesitancy
• Intermittency
• Straining
• Terminal dribbling
• Feeling of incomplete emptying

Storage symptoms

• Frequency
• Urgency
• Nocturia
• Urge incontinence

Complications

• Acute urinary retention
• Chronic urinary retention
• Recurrent UTI
• Bladder stone
• Hematuria
• Hydroureteronephrosis
• Renal impairment
• Overflow incontinence

Examination

• General examination for renal failure, distended bladder
• Abdominal examination for palpable bladder
• Digital rectal examination:
  • Enlarged smooth, firm, non-tender prostate in BPH
  • Hard irregular/nodular prostate suggests carcinoma
• Neurological examination where neurogenic bladder is possible

Investigations

1. Urinalysis and urine culture if infection suspected
2. Serum creatinine/eGFR if renal impairment or retention suspected
3. PSA after counseling, when it will influence management
4. International Prostate Symptom Score: IPSS
5. Frequency-volume chart in men with storage symptoms/nocturia
6. Post-void residual urine
7. Uroflowmetry
8. Ultrasound KUB and prostate volume
9. Cystoscopy when hematuria, suspected stricture/bladder stone, or before selected procedures
10. Urodynamic studies in selected patients with uncertain diagnosis, neurological disease, high residual urine, or possible detrusor underactivity

Conservative management

• Reduce evening fluid intake
• Reduce caffeine and alcohol
• Timed/double voiding
• Treat constipation
• Review drugs that worsen symptoms, such as anticholinergics, decongestants, and opioids
• Regular review with symptom score, renal function, and residual urine where indicated

Medical management

Alpha-1 blockers

• Tamsulosin
• Alfuzosin
• Silodosin
• Doxazosin

• Postural hypotension
• Dizziness
• Retrograde ejaculation
• Intraoperative floppy iris syndrome

5-alpha-reductase inhibitors

• Finasteride
• Dutasteride

• Reduced libido
• Erectile dysfunction
• Ejaculatory dysfunction
• Reduced PSA level

Combination therapy

Other drugs

• Antimuscarinic agents or beta-3 agonist for predominant storage symptoms, with caution if high residual urine
• PDE5 inhibitor, such as tadalafil, may help LUTS with erectile dysfunction

Indications for surgery

1. Recurrent or refractory urinary retention
2. Recurrent urinary tract infection due to obstruction
3. Recurrent gross hematuria due to BPH
4. Bladder stone or diverticulum due to obstruction
5. Hydronephrosis or renal impairment due to bladder outlet obstruction
6. Severe troublesome symptoms despite conservative/medical treatment
7. Intolerance or contraindication to medical treatment
8. Large residual urine or progressive obstruction in selected cases

Surgical options for BPH

Transurethral Resection of Prostate - TURP

Principle

Indications

• Symptomatic BPH with failed medical therapy
• Recurrent retention
• Recurrent UTI, hematuria, stone, or renal obstruction due to BPH
• Moderate-sized obstructing prostate

Steps of TURP

1. Spinal or general anesthesia.
2. Lithotomy position.
3. Cystoscopy and assessment of urethra, prostate, bladder neck, and bladder.
4. Resectoscope introduced.
5. Resection begins at median lobe/bladder neck as appropriate.
6. Resect adenoma systematically while preserving external sphincter and avoiding ureteric orifices.
7. Achieve meticulous hemostasis.
8. Remove chips by evacuation.
9. Insert three-way Foley catheter and start continuous bladder irrigation.

Complications

Early

• Hemorrhage and clot retention
• Urinary tract infection/sepsis
• TUR syndrome: dilutional hyponatremia from excessive hypotonic irrigation absorption, mainly with monopolar TURP
• Bladder perforation
• Capsular perforation
• Ureteric-orifice injury
• Failure to void/temporary retention
• Deep-vein thrombosis or pulmonary embolism

Late

• Retrograde ejaculation
• Erectile dysfunction, less common
• Urethral stricture
• Bladder-neck contracture
• Urinary incontinence, uncommon but serious
• Residual/recurrent adenoma requiring re-treatment

Bipolar TURP

• Avoids classic TUR syndrome from non-electrolyte irrigation
• Good hemostasis
• Similar symptom improvement to monopolar TURP

Transurethral Incision of Prostate - TUIP

• Small prostate, often less than about 30 mL
• High bladder neck
• No large median lobe

• Short procedure
• Less bleeding
• Lower risk of retrograde ejaculation than TURP

• Less suitable for large glands
• Higher re-treatment risk than definitive resection/enucleation

Holmium Laser Enucleation of Prostate - HoLEP

Principle

Advantages

• Suitable for small, medium, and very large prostates
• Excellent hemostasis
• Shorter catheterization/hospital stay in many settings
• Durable symptom relief
• Avoids open surgery in many very large glands
• Useful in patients at increased bleeding risk, with proper perioperative planning

Complications

• Transient stress urinary incontinence
• Retrograde ejaculation
• Urethral stricture
• Bladder-neck contracture
• Bleeding, UTI
• Morcellator-related bladder injury, rare

Open or Simple Prostatectomy

Types

• Open retropubic simple prostatectomy
• Open transvesical/suprapubic simple prostatectomy
• Robotic simple prostatectomy in selected centers

Indications

• Very large prostate, often more than about 80-100 mL depending on available expertise
• Large bladder stone/diverticulum requiring open surgery
• When HoLEP or another endoscopic enucleation procedure is unavailable or unsuitable

Principle

Complications

• Greater blood loss and longer recovery compared with endoscopic methods
• Infection
• Urinary leakage
• Retention
• Bladder-neck contracture
• Incontinence
• Retrograde ejaculation

Postoperative care after BPH surgery

• Monitor pulse, BP, urine output, color of urine, and hemoglobin
• Maintain catheter patency and continuous bladder irrigation after TURP when needed
• Treat clots by bladder washout if required
• Trial without catheter after hematuria settles
• Encourage hydration and mobilization
• Avoid heavy straining and constipation
• Review histopathology of resected tissue
• Counsel about temporary urgency, dysuria, retrograde ejaculation, and expected recovery

1. Basics of trauma
   Primary survey (ABCDE), secondary survey, resuscitation, shock, triage, ATLS principles.
2. Head trauma
   Classification, GCS, extradural/subdural hematoma, diffuse brain injury, investigations, emergency management.
3. Chest trauma
   Pneumothorax, hemothorax, flail chest, cardiac tamponade, chest-tube indications and management.
4. Brain tumour
   Classification, presentation, diagnosis, raised intracranial pressure, surgery and adjuvant treatment.
5. Brain haemorrhage
   Types: extradural, subdural, subarachnoid, intracerebral and intraventricular hemorrhage; CT features and management.
6. BPH and surgeries
   Symptoms, evaluation, medical treatment, indications for surgery, TURP, open prostatectomy, HoLEP and complications.

