good evening everyone hopefully I'm Audible and the screen is visible too please let me know if the audio visuals are absolutely clear if they are then we can begin with the session okay no issues so as per the request I will be using both the languages so please don't worry both of them okay all of you don't worry about anything else okay we'll be covering surgery in a short crisp and a concise manner with both the languages properly each thing that I say in English I'll repeat that in Hindi so all the English viewers you don't need to think that you are missing out on something okay so don't worry about that so hopefully we can start great great great don't worry okay will make Concepts in both the languages no issues with that hopefully all of you are doing good so let me introduce myself first for those who don't know me I'm Dr omkar Sangeetha currently pursuing my Ms general surgery residency and over here we'll be revising the surgery for not only your fmg examination but also for your need on next PG examination whatever it comes your way I'll make sure that whatever surgery we are revising it will be short it will be crisp it will be concise and it will be more than enough to solve most of the mcqs in your examination I will have a proper focus on all the previously year previously asked topics and the questions okay so we will we'll be covering all the questions alongside you don't need to think about anything else okay but the only thing that I will need yes yes yes don't worry about that all of them all of them definitely I'll cover it over here itself yes individually integrated session because surgery as I always say it is a parent Branch I will not only focus on surgery I will definitely focus on all the Allied other subjects as well okay we'll be covering a lot of mcqs and a lot of topics from other subjects too because a surgeon could not say that I don't know a specific thing so like that over here once you have studied surgery you should not say that you do not know anything about the Allied branches as well PDF I'll be sharing after the class in the telegram channel uh Dr bhanu prakash uh telegram Channel I'll be sharing it with him and he'll be sharing it with all of you don't worry about that okay at the end of the session don't worry about anything else everything with images everything so if you're not able to solve your long questions definitely everything will be easier for you after you watch this session because I will be giving you important topics important keywords to solve any questions okay so I'll be telling you on the way how to approach a particular clinical winner in a case of surgery and how to approach the mcqs as well don't worry about anything else got them great my pleasure it is sure sure okay so let's begin without any further delay now the first topic that I'm about to start will be general surgery and a lot of people feel that uh there have not been a lot of questions from general surgery so let me retread the facts that nowadays general surgery has a major chunk of questions okay apart from git definitely if they ask you what is the second most important topic from surgery I'll say it is general surgery no issues with this anybody so that you need to remember properly now in general surgery we'll be covering a lot of topics okay we'll be covering uh the post and the four most important topic and that is what is hemorrhage and bleeding all the aspects about human age bleeding shock everything I'll be covering then further I'll be covering with all the general topics that is ranging from your IV candles to your surgical instruments to your surgical positions everything regarding that once I'm done with that then definitely I'll be starting with the most important topic or subtopic from General surgery and that is what is trauma okay so I'll be starting with trauma will winding up will be winding up trauma and once we are done with that we'll try to approach endocrine surgery as well today and in endocrine surgery we know the most important two topics are usually your breast and thyroid shallow let's start without any further delay Shall We Begin just give a thumbs up in the chat box so I can begin no it won't be deleted don't worry about that sure I'm starting now the first topic that I'm going to start is a dreaded complication for every surgeon okay so it is a dream rather a worst nightmare for every surgeon and that is what is hemorrhage but important is a surgeon with practice definitely knows how to overcome this problem or how to overcome this complication so that's the important thing we need to learn during surgery and that most dreaded complication you during a surgery is usually Hemorrhage rather in most of the surgeries the most common complication if they ask you usually it is a hemorrhage because if you're going to give a cut anywhere what it will happen it will lead to some bleeding and that is what is hemorrhage so Hemorrhage in simple terms guys Hemorrhage does not mean anything else apart from bleeding because of bleeding or okay so bleeding is what is called as Hemorrhage now Hemorrhage can be of various types either it can be a physiological Hemorrhage or it can be a pathological Hemorrhage physiological Hemorrhage that means the normal bleeding which occurs from our body so does it occur from a male body no so usually the physiological bleeding is only seen in females and it is seen every month that means during menstruation so the menstruation the menstrual cycles or the Menses that bleeding which occurs is an example of physiological bleeding apart from that every type of bleeding will be considered as pathological bleeding so normally your females that is what is a physiological breeding that is what is Menses that is considered as pathological bleeding pathological bleeding usually when we have got a cut okay when we have got a cut there is incision there is trauma there is infection all of these conditions can lead to pathological bleeding then definitely bleeding can be we can see blood with our Naked Eyes if we are able to see the blood with our Naked Eyes that is what is called as external bleeding or it can also be called as revealed bleeding it can also be called as revealed bleeding whereas otherwise it will be internal bleeding and internal bleeding when we cannot see the blood with our Naked Eyes but if you are not able to see the blood outside that is what is the internal or a concealed bleeding that is what is the internal concealed period now if the blood is coming outside if the blood is Flowing outside definitely you can make it out easily but if you are not able to see the blood if you are not able to see the blood how you are going to make out that the patient is bleeding so important is if a patient is having some internal or conceived bleeding how we are going to make out again if you are not able to see the blood how we are going to make out if the patient is bleeding internally so for that reason you need to assess the vitals of the patients and what do I mean by vitals over here only two important things you need to check one is the heart rate of the patient and second is the blood pressure of the patient so if a patient is having a lot of bleeding a lot of blood loss from the body what will happen the blood pressure of the patient will go down the blood pressure of the patient goes down and that is what is called as hypotension definitely the patient's blood pressure will go down and that is what is hypertension now if there is hypotension okay if the blood pressure is too low will the organs receive enough amount of blood no the organs will not receive enough amount of blood another organs go enough amount of blood what will the heart try to do the heart will try to compensate and how does the heart compensate so the heart will try beating faster as the heart starts beating faster what will happen definitely the heart rate of the patient will increase so to overcome the decreased blood supply to the organs the hard starts to compensate the heart starts beating faster and that is the reason why if a patient is having too low blood pressure the patient will have a reflex tachycardia the patient has a reflex tachycardia and if the patient is having low blood pressure that is hypotension along with a reflex tachycardia that is increased heart rate both of these signs are suggestive of shock both of these signs are suggest you of shock right so if there is low blood pressure that is