1. Trauma basics: ATLS, ABCDE, shock, resuscitation, secondary survey
2. Head trauma: GCS, types of head injury, CT, observation, operative indications
3. Chest trauma: pneumothorax, hemothorax, flail chest, tamponade, intercostal drain
4. Brain tumours: classification, clinical features, diagnosis, surgery, radiotherapy/chemotherapy
5. Brain haemorrhage: extradural, subdural, subarachnoid and intracerebral haemorrhage, CT and management
6. BPH: presentation, investigations, medical management, indications for surgery, TURP, HoLEP and open prostatectomy

1. General trauma and ATLS approach
2. Head injury
3. Chest trauma
4. Brain tumours
5. Intracranial haemorrhage and its types
6. Benign prostatic hyperplasia and surgical treatment

1. Basic trauma and ATLS approach
2. Head trauma
3. Chest trauma
4. Brain tumour
5. Brain haemorrhage: types and management
6. BPH: all surgical management

Definition

Initial assessment and resuscitation

Preparation

• Ensure personal safety and use PPE.
• Activate trauma team.
• Obtain brief history: mechanism, time of injury, allergies, drugs, past illness, last meal, events surrounding injury.
• Assume cervical-spine injury in blunt trauma until excluded.

Primary survey: ABCDE with simultaneous resuscitation

A - Airway maintenance with cervical-spine protection

• Ability to speak
• Stridor, gurgling, snoring
• Facial injury, blood or vomitus
• Foreign body
• Expanding neck hematoma

• Manual in-line cervical stabilization
• Suction and remove visible foreign body
• Jaw thrust, airway adjuncts if appropriate
• Definitive airway by cuffed endotracheal intubation when airway is threatened, GCS is 8 or less, severe respiratory failure, or anticipated deterioration
• Surgical airway if unable to intubate and unable to oxygenate

B - Breathing and ventilation

• Respiratory rate, effort, chest symmetry
• Oxygen saturation
• Tracheal position
• Breath sounds and percussion note
• Open chest wound, flail segment, subcutaneous emphysema

• Tension pneumothorax: immediate needle/finger thoracostomy followed by intercostal chest drain
• Open pneumothorax: three-sided occlusive dressing followed by chest drain away from the wound
• Massive hemothorax: chest drain and resuscitation
• Flail chest/pulmonary contusion: oxygen, analgesia, ventilatory support if needed
• Cardiac tamponade: urgent resuscitation and operative/pericardial intervention depending on setting

C - Circulation with haemorrhage control

• Pulse, blood pressure, capillary refill, skin temperature
• Level of consciousness
• External bleeding
• Pelvic and long-bone injuries

• Direct pressure, hemostatic dressing, tourniquet for catastrophic limb bleeding
• Two large-bore IV cannulas or intraosseous access
• Send blood for grouping, cross-match, hemogram, coagulation profile, lactate/ABG
• Warmed balanced blood-product resuscitation for major haemorrhage
• Activate massive transfusion protocol when indicated
• Tranexamic acid as early as possible in significant traumatic bleeding, ideally within 3 hours
• Avoid excessive crystalloid infusion
• Pelvic binder over greater trochanters for suspected unstable pelvic fracture
• Urgent damage-control surgery or angioembolization for ongoing bleeding

D - Disability: neurological assessment

• Glasgow Coma Scale
• Pupillary size and reaction
• Limb movement and focal neurological deficits
• Blood glucose
• Look for lateralizing signs and seizures

E - Exposure and environmental control

• Completely expose the patient and examine front and back.
• Log-roll with spinal precautions.
• Prevent hypothermia with warm blankets, warmed fluids, and ambient temperature control.

Adjuncts to primary survey

• ECG
• Pulse oximetry and capnography
• Arterial blood gas and lactate
• Portable chest and pelvic X-ray where useful
• FAST or eFAST ultrasound for intraperitoneal, pericardial, or pleural fluid/air
• Urinary catheter if no suspected urethral injury
• Gastric tube if indicated

Secondary survey

• Head and face
• Neck and cervical spine
• Chest
• Abdomen
• Perineum and rectum when indicated
• Pelvis
• Limbs, pulses, sensory and motor function
• Spine and back

• A: Allergies
• M: Medications
• P: Past illnesses/pregnancy
• L: Last meal
• E: Events/environment related to injury

Definitive care

• CT trauma imaging in stable patients where appropriate
• Emergency operation for uncontrolled bleeding, peritonitis, perforation, tamponade, etc.
• Neurosurgical, orthopedic, vascular, urologic, or thoracic referral as needed
• Tetanus prophylaxis and antibiotics for contaminated/open wounds

Important principles

1. Treat the greatest threat to life first.
2. Reassess ABCDE repeatedly.
3. Do not delay treatment for investigations.
4. Prevent hypoxia, hypotension, hypothermia, acidosis, and coagulopathy.
5. Definitive surgery may be delayed until physiology is restored in severely unstable patients.

2. Head Trauma - Long Answer Question

Definition

Classification

According to severity by Glasgow Coma Scale

According to type

1. Closed head injury
2. Open or penetrating head injury
3. Primary brain injury
4. Secondary brain injury

Primary brain injuries

• Scalp injury
• Skull fracture
• Cerebral concussion
• Cerebral contusion
• Diffuse axonal injury
• Extradural hematoma
• Acute subdural hematoma
• Traumatic subarachnoid hemorrhage
• Intracerebral hematoma

Secondary brain injury

• Hypoxia
• Hypotension
• Hypercapnia or severe hypocapnia
• Cerebral edema
• Raised intracranial pressure
• Seizures
• Fever
• Hypoglycemia or hyperglycemia
• Anemia
• Infection

Clinical assessment

History

• Mechanism and time of injury
• Loss of consciousness
• Vomiting, seizures, headache
• Amnesia
• Alcohol/drug use
• Anticoagulant or antiplatelet use
• Previous neurological disease

Examination

• ABCDE trauma assessment first
• GCS and serial neurological observations
• Pupils: size, equality, reactivity
• Focal deficit: weakness, aphasia, cranial nerve palsy
• Signs of skull-base fracture:
  • Periorbital ecchymosis
  • Mastoid bruising
  • CSF rhinorrhea/otorrhea
  • Hemotympanum
• Scalp wounds and depressed skull fracture
• Examine cervical spine

Danger signs requiring urgent CT brain/neurosurgical opinion

• GCS below 13 initially, or persistent GCS below 15
• Declining GCS
• Focal neurological deficit
• Unequal or fixed dilated pupils
• Post-traumatic seizure
• Repeated vomiting
• Suspected open or depressed skull fracture
• Signs of basal skull fracture
• Anticoagulant use or bleeding disorder
• Significant mechanism of injury
• Persistent severe headache or altered behavior

Investigations

1. Non-contrast CT brain: investigation of choice in acute head injury.
2. CT cervical spine when indicated.
3. Skull X-ray has little role in acute evaluation.
4. CBC, blood group/cross-match, coagulation profile, electrolytes, glucose, ABG.
5. MRI is useful later for diffuse axonal injury, brainstem injury, and subtle lesions.

Management

Initial management

• Follow ABCDE.
• Maintain cervical-spine immobilization until cleared.
• Avoid hypoxia and hypotension.
• Intubate and ventilate if GCS 8 or less, airway compromise, or respiratory failure.
• Elevate head end about 30 degrees and maintain neutral neck alignment.
• Adequate analgesia, sedation where ventilated, temperature control.
• Correct coagulopathy urgently.
• Avoid routine corticosteroids in traumatic brain injury.

Management of raised intracranial pressure

• Worsening consciousness
• Headache, vomiting
• Bradycardia, hypertension, irregular respiration: Cushing response
• Unequal/fixed pupils
• Posturing

• Head elevation and neutral alignment
• Oxygenation and normocapnia
• Sedation/analgesia in ventilated patient
• Hypertonic saline or mannitol in suspected raised ICP/herniation, with hemodynamic monitoring
• Short-term controlled hyperventilation only as a bridge in impending herniation
• Seizure treatment
• Neurosurgical decompression or hematoma evacuation when indicated

Specific lesions

Concussion

• Observation
• Analgesia
• Written head-injury advice
• Return immediately for vomiting, worsening headache, confusion, weakness, seizure, or drowsiness

Cerebral contusion

• Observation with serial GCS and CT
• Control raised ICP
• Surgery if large lesion, mass effect, or deterioration

Depressed skull fracture

• Antibiotics and tetanus prophylaxis for compound injury
• Surgical elevation/debridement when open, contaminated, significantly depressed, associated with CSF leak, dural tear, hematoma, or neurological deficit

Extradural hematoma

• Brief loss of consciousness
• Lucid interval may occur
• Rapid deterioration, ipsilateral dilated pupil, contralateral weakness

Acute subdural hematoma

• Resuscitation and correction of coagulopathy
• Urgent craniotomy/craniectomy and evacuation in appropriate patients with significant clot, midline shift, or deterioration

Complications

• Raised intracranial pressure and brain herniation
• Seizures
• CSF leak and meningitis
• Post-traumatic epilepsy
• Cognitive, behavioral, speech, and motor disability
• Hydrocephalus
• Persistent post-concussion symptoms

3. Chest Trauma - Long Answer Question

Definition

Causes

• Road traffic collision
• Fall from height
• Crush injury
• Assault
• Stab wound
• Gunshot injury
• Iatrogenic injury

Classification

Chest-wall injuries

• Rib fractures
• Flail chest
• Sternal fracture
• Scapular/clavicular fracture

Pleural and pulmonary injuries

• Pneumothorax
• Tension pneumothorax
• Hemothorax
• Massive hemothorax
• Hemopneumothorax
• Pulmonary contusion
• Tracheobronchial injury

Mediastinal injuries

• Cardiac tamponade
• Myocardial contusion
• Great-vessel injury
• Traumatic aortic injury
• Esophageal rupture
• Diaphragmatic rupture

Initial assessment

• Respiratory rate and SpO₂
• Chest movement
• Tracheal position
• Percussion note
• Breath sounds
• External wounds
• Subcutaneous emphysema
• Jugular venous pressure
• Pulse and BP

Immediately life-threatening chest injuries

1. Tension pneumothorax

• Severe respiratory distress
• Hypoxia
• Unilateral absent breath sounds
• Hyperresonance
• Hypotension
• Distended neck veins may occur
• Tracheal deviation is a late sign

• Clinical diagnosis: do not wait for X-ray.
• Immediate needle decompression or finger thoracostomy.
• Insert intercostal chest drain subsequently.

2. Open pneumothorax

• Three-sided occlusive dressing
• Oxygen
• Chest drain placed away from wound
• Surgical closure after stabilization

3. Massive hemothorax

• Shock
• Respiratory distress
• Reduced breath sounds
• Dull percussion note
• Flat neck veins due to hypovolemia

• Large-bore chest drain
• Blood transfusion and massive haemorrhage protocol if needed
• Thoracotomy if immediate drainage is about 1.5 L, ongoing bleeding is roughly more than 200 mL/hour for 2-4 hours, or persistent hemodynamic instability

4. Flail chest with pulmonary contusion

• Paradoxical inward movement on inspiration
• Severe pain
• Respiratory distress
• Underlying pulmonary contusion is often the major cause of hypoxia

• Oxygen and aggressive multimodal analgesia
• Chest physiotherapy and pulmonary toilet
• Treat associated pneumothorax/hemothorax
• Non-invasive or invasive ventilation if respiratory failure
• Consider surgical stabilization of rib fractures in selected patients

5. Cardiac tamponade

• Hypotension
• Raised JVP
• Muffled heart sounds: Beck triad
• Tachycardia, pulsus paradoxus
• Positive FAST/eFAST pericardial fluid

• Urgent surgical exploration/pericardial drainage in trauma setting
• Pericardiocentesis may be a temporary measure if surgery is not immediately available

Potentially life-threatening chest injuries

Simple pneumothorax

• Oxygen and observation if small/stable
• Chest drain if large, symptomatic, ventilated, or progressing

Rib fractures

• Good analgesia, including regional methods where appropriate
• Incentive spirometry/chest physiotherapy
• Early mobilization
• Treat associated complications such as pneumonia and pneumothorax