hypertension and increased heart rate that is tachycardia both are signs are actually of shock so definitely if you even if you are not able to see external bleeding you need to check the vitals of the patient and if the patient is lining up in shock that is an indicator that the patient might have some internal bleeding or some conceived bleeding okay so that's the most important thing you need to remember over here okay so that's one thing that we need to discuss and we will discuss about shock in details further definitely don't worry about that right apart from that if there is a cut to the artery now how the blood will come out if there is a cut to the artery if I give a cut over the artery the blood will come out with every pulsation there will be more blood coming out during every pulsation why because we know in an artery there are stronger pulsations therefore if there is a bleeding or Hemorrhage from an artery there will be stronger pulsations right so the blood will come out with every pulsation so if there is a jet-like pulsations the bleeding is seen as jet-like pulsations that is what is suggestive of an arterial breed next if there is a continuous bleed there is no jet-like pulsations if there is a continuous bleed please remember if there is a continuous bleed then definitely that is what is suggestion of a venous bleeding right because veins does not generally have pulsations other veins May pulsations so if there is a continuous bleed which occurs without any jet like pulsations that is what is suggestion of a venous bleed the third type of bleeding is usually from the small small vessels of your body the smallest vessels of your body are what are your capillaries and if there is damage to the capillaries for example if I only give a superficial cut but okay if I give a superficial cut the capillaries will be damaged and then there will be a generalized oozing of blood there will not be massive bleeding which comes there will only be minimal amount of bleeding and that is what is called as a generalized Foods so if tension generalized ooze definitely please remember that is what is suggestion of a capillary Hemorrhage or a capillary bleeding so don't worry Depot I am using both the languages I'm translating it okay but we need to be considerate about all other peoples who cannot understand Hindi as well right so I need to talk in both the languages yes I'm talking in both don't know languages don't worry about that don't think don't have a fomo that you are missing out on something no now these was about the general types of breeding now if I talk about the surgical bleeding or surgical Hemorrhage if I talk about surgical bleeding or surgical Hemorrhage that means any bleeding or any Hemorrhage which occurs during surgery or after surgery these are called as surgical bleedings or surgical Hemorrhage bleeding that is what is a surgical bleeding or a surgical Hemorrhage now these surgical bleedings are classified into three types there can be three types of surgical Hemorrhage the first one that we have is called as a primary surgical humor the first one we have is called as the primary surgical Hemorrhage what do I mean by primary surgical hemorrhage any bleed please remember any bleed which occurs during surgery any bleed which occurs during surgery is known as a primary Hemorrhage surgery that is what is the primary Hemorrhage so that you need to remember any bleed which occurs during surgery that is what is the primary Hemorrhage what is the cause if we are performing a surgery okay what happens usually with a sharp instrument there can be injury to some of the artery or there can be injury to some of the vessel he can then definitely the bleed which is there it is known as primary Hemorrhage so what is the primary Hemorrhage and shot usually when we were performing a surgery there was some injury to a vessel in the surgical site and that is causing a breed that is what is the primary Hemorrhage that is what is primary image what is the cause now if there is injury to the bleeding vessel that bleeding vessel is known as a breeder so the cause of a primary Hemorrhage is usually a breeder now what is the treatment as we have the surgical site open in front of us we have the surgical site open in front of us so what should be the treatment but definitely the treatment is just like it this bleeding vessel we need to perform a ligation of the bleeding vessel or if the bleeding vessel is very small or if the bleeding vessel is very small we can just use the cautery that is what is called as cauterization so either we can go for ligation of the breeding vessel or we can go for cauterization of the breathing vessel okay so that's what about your primary humerus you need to remember next one is called as the reactionary Hemorrhage what is the reactionary Hemorrhage on the other hand so please remember reactionary Hemorrhage is any bleeding it is any bleeding which occurs okay any bleeding which occurs within 4 to 24 hours of surgery any bleeding which occurs within 4 to 24 hours of surgery okay so that's the important thing please remember any bleeding which occurs after four hours till 24 hours of surgery that will be considered as reactionary Hemorrhage till 24 hours that will be considered as reactionary Hemorrhage now what is the cause of reactionary Hemorrhage usually at the end of surgery at the end of surgery you took sutures okay and after taking the sutures you finally tied a knot okay to secure the sutures you finally tied a knot that guard is what is called as a knot okay so you have tied a knot but instead of tying a secure knot instead of tying a secure or not you have tied a insecure knot okay and what is the what do I mean by insecure or not a knot which can slip off easily is known as insecure knot insecurity and therefore it has slept off easily so important is what is the most common cause of reactionary Hemorrhage if they ask you what is the most common cause of reaction Hemorrhage is what is the slippage of knot or a slippage of ligature okay so most common cause of a reactionary Hemorrhage will be Shield page of a knot or slippage of a light nature okay apart from that what can be another cause of reactionary Hemorrhage so you need to remember during surgery we ask the anesthetist to maintain the blood pressure on the lower limit of normal we ask the anesthetist to maintain the blood pressure on the lower limit of normal to avoid any excessive bleeding during surgery blood pressure lower normal why to avoid any excessive bleeding during surgery so after the surgery is over after the effect of anesthesia is gone after the patient comes out of anesthesia there will be sudden spike in the blood pressure of the patient after the influence of anesthesia gets over there can be a sudden spike in the blood pressure and that is due to reflex vasospasm and that increased blood pressure after surgery can also be a important sudden increase in blood pressure after surgery can also cause reactionary Hemorrhage now here the patient is going to present to me with excessive bleeding or minimal bleeding so here after surgery the patient is going to present to me with a massive bleeding okay so the patient is going to present to me with massive bleeding in a case of reactionary Hemorrhage yes the other cause can be dislodgement of clot 2. now what should be the treatment over here please remember the treatment in this condition is we cannot manage this patient in the emergency room we need to take this patient to the operation theater so take the patient to the OT take the patient to the operation theater and re-explore the surgical site that is what is called as re-exploration so re-exploration of the surgical site should be done you need to find that actually which vessel at the surgical site is bleeding and then go for re-ligation again like it because the suture has come off now will not have come off therefore you need to again re-like it so re-exploration and re-legation at surgical site is what is done in cases of reactionary Hemorrhage the next the third type of hemorrhage is known as secondary Hemorrhage another type is known as secondary Hemorrhage what do I mean by secondary Hemorrhage secondary hemorrhages any bleed which occurs 24 hours after surgery any bleeds which occurs usually 24 hours of surgery it is known as secondary hemorrhage you will say okay so we have read in a lot of books that usually secondary Hemorrhage is the one which occurs after