Pulmonary contusion

• Hypoxia and increasing respiratory distress, sometimes delayed
• Patchy infiltrates on imaging

• Oxygen, analgesia, pulmonary hygiene
• Avoid fluid overload
• Ventilatory support if required

Myocardial contusion

• ECG
• Troponin
• Echocardiography if abnormal ECG, raised troponin, or instability

Traumatic aortic injury

• CT angiography
• Blood-pressure/heart-rate control
• Urgent endovascular repair in appropriate cases

Diaphragmatic rupture

• Respiratory distress
• Bowel sounds in chest
• Herniation of abdominal viscera on X-ray/CT

Investigations

• eFAST ultrasound
• Portable chest X-ray
• CT chest with contrast in stable patients
• ECG, ABG, CBC, blood grouping/cross-match
• Echocardiography for suspected cardiac injury

Chest-drain principles

• Usually inserted in the safe triangle.
• Connect to underwater-seal drainage.
• Document air leak and amount/nature of drainage.
• Obtain post-procedure imaging when feasible.
• Never clamp a bubbling drain in a patient with pneumothorax unless specifically directed by a thoracic specialist.

4. Brain Tumour - Long Answer Question

Definition

Classification

According to origin

Primary brain tumours

• Gliomas:
  • Astrocytoma
  • Oligodendroglioma
  • Glioblastoma
  • Ependymoma
• Meningioma
• Pituitary adenoma
• Schwannoma, especially vestibular schwannoma
• Craniopharyngioma
• Medulloblastoma
• Primary CNS lymphoma
• Pineal tumours
• Germ-cell tumours

Secondary brain tumours

• Lung
• Breast
• Melanoma
• Kidney
• Colorectal cancer

According to behavior

• Benign or low-grade
• Malignant/high-grade
• WHO classification also incorporates histology and molecular features in modern practice.

Clinical features

Features due to raised intracranial pressure

• Headache, often worse in morning
• Vomiting, sometimes projectile
• Papilledema
• Drowsiness and altered consciousness
• Diplopia due to sixth-nerve palsy
• Bradycardia and hypertension late in disease

Focal neurological features

• Frontal lobe: personality change, disinhibition, weakness
• Parietal lobe: sensory loss, visuospatial dysfunction
• Temporal lobe: memory disturbance, aphasia, seizures
• Occipital lobe: visual field defect
• Cerebellum: ataxia, nystagmus, dysmetria
• Brainstem: cranial-nerve palsies, long-tract signs
• Pituitary region: visual-field defect, endocrine disorder

Other features

• New-onset focal seizure
• Progressive neurological deficit
• Cognitive or behavioral change
• Endocrine abnormalities
• Hydrocephalus

Investigations

Imaging

1. MRI brain with contrast is the investigation of choice.
2. CT brain is useful in emergencies, hemorrhage, calcification, hydrocephalus, or when MRI is unavailable.
3. CT chest/abdomen/pelvis or PET-CT when metastasis is suspected.
4. Angiography may be required for highly vascular lesions or preoperative embolization.

Other tests

• Visual-field testing for pituitary lesions
• Endocrine profile for sellar/suprasellar lesions
• Histopathology and molecular testing after biopsy/resection

Principles of management

General supportive treatment

• Dexamethasone for symptomatic vasogenic edema around many tumours, especially metastases
• Antiseizure drug after a seizure. Routine prophylaxis in seizure-naive patients is not universal.
• Analgesia and antiemetics
• Management of hydrocephalus: external ventricular drain, endoscopic third ventriculostomy, or VP shunt where appropriate
• Rehabilitation, neuropsychology, and palliative care support

Definitive treatment

1. Observation

• Small asymptomatic meningiomas
• Incidental low-risk lesions
• Frail patients with slow-growing tumours

2. Surgery

• Obtain tissue diagnosis
• Maximal safe resection
• Reduce mass effect and raised ICP
• Control seizures
• Relieve hydrocephalus

• Craniotomy and excision
• Stereotactic biopsy for deep, multiple, diffuse, or unresectable lesions
• Endoscopic biopsy for ventricular lesions

3. Radiotherapy

• External-beam radiotherapy
• Stereotactic radiosurgery for selected small tumours/metastases
• Fractionated radiotherapy for high-grade glioma or residual disease

4. Chemotherapy/systemic therapy

• Temozolomide is commonly used with radiotherapy for glioblastoma
• High-dose methotrexate-based therapy for primary CNS lymphoma
• Targeted therapy or immunotherapy for selected metastatic tumours

Management according to common tumour type

Glioblastoma

• Maximal safe surgical resection where feasible
• Radiotherapy with concurrent and adjuvant temozolomide
• Steroids for edema
• Prognosis is generally poor despite treatment

Meningioma

• Observation if small/asymptomatic
• Surgical excision where symptomatic, enlarging, or causing mass effect
• Radiosurgery/radiotherapy for residual, recurrent, or inaccessible tumour

Solitary brain metastasis

• Surgery or stereotactic radiosurgery for suitable accessible lesions
• Whole-brain radiotherapy is used selectively
• Treat primary cancer systemically where appropriate

Pituitary adenoma

• Endocrine evaluation
• Dopamine agonist for prolactinoma
• Transsphenoidal surgery for visual compromise, hormone hypersecretion not controlled medically, or mass effect

Complications

• Seizures
• Herniation
• Hydrocephalus
• Endocrine dysfunction
• Neurological deficits after surgery
• Tumour recurrence
• Radiation necrosis
• Cognitive decline

5. Brain Haemorrhage: Types and Management - Long Answer Question

Definition

Types

General clinical presentation

• Sudden severe headache
• Vomiting
• Altered consciousness
• Focal neurological deficit
• Seizure
• Neck stiffness in subarachnoid hemorrhage
• Signs of raised intracranial pressure
• Pupillary asymmetry or coma in major traumatic hematoma

Investigations

1. Urgent non-contrast CT brain: first-line test.
2. CT angiography or MR angiography for aneurysm, AVM, or vascular cause.
3. Digital subtraction angiography when needed.
4. CBC, electrolytes, renal/liver function, blood glucose.
5. PT/INR, aPTT, platelet count, drug history.
6. ECG and cardiac evaluation in spontaneous hemorrhage.
7. Lumbar puncture only if subarachnoid hemorrhage remains suspected after negative CT and imaging strategy permits it. Never perform if raised ICP/mass lesion is suspected.

A. Extradural Hematoma

Etiology

• Temporal/parietal skull fracture
• Laceration of middle meningeal artery
• Less commonly venous bleeding

Clinical features

• Loss of consciousness followed by lucid interval in some patients
• Headache, vomiting
• Rapid fall in GCS
• Ipsilateral fixed dilated pupil
• Contralateral hemiparesis

CT appearance

• Biconvex/lens-shaped hyperdense collection
• Usually does not cross suture lines

Management

• ABCDE and prevention of hypoxia/hypotension
• Urgent neurosurgical referral
• Craniotomy/craniectomy and evacuation if significant size, mass effect, neurological deficit, declining consciousness, or pupillary changes
• Small stable hematomas may be observed in a neurosurgical setting with serial CT and examination

B. Acute Subdural Hematoma

Etiology

• Tearing of bridging veins after acceleration-deceleration injury
• Common in severe head injury
• Risk increased in elderly people, alcohol misuse, cerebral atrophy, anticoagulation

Clinical features

• Headache and altered sensorium
• Focal neurological deficit
• Rapid deterioration in acute cases
• May have associated contusions and diffuse brain injury

CT appearance

• Crescent-shaped hyperdense collection
• Can cross suture lines but not dural reflections
• Midline shift may be present

Management

• Resuscitation and correction of coagulopathy
• Urgent neurosurgical assessment
• Craniotomy/craniectomy and clot evacuation for significant hematoma, mass effect, low GCS/deterioration, or raised ICP
• ICU care and ICP control

Chronic subdural hematoma

• Weeks after minor trauma, especially in elderly persons
• Headache, cognitive decline, gait disturbance, hemiparesis, fluctuating consciousness

• Hypodense or mixed-density crescentic collection

• Burr-hole drainage with closed drainage system for symptomatic/significant hematoma
• Correct anticoagulation where possible

C. Subarachnoid Hemorrhage

Causes

• Ruptured berry aneurysm
• Arteriovenous malformation
• Trauma
• Less often coagulopathy or other vascular lesions

Clinical features

• Sudden severe “thunderclap” headache
• Neck stiffness and photophobia
• Vomiting
• Collapse or coma
• Seizure
• Focal deficit if associated vasospasm, hematoma, or hydrocephalus

Investigations

• Urgent non-contrast CT brain
• CT angiography to detect aneurysm
• Lumbar puncture in selected patients with continued suspicion after negative imaging, based on local protocol
• Digital subtraction angiography if needed

Management

• ICU/neurosurgical management
• Control pain, vomiting, fever, glucose, and BP carefully
• Nimodipine to reduce delayed ischemic neurological deficit from vasospasm
• Secure aneurysm early by endovascular coiling or surgical clipping
• External ventricular drainage for hydrocephalus
• Treat vasospasm and delayed cerebral ischemia in specialist neurocritical care

• Rebleeding
• Vasospasm and cerebral infarction
• Hydrocephalus
• Hyponatremia
• Seizures
• Cardiac arrhythmias

D. Intracerebral Hemorrhage

Causes

• Chronic hypertension: deep ganglia, thalamus, pons, cerebellum
• Cerebral amyloid angiopathy: lobar hemorrhage in elderly people
• Anticoagulants/thrombolysis
• AVM/aneurysm
• Tumour
• Coagulopathy
• Illicit sympathomimetic drugs

Clinical features

• Sudden focal deficit
• Headache, vomiting
• Reduced consciousness depending on size/site
• Seizures, particularly lobar hematoma

Management

• ABCDE and neurocritical care
• Rapid CT scan
• Controlled BP reduction according to stroke protocol
• Stop and reverse anticoagulation where indicated
• Treat raised ICP
• Neurosurgical evacuation for selected cerebellar hemorrhage, hydrocephalus, deterioration, or selected accessible lobar hematomas
• External ventricular drain for obstructive hydrocephalus/intraventricular hemorrhage
• Rehabilitation: physiotherapy, speech therapy, occupational therapy, secondary prevention

E. Intraventricular Hemorrhage

• Acute obstructive hydrocephalus
• Raised intracranial pressure
• Reduced consciousness

• Neurocritical care
• Correct coagulopathy
• External ventricular drainage if hydrocephalus or reduced consciousness
• Treat underlying cause

General principles in all intracranial hemorrhages

1. Stabilize airway, oxygenation, circulation, and glucose.
2. Urgent CT brain.
3. Repeated GCS and pupil examination.
4. Stop/reverse anticoagulants where indicated.
5. Avoid hypotension, fever, hypoxia, and hyperglycemia.
6. Manage raised ICP.
7. Obtain early neurosurgical or stroke-team input.
8. Start rehabilitation and secondary prevention early.

6. Benign Prostatic Hyperplasia and Surgical Management - Long Answer Question

Definition

Etiology and pathogenesis

• Increasing age
• Androgen-dependent process
• Dihydrotestosterone stimulates prostatic growth
• Enlargement in transition zone compresses prostatic urethra
• Dynamic obstruction is due to increased smooth-muscle tone mediated by alpha-1 adrenergic receptors
• Static obstruction is due to enlarged prostate tissue

Clinical features

Voiding symptoms

• Poor stream
• Hesitancy
• Intermittency
• Straining
• Terminal dribbling
• Feeling of incomplete emptying

Storage symptoms

• Frequency
• Urgency
• Nocturia
• Urge incontinence

Complications

• Acute urinary retention
• Chronic urinary retention
• Recurrent UTI
• Bladder stone
• Hematuria
• Hydroureteronephrosis
• Renal impairment
• Overflow incontinence

Examination

• General examination for renal failure, distended bladder
• Abdominal examination for palpable bladder
• Digital rectal examination:
  • Enlarged smooth, firm, non-tender prostate in BPH
  • Hard irregular/nodular prostate suggests carcinoma
• Neurological examination where neurogenic bladder is possible

Investigations

1. Urinalysis and urine culture if infection suspected
2. Serum creatinine/eGFR if renal impairment or retention suspected
3. PSA after counseling, when it will influence management
4. International Prostate Symptom Score: IPSS
5. Frequency-volume chart in men with storage symptoms/nocturia
6. Post-void residual urine
7. Uroflowmetry
8. Ultrasound KUB and prostate volume
9. Cystoscopy when hematuria, suspected stricture/bladder stone, or before selected procedures
10. Urodynamic studies in selected patients with uncertain diagnosis, neurological disease, high residual urine, or possible detrusor underactivity