few days of surgery yes because majority of cases are 90 cases of secondary Hemorrhage present to us after five days of surgery okay so majority or 90 of the cases of secondary humerage present to us after five days of surgery okay so commonly most of the books write or Define secondary Hemorrhage or any breed which can occur after after five days of surgery no issues with this that's important what is the most common cause of secondary Hemorrhage now if they ask you what is the most common cause of secondary humerage your answer should be infection the answer should be infection where infection at the surgical site okay so infection at the surgical site or a surgical site infection is a cause of secondary Hemorrhage so we'll see so how due to an infection the patient can bleed yes the patient can bleed how because the infection will start damaging the blood vessel wall okay it will start eroding or damaging the blood vessel wall so infection blood vessels and due to which the patient is bleeding secondary Hemorrhage here the blood vessel wall is completely open or what no in reactionary Hemorrhage the blood vessel wall was completely open due to slippage of ligature but over here the blood vessel wall is not completely open there is only some damage to the blood vessel work so here the patient will not have massive bleeding rather the patient will come to you only with mild bleeding or minimal bleeding so important is that please remember here the patient only complains of mild or minimal bleeding that is what is your keyword you need to pick up in the question okay so it is the time of presentation second is the type of bleeding and third they might give you about the cause as well now what is the treatment of secondary Hemorrhage so treatment of secondary image if infection is the cause treatment will be definitely antibiotics but antibiotics should be given orally or IV definitely the antibiotics should be given IV and for IV antibiotics we know that the patient should be admitted as well because in one of the previous year questions the question was will you give IV antibiotics and the other option was admission plus IV antibiotics what is the better answer now you know so it is admission plus IV antibiotics because antibiotics are never never given IV antibiotics are never administered or never given on an OPD basis they are always administered or only is given in an ipd basis so these are the important types of surgical Hemorrhage you need to be aware of please remember this trigger so this is very important and a very commonly asked question from ENT as well as surgery okay so they commonly ask you about the reactionary Hemorrhage that is your top most favorite and second is the secondary humidation they're not interested about talking about the primary Hemorrhage they are more interested talking about or asking you about the reactionary or the secondary emerge moving further now please answer this question which you can see over here this was a previous year question of fmge as well as your need pj examination and what was that question a patient and event hernioplasty okay and post-operative period was uneventful what do I mean by uneventful for those who don't know uneventful that means without any complications okay he presents on post of day seven the patient presents you after post operative day seven with complaints of minimal bleeding see he is presenting on post of day seven and the complaint is only minimal bleeding from the surgical site what is the cause and what is the treatment make a provisional diagnosis which type of hemorrhage is it make a provisional diagnosis which type of hemorrhage is it primary reactionary or secondary so definitely what I've highlighted are your keywords to be in found in the question as the patient mentions that the bleeding is occurring after post operated day five that means it is the case of which bleeding anybody it is a case of secondary bleeding very good it is the case of secondary bleeding or a secondary humerage very good and what should be done so we know secondary Hemorrhage or secondary bleeding is usually due to infection therefore the treatment should also be IV antibiotics but IV antibiotics are always administered after admission so admission plus IB antibiotics okay done with the concept no issues with this and that's how you need to answer your questions not reactionary not reactional reactionary then the patient would have presented to us within 24 hours of surgery here the patient is presenting to us after post of day five so it is a case of secondary Hemorrhage now talking about once if the patient is having excessive bleeding once if a patient is having excessive bleeding what we are going to give the patient definitely we need to give the patient blood and that is what is called as blood transfusion so we need to administer blood to the patient that is what is called as blood transfusion now take example if a patient is suffering from Dengue hemorrhagic fever okay and in cases of dengue hemorrhagic fever we know that the patient's platelet count goes very low so in cases of dengue patients come that condition is what is called as thrombocytopenia so in a case of thrombocytopenia will you like to give only platelets to the patient or will you like to give whole blood to the patient definitely we will only like to give platelets so definitely does not require any other components of blood he's only suffering from thrombocytopenia so you give only platelets so for that reason please remember usually in blood banks what is done we will store whole blood definitely but we also isolate some other components of the blood as well so whatever is required we can only administer that component of blood to the patients okay you do not require every other component of blood in every patient okay so that's the reason why we have various blood components if I talk about these important blood components first is whole blood whole blood that means we collect the blood from the donor we store it and we directly definitely after grouping and cross matching we will give it to the recipient okay we will store it in the pure form we are not isolating any component in it so yeah that is the whole blood one unit of whole blood now one bag you can say or one unit you can see the one unit is written as like this so one unit of whole blood contains how much amount of blood and that has been asked so one unit of blood contains around 350 mls in India whereas 450 Ms in the USA one unit of blood contains around 350 to 450 mL of blood important is that you need to remember and when do we need to give whole blood to the patient so usually whole blood is given to the patient in cases of excessive blood loss okay so usually in the cases of excessive blood loss we need whole blood in the patient okay we need whole blood usually in cases of trauma usually in cases of trauma definitely we need whole blood to be given in the patient then if I talk about the second component of blood okay next if I talk about second component of blood is packed or BC if I talk about pact RBC please remember packed rbcs here we try to isolate the rbc's mainly as there is liquid also but we try to mainly isolate the rbcs in the patient at obese is one unit of path or BCS contains around 250 MLS of blood one unit of path RBC contains around 250 ml of blood and when a packed RBC is administered to the patient definitely packed our BCS are given to the patient see nowadays commonly we give packed rbcs to most of the patients in case of blood loss also or in cases of trauma also but if packed rbcs are not available less than seven okay so six to eight some book say six to eight is Norm uh six to eight is moderate anemia so less than six but majority of the books say hemoglobin value less than seven is considered to be severe anemia and if a patient is having hemoglobin value less than seven that means the patient is suffering from severe anemia and we need to give Pat rbcs to the specific patient take it that's important next component of blood is what is called as fresh frozen plasma next component of blood is known as fresh frozen plasma also we commonly refer it to as ffp the fresh frozen plasma important is fresh frozen plasma one unit of fresh frozen plasma usually consists of how much ml of blood so it usually consists 150 ml volume one unit contains 150 ml volume please remember so that's important and important to one liners about fresh frozen plasma that