Conservative management

• Reduce evening fluid intake
• Reduce caffeine and alcohol
• Timed/double voiding
• Treat constipation
• Review drugs that worsen symptoms, such as anticholinergics, decongestants, and opioids
• Regular review with symptom score, renal function, and residual urine where indicated

Medical management

Alpha-1 blockers

• Tamsulosin
• Alfuzosin
• Silodosin
• Doxazosin

• Postural hypotension
• Dizziness
• Retrograde ejaculation
• Intraoperative floppy iris syndrome

5-alpha-reductase inhibitors

• Finasteride
• Dutasteride

• Reduced libido
• Erectile dysfunction
• Ejaculatory dysfunction
• Reduced PSA level

Combination therapy

Other drugs

• Antimuscarinic agents or beta-3 agonist for predominant storage symptoms, with caution if high residual urine
• PDE5 inhibitor, such as tadalafil, may help LUTS with erectile dysfunction

Indications for surgery

1. Recurrent or refractory urinary retention
2. Recurrent urinary tract infection due to obstruction
3. Recurrent gross hematuria due to BPH
4. Bladder stone or diverticulum due to obstruction
5. Hydronephrosis or renal impairment due to bladder outlet obstruction
6. Severe troublesome symptoms despite conservative/medical treatment
7. Intolerance or contraindication to medical treatment
8. Large residual urine or progressive obstruction in selected cases

Surgical options for BPH

Transurethral Resection of Prostate - TURP

Principle

Indications

• Symptomatic BPH with failed medical therapy
• Recurrent retention
• Recurrent UTI, hematuria, stone, or renal obstruction due to BPH
• Moderate-sized obstructing prostate

Steps of TURP

1. Spinal or general anesthesia.
2. Lithotomy position.
3. Cystoscopy and assessment of urethra, prostate, bladder neck, and bladder.
4. Resectoscope introduced.
5. Resection begins at median lobe/bladder neck as appropriate.
6. Resect adenoma systematically while preserving external sphincter and avoiding ureteric orifices.
7. Achieve meticulous hemostasis.
8. Remove chips by evacuation.
9. Insert three-way Foley catheter and start continuous bladder irrigation.

Complications

Early

• Hemorrhage and clot retention
• Urinary tract infection/sepsis
• TUR syndrome: dilutional hyponatremia from excessive hypotonic irrigation absorption, mainly with monopolar TURP
• Bladder perforation
• Capsular perforation
• Ureteric-orifice injury
• Failure to void/temporary retention
• Deep-vein thrombosis or pulmonary embolism

Late

• Retrograde ejaculation
• Erectile dysfunction, less common
• Urethral stricture
• Bladder-neck contracture
• Urinary incontinence, uncommon but serious
• Residual/recurrent adenoma requiring re-treatment

Bipolar TURP

• Avoids classic TUR syndrome from non-electrolyte irrigation
• Good hemostasis
• Similar symptom improvement to monopolar TURP

Transurethral Incision of Prostate - TUIP

• Small prostate, often less than about 30 mL
• High bladder neck
• No large median lobe

• Short procedure
• Less bleeding
• Lower risk of retrograde ejaculation than TURP

• Less suitable for large glands
• Higher re-treatment risk than definitive resection/enucleation

Holmium Laser Enucleation of Prostate - HoLEP

Principle

Advantages

• Suitable for small, medium, and very large prostates
• Excellent hemostasis
• Shorter catheterization/hospital stay in many settings
• Durable symptom relief
• Avoids open surgery in many very large glands
• Useful in patients at increased bleeding risk, with proper perioperative planning

Complications

• Transient stress urinary incontinence
• Retrograde ejaculation
• Urethral stricture
• Bladder-neck contracture
• Bleeding, UTI
• Morcellator-related bladder injury, rare

Open or Simple Prostatectomy

Types

• Open retropubic simple prostatectomy
• Open transvesical/suprapubic simple prostatectomy
• Robotic simple prostatectomy in selected centers

Indications

• Very large prostate, often more than about 80-100 mL depending on available expertise
• Large bladder stone/diverticulum requiring open surgery
• When HoLEP or another endoscopic enucleation procedure is unavailable or unsuitable

Principle

Complications

• Greater blood loss and longer recovery compared with endoscopic methods
• Infection
• Urinary leakage
• Retention
• Bladder-neck contracture
• Incontinence
• Retrograde ejaculation

Postoperative care after BPH surgery

• Monitor pulse, BP, urine output, color of urine, and hemoglobin
• Maintain catheter patency and continuous bladder irrigation after TURP when needed
• Treat clots by bladder washout if required
• Trial without catheter after hematuria settles
• Encourage hydration and mobilization
• Avoid heavy straining and constipation
• Review histopathology of resected tissue
• Counsel about temporary urgency, dysuria, retrograde ejaculation, and expected recovery

Section B - Q2: Short Answer Questions

a. Management of an impacted renal/ureteric calculus

Definition

Assessment

Clinical assessment

• Renal colic or persistent loin pain
• Fever, dysuria, pyuria or features of urosepsis
• Vomiting/dehydration
• Oliguria or anuria, especially in bilateral obstruction or solitary kidney
• Previous stone history and comorbidities
• Examine for fever, tachycardia, hypotension, loin tenderness

Investigations

• Urinalysis and urine culture
• Complete blood count, serum creatinine/eGFR, electrolytes
• Non-contrast CT KUB: defines stone size, location, density, obstruction, and anatomy
• Ultrasound KUB: hydronephrosis and renal status
• X-ray KUB if stone is radio-opaque and for follow-up
• Functional imaging in selected chronic obstruction cases

Management

1. Emergency decompression

• Fever, sepsis, pyonephrosis
• Acute kidney injury
• Anuria
• Obstruction in a solitary kidney
• Bilateral obstruction
• Uncontrolled pain/vomiting despite treatment

• Retrograde ureteric stenting: internal drainage with double-J stent
• Percutaneous nephrostomy (PCN): preferred when retrograde stenting fails, anatomy is difficult, or sepsis is severe

2. Conservative treatment/medical expulsive therapy

• Stone is small, generally less than 5-6 mm
• No sepsis, renal impairment, refractory pain, or high-grade obstruction
• Patient can be followed closely

• NSAID analgesia if renal function permits
• Antiemetics
• Adequate oral hydration, without forced overhydration
• Alpha blocker, such as tamsulosin, may facilitate expulsion of selected distal ureteric stones
• Serial imaging and renal-function monitoring

3. Definitive treatment

Complications of untreated impacted stone

• Recurrent colic and infection
• Hydroureteronephrosis
• Pyonephrosis and urosepsis
• Ureteric stricture
• Progressive renal damage or loss of renal function

b. Coup-contrecoup injuries

Definition

• Coup injury: brain injury directly beneath the site of impact.
• Contrecoup injury: brain injury on the side opposite to the site of impact.

Mechanism

Coup injury

Contrecoup injury

Why contrecoup injury occurs

• Sudden deceleration causes displacement of the brain within the CSF-filled cranial cavity.
• The rough internal surfaces of the anterior and middle cranial fossae injure the brain surface.
• Frontal and temporal lobes are therefore frequent sites.

Sites commonly involved

• Frontal poles
• Inferior frontal surfaces
• Temporal poles
• Inferolateral temporal lobes

Clinical features

• Loss of consciousness
• Headache and vomiting
• Confusion, amnesia
• Focal neurological deficit
• Seizures
• Deterioration due to edema or hemorrhagic progression of contusions

Diagnosis

• Non-contrast CT brain: hemorrhagic contusions, edema, associated skull fracture or hematoma
• MRI is more sensitive for small contusions and diffuse axonal injury

Management

• ABCDE resuscitation with cervical-spine protection
• Prevent hypoxia and hypotension
• Serial GCS, pupil checks, and neurological observation
• CT brain and repeat CT if neurological deterioration
• Treat raised intracranial pressure when present
• Neurosurgical intervention if there is a large contusion, mass effect, worsening deficit, or associated hematoma

c. Coronary Artery Bypass Grafting - indications, procedure, and complications

Definition

Common conduits

• Left internal mammary artery (LIMA) to left anterior descending artery: preferred conduit
• Right internal mammary artery
• Radial artery
• Great saphenous vein

Indications

1. Left main coronary artery disease, particularly significant stenosis or complex anatomy.
2. Triple-vessel coronary artery disease, especially with diabetes mellitus or impaired LV function.
3. Complex multivessel disease unsuitable for or unlikely to have durable results with PCI.
4. Significant proximal LAD disease with multivessel coronary disease.
5. Persistent/refractory angina despite optimal medical therapy.
6. Acute coronary syndrome when PCI fails or is not feasible.
7. Mechanical complications of myocardial infarction requiring surgery, with associated coronary disease.
8. Concomitant CABG during valve surgery, aortic surgery, or other cardiac operation when significant coronary disease is present.

Procedure: on-pump CABG

Preoperative preparation

• Coronary angiography, echocardiography, ECG, blood tests
• Control diabetes, hypertension, anemia, and infection
• Antiplatelet/anticoagulant planning
• General anesthesia, invasive monitoring, transesophageal echocardiography where needed

Operative steps

1. Median sternotomy.
2. Harvest grafts: LIMA, radial artery, and/or saphenous vein.
3. Systemic heparinization.
4. Cannulate aorta and right atrium.
5. Establish cardiopulmonary bypass.
6. Apply aortic cross-clamp and give cardioplegia to arrest/protect the heart.
7. Perform distal graft anastomoses beyond coronary stenoses.
8. Construct proximal vein-graft anastomoses to ascending aorta.
9. Remove air from heart, release cross-clamp, and restore cardiac rhythm.
10. Wean from bypass with hemodynamic support if needed.
11. Reverse heparin with protamine.
12. Achieve hemostasis, insert mediastinal/pleural drains, and close sternum.

Off-pump CABG

Complications

Early cardiac complications

• Perioperative myocardial infarction
• Arrhythmias, especially atrial fibrillation
• Low cardiac output syndrome
• Graft thrombosis/occlusion
• Cardiac tamponade
• Cardiogenic shock

Bleeding and surgical complications

• Hemorrhage and need for re-exploration
• Coagulopathy after cardiopulmonary bypass
• Mediastinitis/sternal wound infection
• Sternal dehiscence
• Leg-wound infection after vein harvest
• Pneumothorax, pleural effusion

Systemic complications

• Stroke or transient ischemic attack
• Delirium and postoperative cognitive dysfunction
• Acute kidney injury
• Respiratory failure, atelectasis, pneumonia
• Deep-vein thrombosis and pulmonary embolism
• Sepsis and multiorgan dysfunction

Late complications

• Recurrent angina due to graft failure or progression of native disease
• Vein-graft atherosclerosis
• Chronic sternal pain or non-union

d. Types of arteriovenous malformations of the brain

Definition

Types of cerebral vascular malformations

1. True cerebral AVM

• Most important high-flow lesion.
• Consists of feeding arteries, a central nidus, and draining veins.
• May present with intracerebral, subarachnoid, or intraventricular hemorrhage; seizure; headache; or focal deficit.

2. Pial AVM

• Located in brain parenchyma or on pial surface.
• Fed by intracranial arteries and drains into cortical or deep cerebral veins.
• May be superficial or deep.

3. Dural arteriovenous fistula (dAVF)

• Acquired abnormal shunt between meningeal arteries and dural venous sinuses or cortical veins.
• There is usually no parenchymal nidus.
• May present with pulsatile tinnitus, headache, ophthalmic symptoms, venous hypertension, seizures, or hemorrhage.

4. Vein of Galen aneurysmal malformation

• Congenital high-flow arteriovenous shunt involving the median prosencephalic vein.
• Usually presents in neonates/infants with high-output cardiac failure, hydrocephalus, or macrocephaly.

5. Arteriovenous fistula

• Direct connection between artery and vein without a nidus.
• May be pial or dural.
• Usually high-flow.

6. Cavernous malformation/cavernoma

• Low-flow lesion composed of dilated vascular channels.
• Often called a cavernous angioma.
• Not a true high-flow AVM.
• Presents with seizures, focal deficits, or repeated small hemorrhages.

7. Capillary telangiectasia

• Small, low-flow capillary lesion, often in pons.
• Usually incidental and asymptomatic.

8. Developmental venous anomaly

• Variant venous drainage pattern, often described as a “caput medusae.”
• Usually benign and incidentally detected.
• Generally should not be surgically removed.