you need to remember so fresh frozen plasma is the richest source it is the richest source of all clotting factors please remember okay so fresh frozen plasma is the richest source of all clotting factors all every other chronic factors present in fresh frozen plasma okay so friction source of all clotting factors if they ask you answer is same it is ffp or fresh frozen plasma next is as you can see in the name itself they have mentioned Frozen if it is frozen that means it will be not stored at the temperature at which other blood components are stored it is usually stored at freezing temperature is freezing temperatures so what is the temperature of storage for a fresh frozen plasma it is stored at minus 42 degree Centigrades it is stored at minus 42 degree Centigrades please remember that okay so it is stored at freezing temperatures definitely it is stored at lower temperatures like minus 42 degree Centigrades next is platelet-rich plasma platelet-rich plasma mainly contains only the platelet okay so it is also known as platelet concentrate a lot of times so platelet-rich plasma producers platelet concentrate also later rich plasma one unit of platelet-rich plasma contains approximately around 50 mL of platelets one unit of PRP contains around 50 MLS of platelets and by the name it is evident it is the richest source of platelets definitely and important is the question has been and all of you are going to answer please remember below minus 30 degree below minus 30 degree usually the refer recommended temperature is minus 42. that's the important thing so usually platelet-rich plasma or plated concentrate is usually given to the patients please remember it is usually given to the patients like in case of dengue or any condition which will cause low platelet ground and what is that condition known as thrombocytopenia so any patient who is suffering from thrombocytopenia like a case of dengue hemorrhagic fever or it can be a case of ITP that is idiopathic or immune thrombocytopenic purpura okay because thrombocytopenic now so that means the patient is suffering from low platelet count and important is all of you are going to answer this now platelet-rich plasma or platelet concentrate is stored at what temperature it is stored at what temperature and that has been a previous year question in your examination a very important component okay so please answer it platelet-rich plasma platelet concentrate is the only component which is stored at how much degree temperatures please let me know that next is cryoprecipitate okay so cryoprecipitate freezing so again cryoprecipitate is also stored at freezing temperature and what is that freezing temperature the temperature is again same as around the fresh frozen plasma it is around minus 42 degree Centigrade important you need to remember is cryoprecipitate is the richest source of two important clotting factors trioprecipitate is the Richer source of two important clotting factors one of them is clotting Factor number one okay that is fibrinogen so it is richer source of caroting factor number one that is fibrinogen and second is carotene Factor number eight the second one is known as clotting Factor number eight so please remember cryoprecipitate is the Richer source of clotting Factor number one and eight and when do we require clotting Factor number eight mainly when there is deficiency of clotting factor 8 and deficiency of clotting factor 8 is usually seen in a condition and that is what is called as hemophilia so please remember if they ask you richer source of all clotting factors your answer is ffp or fresh frozen plasma but if they ask you richer source of clotting Factor number one and eight then your answer is cryo precipitate and when do we give cryo precipitate when there is deficiency of these two clotting factors usually we give usually 10 cases of hemophilia or we can also use it in cases of born wilbra indices we can also use it in cases of f PPH that is postpartum humerus as well in multiple other conditions it can be used and one unit of cryoprecipitate contains 15 mL of clotting factors it contains 15 mL of clotting factors very good very good very good Mohit very good vineeth okay all of you are right please remember platelet concentrate or platelet-rich plasma is the only component of blood which is stored at room temperature it is stored at room temperature and what is that room temperature it is between 20 to 24 degrees Celsius it is between 20 to 24 degrees Celsius and that is the important thing to be remembered no issues with this that has been a p-bike moving further now moving further talking about the next important one-liners about blood donation if I talk about blood donation guys definitely if you need to transfuse blood if you need to administer bread from here that process of blood collection is what is blood donation because blood cannot be prepared in the laboratory it has to be donated always so if I talk about blood donation these are the important one liners you need to be aware of now first one that was asked was one unit of blood contains how much amount of blood that we have already discussed one unit of whole blood contains around 350 to 450 mL of blood one unit of whole blood contains around 350 to 450 mL of blood next now while blood transfer your blood donation or is done during blood donation a bigger needle is used okay a bigger needle is used definitely and what is the size of that needle okay what is yes it is enough for fmg most of the notes don't even cover these topics that I'm covering over here please remember that okay most of the nodes don't and that is like I can assure you that okay you can check in most of the notes you will not find most of the things which are covered okay I'm trying my best to cover each and everything in a very short span of time so the size of needle which is preferred for blood donation it is usually a bigger needle bigger diameter is required and that is what is 16 gauge needle it is a 16 gauge needle which is used that was a pyq next which near which vein is preferred for blood donation so you might have seen if you have donated blood that the big needle is inserted over here at the level of the cubital sposa and that vein is what is your median cubital Wing the preferred win for blood donation is your median cubital beam it is the median cubital Wing largest board is definitely 14 gauge but the preferred one is the 16 gauge needle that we used and the preferred vein is the median cubital vein for blood donation next now once we have inserted the needle definitely we have a set or a tubing which is connected and then why are that tubing the blood will go and it is collected in a pre-sterile plastic bag that presterile plastic bag contains some amount of anticoagulants so why do we require anticoagulants in the patient because if anticoagulants are not present in the plastic bag definitely what will happen the blood is going to clot okay and we don't want the blood to be clot okay so that's the reason why we have some anticoagulants in the pre-sterile plastic bag in which the blood is collected the anticoagulants that we generally use is either called as CPD that is citrate phosphate dextrose CPD or the another one that we have commonly is known as cpda that is citrate phosphate dextrose acetate okay what is different in both of them the basic difference between both of them is definitely the shelf life okay shelf life is the duration okay so it's like the shelf life of CPD that we need to know here it is around 21 days that is three weeks the shelf life of CPD is around 21 days or three weeks okay whereas if I talk about the shelf life of cpda it is around 28 to 35 days it is around 28 to 35 days that is around 4 to 5 weeks so that's the important thing please remember usually when so blood can be stored in the blood bank for a period of around 35 days to maximum 42 days why because after 35 days the anticoagulants will be finished okay and if the anticoagulants are finished in the bloodbath definitely the blood will start clotting coagulants therefore blood could not be stored for more than one and a half months in the blood bank that's the maximum so what is the size of filter now so what do I mean by the size of filter a lot of times you might have seen in the hospitals as well that normally if we give fluids like wrinkle lactate or normal slime they are given with a normal IV tube okay they are given with a normal sorry IV tubings or IV line but if we need to give blood to a patient we do not use a normal IV line right we do not use the normal IV line or the IV set we need a specialized set and that specialized ID set used for blood transfusion is known as the BT set that specialized set used for blood transfusion is known as the BT set while it is special because it contains a filter it contains this filter okay and they are they are asking you the size of the filter okay so the size of the filter which is present in the BT set that filter is also known as leukor reduction filter that filter is also known as leuko reduction filter and if gluco reduction filter is used the chances of transfusion reactions will go down during blood transfusion the chances of infections transfusion reactions will go down the size of filter you need to remember it is around 40 microns the size of filter used in a BT state is around 40 microns next if I talk about the temperature of storage so the blood when it is collected then the blood bag is stored at what temperature so important is the blood back is usually stored at plus 4 degree celsius so the blood back is usually stored at plus 4 degree Centigrades that's important plus minus two that means if they ask you the range it will be between 2 to 6 degree celsius so yeah that now if you need to answer best definitely the single best answer will be plus 4 degree Centigrades but if they ask you the range it is between plus two to plus 6 degree Centigrades please remember that okay next if they ask you what is the shelf life of RBC shelf life is nothing but the duration or the lifespan so the lifespan of RBC is normally we know the lifespan of RBC is within the body is how much the lifespan of RBC is within the body is around 120 days the lifespan of RBC is within our human body is around 120 days but if they ask you the lifespan or the shelf life of rbcs in a stored blood if they ask you the lifespan or the shelf's life of our bases in a stored blood it is as low as 24 to 72 hours when when the temperature of the blood is not maintained so important is why do you need to maintain the temperature of the blood otherwise if you did not maintain the temperature of blood between this two to six degree Centigrades the rbcs will start undergoing destruction that means hemolysis is going to occur okay so usually if the blood temperature is not maintained it will only live up to around 24 to 72 hours maximum it can live up to around 42 days if the temperature is maintained and if they ask you the shelf life of RBC is in a transfused blood if they ask you shelf life of RBC is in transfused blood please remember then your answer should be around 50 to 60 days in a case of transfused blood the shelf's life of RBC will be around 50 to 60 days okay so that is the important thing you need to remember next is what is the most common complication of blood transfusion okay what is the most common complication of blood transfusion the most common complication of blood transfusion is usually a transfusion reaction the most common don't worry we will discuss what transfusion reactions are the most common complication of blood transfusion is a transfusion reaction there will be some kind of reaction which will occur after transition reactions that is what is the transmission reaction they can be of various types so you need to remember the basic term that is transfusion reaction now important question which has been asked in the recent fmg as well as need PG examination and the question was sorry when the blood is collected it is screened for all of the following diseases except and that was the question so now we need to remember that for which of the following diseases or work for which of the following infections we are going to screen the blood after collecting it so once we have collected the blood we are going to screen it for which particular diseases or which particular infections are you going to screen it for measles are you going to screen it for polio please let me know that okay so please let me know that jaldi said are you going to screen it for measles or are you going to screen it for polio delete it let me know in the chat box are you going to screen it for Hepatitis A beneath are you going to strengine for Hepatitis A so important is measles as I've told you measles spreads by which root measles spread by respiratory root or air droplet root again next is polio polio spreads by which root it spreads by fecal oral root and I hope all of you are quite aware that Hepatitis A and hepatitis E both of them also spread by FICO oral root so if they're spread by fecal oral root do we need to check or do we need to screen the blood no definitely no screening is required if the infection spreads by respiratory or air droplet root or if the infection spreads by fecal oral root we only require screening for those kind of infection or those kind of diseases where there is a risk of spread from the blood root or from the hematogenous fruit Joe infections and what are those infections definitely the most important one being HIV we screen the blood for HIV one as well as HIV two both of them second one is definitely Hepatitis B okay because it spreads by blood root next is Hepatitis C okay next is a important is Hepatitis C the next one that you need to remember is malaria because definitely malaria can also spread via blood okay because we know the active or the infective forms can be there okay so that's important and definitely in some countries or in some blood banks they also screen for the fifth infection of the fifth disease and that is what a syphilis not all blood banks will screen for syphilis but yes if they ask you now which among the following infections do we screen before blood transfusion all of the following except so options are hepatitis A Hepatitis B hepatitis C and syphilis here you know now the best answer is Hepatitis A because it does not spread by a blood root so no screening should be done before blood transfusion for Hepatitis A great so that was a previous previous year question you need to remember these important infections for which screening is done before blood transfusion great next is talking about the transfusion reactions if I talk about the transfusion reactions as I've told you it is the most common complication after blood transfusion which is the most common transfusion reaction you need to remember so the most common transfusion reaction and a lot of people are not aware with this name that name you need to remember it is f and Str what do I mean by fnstr in simple terms F and Str is nothing but the full form is febrile non-hemolytic transfusion reaction so they will play with you with this term definitely right because it is a fancy term so important is you need to remember the most common transfusion reactions which occur after blood transfusion is fnstr that means nothing else but febrile non-hemolytic non-hemolytic Matlab RBC destruction is not occurring there is no hemolysis koi RBC destruction only it is a febrile reaction what do I mean by febrile febrile febrile means fever okay so febrile non-humolitic translation reaction also known as simple febrile reaction or simple pyrexial reaction so that can be the option or usually they give this option in the choice that is febrile non-hemolytic transfusion reaction you need to remember this properly no issues with this anybody that's the important thing to be remembered okay so usually that's the reason why once we have started blood transfusion in a patient we ask the patient after every now and then do you feel any fever are you feeling feverish that's the important thing because the most common transfusion reaction after blood transfusion is fever next transfusion reaction is severe one fever was a mild transmission reaction but a severe form of transfusion reaction is that as incompatibility what do I mean by Avo incompatibility so incompatibility is also known as mismatched BT or a mismatched blood transfusion incompatibility is also known as mismatched ability or mismatched blood transfusion that's important okay so mismatch blood transfusion means what do I mean by this so if a patient was having a blood group a positive if a patient was having blood group a positive and you have given which blood to the patient you have given the blood which was B positive you have given him a blood which is B positive what can happen now as the patient is a positive I hope all of you are quite aware this a