Spetzler-Martin grading of brain AVM

• Grade I-II: often suitable for microsurgical treatment if symptomatic/ruptured.
• Grade III: individualized multimodal management.
• Grade IV-V: frequently managed conservatively or with selected staged treatment because intervention risk is high.

Diagnosis and treatment principles

• CT/MRI identifies hemorrhage and lesion anatomy.
• CT angiography/MR angiography help define vessels.
• Digital subtraction angiography is the definitive vascular mapping investigation.
• Treatment options: microsurgical excision, endovascular embolization, stereotactic radiosurgery, or observation.
• Choice depends on rupture status, size, location, venous drainage, patient age, and surgical risk.

e. Case: anterior mediastinal mass compressing trachea and superior vena cava

Most likely diagnosis

1. Thymic tumour: thymoma or thymic carcinoma
2. Terrible lymphoma: Hodgkin or non-Hodgkin lymphoma
3. Teratoma/germ-cell tumour
4. Thyroid mass: substernal goitre

Anterior mediastinal malignancy, most likely lymphoma, causing SVC obstruction and tracheal compression, pending tissue diagnosis.

Immediate assessment and stabilization

• Admit urgently and involve respiratory medicine, thoracic surgery, oncology/hematology, anesthesiology, and critical care.
• Keep patient upright and administer oxygen.
• Monitor respiratory status, oxygen saturation, hemodynamics, and signs of worsening SVC syndrome.
• Look for facial/neck/upper-limb edema, distended chest-wall veins, cyanosis, stridor, orthopnea, and neurological symptoms.
• Avoid unnecessary sedation and avoid supine positioning if it worsens breathlessness.
• Avoid routine general anesthesia before a safe airway plan because induction can precipitate complete airway or cardiovascular collapse in a compressive mediastinal mass.

Investigations

1. Contrast-enhanced CT chest, neck, and upper abdomen to define:
   • Site, size, invasion, lymph nodes
   • Tracheal/bronchial compression
   • SVC obstruction and collateral veins
2. CBC, renal/liver function, LDH, uric acid, coagulation profile.
3. Tumour markers:
   • AFP and beta-hCG for germ-cell tumour
   • Thyroid function tests if thyroid lesion possible
4. PET-CT for lymphoma staging, generally after tissue diagnosis.
5. Echocardiography if cardiac/pericardial involvement is suspected.
6. Tissue diagnosis:
   • CT-guided core biopsy or ultrasound-guided biopsy of accessible node/mass
   • Prefer local anesthesia where possible
   • In suspected lymphoma, obtain adequate core tissue for histology, immunohistochemistry, and flow cytometry
   • If a completely resectable thymoma is strongly suspected, primary surgical resection may be considered without preoperative biopsy in selected cases. In this case, SVC involvement makes biopsy and multidisciplinary staging more likely.

Definitive management

If lymphoma is confirmed

• Hematology referral and full staging.
• Systemic chemotherapy is the main treatment.
• In selected cases, radiotherapy may be added.
• Treat/prevent tumour lysis syndrome in bulky, highly chemosensitive disease.
• Steroids can rapidly reduce mass effect but should ideally be withheld until diagnostic tissue is obtained, unless airway/SVC compromise is life-threatening, because steroids may obscure lymphoma histology.

If thymoma/thymic carcinoma is confirmed

• Resectable disease: complete thymectomy with en-bloc resection of involved structures, sometimes including SVC reconstruction.
• Locally advanced/unresectable disease: induction chemotherapy with or without radiotherapy, then reassess for surgery.
• Thymic carcinoma usually requires multimodal oncological treatment.

Management of SVC syndrome

• Head elevation, oxygen, symptom control.
• Endovascular SVC stenting can provide rapid relief when obstruction is severe.
• Definitive treatment depends on histology: chemotherapy for lymphoma, surgery/chemoradiotherapy for thymic malignancy, and disease-specific treatment for other causes.

f. Case: fever, severe headache, neck stiffness, photophobia, altered sensorium after sinusitis

Likely diagnosis

Acute community-acquired bacterial meningitis, with altered mental status.

Immediate management

Resuscitation

• ABCDE assessment.
• Oxygen if hypoxemic.
• IV access, monitoring, fluid resuscitation if septic/hypotensive.
• Check capillary blood glucose.
• Treat seizures if present.
• Admit to high-dependency unit/ICU if reduced GCS, shock, respiratory failure, or raised intracranial pressure is suspected.

Blood tests and cultures

• Two sets of blood cultures
• CBC with differential
• Serum glucose, electrolytes, renal and liver function
• CRP, lactate
• Coagulation profile
• HIV test where appropriate

Empirical treatment

• IV ceftriaxone or cefotaxime for community-acquired bacterial meningitis.
• Add vancomycin where local pneumococcal resistance risk warrants it.
• Add ampicillin/amoxicillin if Listeria risk is present, such as age over 50-60 years, pregnancy, immunocompromise, alcoholism, or significant comorbidity.
• Give IV dexamethasone just before or with the first antibiotic dose when pneumococcal meningitis is suspected.
• Add IV acyclovir if encephalitis is clinically possible, especially due to altered behavior, focal signs, seizures, or temporal-lobe features.

Confirmatory investigations

CT brain before lumbar puncture

• Antibiotics and dexamethasone must be administered first if CT will delay lumbar puncture.
• Lumbar puncture must not delay life-saving treatment.

Lumbar puncture

• Opening pressure
• Appearance
• Cell count and differential
• Protein
• CSF glucose with simultaneous serum glucose
• Gram stain
• Culture and sensitivity
• PCR/NAAT for bacterial and viral pathogens

• Raised opening pressure
• Turbid CSF
• Neutrophilic pleocytosis
• High protein
• Low glucose or low CSF:serum glucose ratio
• Gram stain/culture may identify organism

Additional management

• Droplet isolation initially if meningococcal disease is possible.
• Notify public-health authorities if meningococcal infection is suspected or confirmed.
• Provide antibiotic chemoprophylaxis to close contacts if meningococcal disease is confirmed.
• Monitor for septic shock, DIC, seizures, raised ICP, hearing loss, hydrocephalus, and focal deficits.
• Consider ENT evaluation and imaging for complicated sinusitis, mastoiditis, or a brain abscess source.

Important cautions

• Do not perform lumbar puncture in a patient with signs of impending herniation, focal neurological deficit, papilledema, uncontrolled seizures, severe cardiorespiratory compromise, or major coagulopathy.
• Do not delay empirical antibiotics merely to obtain CSF.