positive blood group is decided by the antigenes which are present on the surface of the RBC your antigenes RBC is whatever it is okay so definitely these surface antigen in a case of a positive blood group is usually a antigen and if a patient is having a antigen on the surface of rbcs what antibodies will be present in him the patient normally has B antibodies in his blood now you are giving a B positive blood group and the B point positive blood group is having which type of rbcs the rbcs which are having B antigen on their surface as soon as you give B positive blood to a patient who is having a a positive blood group all these B and T bodies which are present in the patient are going to Target these antigens all these B antibodies which are present in the patient's blood are going to Target these rbcs which are having a b antigen on their surface is excessive hemolysis in the patient and that is what is called as your Avio incompatibility or a massive sorry mismatched blood transfusion please remember no issues with this anybody so I'm using every everything don't worry about that I am trying to use every each and everything English please ask me okay pyrexia means fever pyrexation simple terms means so incompatibility is also known as mismatched blood transfusion or mass masturbating please remember that okay and we know how it has happened now so usually incompatibility or mismatch ability is usually which type of transfusion reaction mainly if you need to answer single best because some amount of histamine is also relieved and some kind of anaphylaxis is also seen but better answers type 1 or type 2 may say so answer should be a type 2 hypersensitivity reaction okay so please remember you have completed your patho so please remember incompatibility or mismatched blood transfusion is which type of hypersensitivity reaction it is a type 2 hypersensitivity reaction next is what is the most common cause of incompatibility so the most common cause of incompatibility you need to remember is usually a clerical error that means we made some mistake okay yes the healthcare professionals so definitely there was some mistake while collecting the blood or while naming the blood okay or while checking the blood group or while doing a cross matching so that definitely you are not wrong you said that we want a a positive blood but what happened in the blood bank the technician who was there he gave you the B positive blood and then after that what did you do you administered the B positive blood without checking twice and that has caused the ABN compatibility that is what we mean by clerical error most common symptom as usually most common symptom after a smashed blood transfusion or after above incompatibility you need to remember usually here are the patient symptom is what the patient will complain of sign is what that we will examine as an examiner or a clinician symptoms the most common symptom you need to remember is usually pain and heat sensation along the wheel the patient will have pain and heat sensation along the wind what is the most common sign now as an examiner what is the most common sign definitely if there is a mismatched blood transfusion all of these antigen antibody complexes which are formed these antigen antibody complex job all of these antigen antibody complexes or immune complexes they will go to the kidneys they will go to the kidneys and they will block the small small capillaries of the kidneys known as glomerulus all these antigen antibody or immune complexes will block the small small capillaries of kidneys and that will cause decrease urine output and decreased urine output is what is called as oliguria so oliguria in simple terms is decreased urine output so oliguria is less than 400 MLS per day of urine output that will be seen if that is not an option the second best answer will be hemoglobin urea the second best answer is hemoglobinuria you will see a dark or a red color urine in the patient dark brown or a red color urine can be seen in the patient if that is not an option then you need to mark it as tachycardia next is what is the most common sign in an anesthetized patient in an anesthetized patient if they ask you then it is generalized oozing of blood anesthetized patient that means we are operating on the patient home surgery patiently so therefore he is under anesthesia so if most common sign of mismatched blood transfusion is usually generalized oozing of blood while you are performing a surgery you will see that blood is coming out from all the vessels okay so that is what is a side important sign in a case of anesthetized patient of a mismatched BT or of incompatibility what should be the treatment definitely what should be treatment you are transfusing wrong blood to the patient immediately stop the BT okay so first line management will be immediate elimination or you can say immediately stop the BT immediately stop blood transfusion in the patient and then to avoid further any complications in the patient then to further avoid any complications in the patient definitely you need to give three important drugs to the patient okay the first one definitely you need to give injection of steroids and the preferred steroid that we use that is what is a hydrocort or hydrocortisone okay second drug that we usually give in the patient is I will an evil you might have heard a lot of times so evil is nothing else but antihistaminic drug because as I've told you there will be a release of histamine also in cases of Abu incompatibility so due to that we will give also antihistaminic drug known as evil that is known as pheneramine the generic name is pheneramine and the third one that we give is usually diuretics why because the most common sign was oliguria or decrease urine output that's the reason why we need to increase the urine output by giving diuretics in the patient and once you have done that please send all the blood back all the tubings with which you are transfusing the blood okay and the blood sample of the patient immediate to the blood bank and ask the technician for regrouping and re-cross matching okay ask the patient pass the blood bank technician for regrouping and cross matching okay so maybe blood back teeth and definitely blood sample patient ask the technician to regroup and Cross Match it next is massive BT or massive blood transfusion if I talk about massive blood transfusion what do I mean by massive blood transfusion the definition says replacement of whole blood volume okay and how much is around whole blood volume it is around 5 liters to 6 liters maximum okay so how much units will be five liters it will be around approximately 10 units so either the definition of massive blood transfusion will be replacement of whole blood volume or transfusion of 10 units within a span of 24 hours that is what is massive PT okay replacement of whole blood volume or transmission of 10 units within a span of 24 hours or the other definition can be replacement or transfusion of four units of blood within one hour okay replacement or transfusion of four units of blood within a span of one Earth yes normally one unit takes four hours recommended time for transmission of one unit of blood is around four hours we should give blood transfusion at a very very slow rate okay so it is usually one unit of blood should be transfused in a span of four hours but if we are giving four units in a span of one hour when do we require such a massive blood transfusion usually when a patient is having excessive or a massive blood loss in cases of trauma when the patient is an hypovolemic shock your patient hyperbolic shock at that time we need massive blood transfusion next is you need to give all of these things you need to give prbc that is packed rbcs to the patient you need to give ffp that is fresh frozen plasma to the patient and you need to give PRP that is plated rich plasma to the patient why now you will say sir we understood why prvc is given in a case of blood loss but why are we giving ffp and PRP to the patient separately the reason is please remember if you only give prbc to the patient if you are only giving prbc to the patient you will cause hemodilution what will happen it will be dilution of the blood because you are only giving prbc is it containing does it contain carotene factors no rotting factors are very minimal in a paste in a case of prbc Earth rbc's Map carotene factors so what will happen there will be hemodilation there will be dilution of blood dilution of blood that I mean there will be very less amount of clotting factors and if there are various amount of clothing factors definitely the bleeding of the patient will stop or it will increase if if there is less amount of clotting factors clot will not be formed and a clot is not formed definitely the bleeding of the patient will increase further okay and that is what is called as coagulopathy one of the deadly complications in a case of trauma and that is what is DIC that is disseminated intraascular coagulation so the patient can land up in coagulopathy if you only give prbc to the patient that's the reason why we need to give three components the RBC ffp and PRP and they should be given in a ratio of 6s to success to six so if we need to give massive blood transfusion we need to give six units of prbc 6 units of fresh frozen plasma and six units of PRP fresh frozen plasma and PRP are generally given to prevent any coagulopathy either bleeding patient okay so that's important now if they ask you what is the most common complication of a massive blood transfusion you are giving so much amount of blood to the patient in a very short duration of time so what can be the most common complication the most common complication usually is known as CHF what do I mean by CHF congestive heart failure what is congestive heart failure excessive amount of blood is given to the patient excessive load excessive volume load is given to the patient TK so if there is higher volume or there is a volume overload in the patient that will land up the patient into congestive heart failure patient may you have given so much amount of blood to the patient that his heart is not able to handle his heart is not able to handle this much excess amount of blood and therefore the heart is not able to pump and if the heart fails to pump that is what is called a CHF congestive heart failure due to excess of volume of blood the heart fails to come that is what a CHF is it seen in every patient no volume overload will only be seen in patients who are not able to handle excess amount of volume of blood and that is usually anemic patients or elderly patients that is usually anemic or elderly patients because their body or their heart will not be able to handle excess amount of blood blood okay another complications you need to remember now definitely we know blood is stored at how much degree temperature it is stored at plus 4 degree Centigrades but important is can we give directly the uh can we give them the blood directly to the patient no we cannot give blood directly at four degree Centigrades why because if you give a cold blood to the patient definitely the patient will land up into hypothermia normal pressure normal temperature of our body is how much the normal temperature of our body is 37 degree Centigrade so 37.5 degree centigrade to be specific if you are giving blood which is at 4 degree Centigrade the patient is going to land open to hypothermia that will not be seen usually please remember that will not be seen when the patient is having sorry that will not be seen when you need to only transfuse one unit of blood yet when you have enough time in your hands you can properly warm up the blood and how is warming of blood done warming of blood done forming of blood is done by wrapping up the blood back into a blanket you wrap up the bloodbug in a blanket and you keep it usually for a span of half an hour the recommended time for warming of blood is usually half an hour you should not warm the blood for more than two hours why because if you warm the blood for more than two hours the patient is going to land up into infections because if the temperature of blood increases too much definitely the bacterial activity increases and the patient will have a lot of infections but hypothermia caboga when the warming is less than half an hour when the warming of blood is done for less than half an hour definitely the patient can land up into hypothermia and when is hypothermia commonly seen in a regular blood transmission or massive blood transfusion definitely in a case of massive blood transfusion it is commonly seen why is so much of blood will you have enough time in your hands to warm every blood bag no so a lot of time what happens we don't live we don't let every blood back to warm and therefore a lot of times the patient can land up into hypothermia okay so if warming is done for less than half an hour if warming is done for less than half an hour the patient will definitely land up into hypothermia there can be other complications as well I am just enumerating it important is there will be excess destruction of rbcs and due to extra destruction of rbcs what is present which iron is present within a cell or within the RBC potassium so if there is excess hemolysis excess destruction of RBC all this potassium is going to be released into the blood that means definitely the patient will have hyperkalemia as well the patient will have increased potassium values in the blood that is called as hyperkalemia as well and that can lead to arrhythmias in the patient as well that will lead to arrhythmias in patient apart from that only potassium is the ion which will increase okay only potassium is the iron which increases otherwise the patient has hypocalcemia the patient has hypomagnesemia the patient has hypophosphatemia why because all of these ions will decrease in amount because they are going to bind to the citrate and where was citrate citrate was present in the anticoagulant so that all these ions which are there calcium magnesium phosphate they are going to bind to that citrate or to that anticoagulant therefore their values are going to go down definitely only one that increases is potassium please remember that no issues with this anybody important after a massive blood transfusion two important questions I'm going to ask you after massive blood transfusion first case case number one after massive BT the patient is complaining of respiratory distress the patient is having increased jugular venous pressure the patient is having edema throughout the body the patient is having facial edema the patient is having Peter edema as well and the patient is having respiratory distress what is your diagnosis in this condition anybody what is your diagnosis a patient complains of all of these symptoms after massive BT what is the complication that you are suspecting anybody answer it definitely it is not cardiac tamponade it is CHF but very good CHF that occurs after massive blood transfusion CHF that occurs after massive blood transfusion cardiac tamponade can occur after injury usually or when there is massive pericardial effusion I have not given you any signs of cardiac tamponade as such cardiac tamponade depletion's blood pressure goes down okay there is also muffled hard sounds I did not mention about any muffled heart sounds no I did not mention about the complete backstride nope yes not only right-sided but also the left-sided heart failure you know right sided heart failure you have suspected because the patient was having facial edema and pedal edema okay and race jvp but I also mentioned one thing about left ventricular failure and that was respiratory distress because there was pulmonary edema in the patient the patient was having respiratory distress so it is definitely a CHF that is congestive heart failure so a CHF which occurs usually after massive blood transfusion it is usually taco and that taco is what is called as transfusion Associated circulatory overload a transfusion Associated cardiac overload and the treatment for taco we know now the treatment for Tyco should be diuretics in the patient because there is excess of volume inside your body excess of blood volume you have given to the patient you need to get rid of that excess blood okay that is what is done by diuretics next important question that I want to ask you a patient after a massive blood transfusion now is only complaining of severe respiratory distress and maybe his saturation is falling down a patient after a massive blood transfusion is only complaining of severe respiratory distress his saturation of oxygen is falling down and the X-ray the chest x-ray is usually showing a ideas like features okay that is ground glass opacities in both balance okay the chest x-ray is showing AIDS like features that is hopefully I am audible to all of you the ideas like features are seen okay so what is your diagnosis now answer it faster what should be your diagnosis now only respiratory distress saturation is falling and just x-ray showing ards like picture not left heart failure usually left heart failure there will not be a ards like picture there will be patchy infiltrates pulmonary edema causes patch infiltrates the whole lungs are white very good it is lung injury beneath very good and that lung injury is called as trolley that is called as trolley transfusion related acute lung injury very good transfusion related acute lung injury so two things that will help you differentiate a taco and trolley Taco May the patient uh two things that will help you differentiate both of this first is the chest x-ray and second is your BNP level so that is B type natural uretic levels okay so chest x-ray will show cardiac enlargement in cases of Taco but there will be a normal cardiac shadow in case of trolley second is BNP levels BNP levels are elevated in cases of Taco because it is a CHF but BNP levels are normal in case of trolley so that's the important thing okay and if there is acute lung injury definitely we need to give ventilation to the patient in erds do we give high volume ventilation or a low volume ventilation low volume why because the lungs are already injured will you like to injure the lungs more by giving high pressure ventilation no we will give low volume ventilation that means oxygen is given to the patient but at 6 liters per minute not at around 12 to 15 liters okay we will give low volume ventilation to the patient okay so that's the important thing chest x-ray and BNP levels will help you differentiate between both of these again now moving further now talking about once we have done with the blood transfusion now talking about surgical positions if I talk about important surgical positions guys if I talk about important surgical positions I'm doing short after this okay don't worry about that I'll talk about shock properly now if I talk about surgical positions guys so these are important surgical positions yes yes rally is due to anti-actional antibodies so this first surgical position that is position number a here you can see the OT table the foot end and the head end are both at the same level okay and the patient is facing upwards this is what is called as a Supine position and we know Supine position is the most common position during a surgery so Pine is the most common position during a surgery important okay for all abdominal surgeries or breast surgeries you will prefer this position that is your Supine position for all abdominals and breast surgeries you prefer this position no issues with this anybody next one that you can see this has been asked to you in the examination the foot end of the OT table is elevated that is elevated the foot end of the OT table is elevated and this position is known as the trendel and Bug position this position of surgery is known as the trendel and Bug position and we know Trendelenburg position is usually preferred for which kind of surgeries brendell and Bug position is generally preferred for pelvic surgeries why because as the food tend is elevated all the blood flow will go towards the upper part of the body upper part of body pain so usually in the pelvis there will be less amount of blood and therefore you will get a better surgical view or you will get a better exposure blood flow the pelvis will be somewhat blood free and you will get a better view or a better exposure during surgery that is what is the trender in back position next the C position that we have here you can see the head end of the OT table is elevated and at the head end of the OT table is elevated it is completely opposite to that of the trendoline work therefore the type C position is known as reverse render then work position it is known as the Reversed render and Bug position and reverse to understand my position the blood flow is going towards the lower limbs okay the blood flow is mainly going towards the lower limbs therefore if we need to operate on the abdomen of this patient like in a case of lap Cola what is usually in the cases of open Cola that is open cholecystectomy okay that means removal of your gallbladder so in that surgery open cholecystectomy we can prefer this reverse render Landmark position itself no issues with this anybody usually or for any breast reconstruction surgery for that also we can prefer this reverse Trend doesn't work next is this position which is very important from exam point of view this has been asked already in the exam and this important one you can see there is selection at the hip there is flexion at the knee joint and second there is abduction of the hip and Abduction of the knee joint as well what is abduction outward movement so please remember there is selection at the hip joint flexion at the knee joint and there is abduction or outward movement this is what is called as the lithotomy position this is what is known as the lithotomy position so this has been asked earlier in the examination and we know lithotomy position is generally used for with surgeries so definitely it is commonly used during a normal vagina delivery so usually it is used for any obstetric and gynecological procedures it is generally used to OBG that is obstetric and gynecological procedure it is also used for some perennial surgeries it is also used for some perennial or some neurological surgeries so for perennial or Urology surgeries you prefer this lithotomy position what is the complication of this lithotomy position if there is over abduction if there is over Abduction of the leg if there is over Abduction of the leg what will happen here we have a nerve laterally in the leg okay at the level of knee or in the leg we have a nerve over here that nerve can get injured and what is that nerve that is what is your CPN that is common peroneal nerve so if they ask you what is the complication of lithotomy position your answer should be common peroneal nerve injury and we know if the common peroneal nerve is injured definitely the patient is going to suffer from a foot drop the patient will have a foot drop next is these three positions the E the F and the g all of these are variants of the same position these positions are known as the lateral position or they are known as the kidney position these positions are known as lateral kidney why kidney position because you can see we get a better access to the kidney in the lateral position and therefore operating on kidney becomes much much easier okay so lateral or kidney position definitely will be much much easier okay so lateral kidney positions are preferred for which type of surgeries here you can see you are getting a better access to the thoracic cavity and better access to the kidney so that's the reason why this is generally used for thoracotomy we will generally prefer it for thoracotomy surgeries or we can prefer it for pilo lithotomy surgeries that is nephrolithotomy kidney surgeries you can just remember lithotomy or nephrolithotomy surgeries we prefer this lateral kidney position next one is this The Edge one what is important over here in this H position you can see guys over here the patient is facing downwards and the foot end and the head end of the Ooty table are both at same level this is what is called as the prone position if you are facing upwards that is supine if you are facing downwards that is what is proven so we target patient data that is what is the prone position and prone position you are getting better access to the back of the patient and to the buttocks of the patient therefore prone position is preferred for with surgeries prone position is generally preferred for spinal surgery prone position is prepared for spinal surgeries and second one it is also preferred for a pilonidal sinus surgery pilonidal sinus is usually seen in buttocks that will study further the pilonidal sinus surgery we prefer the prone position okay no issues with this the last position that you need to remember over here in this table is what is the sitting position yes sitting positions can also be used during surgery this sitting position you need to remember the name of this position sitting position during surgery is also known as the Fowler's position so sitting on Fowler's position are generally useful you can see all the blood flow will be going towards the lower part of the body so which part of the body Will Be Blood free it will be your the head or the cranial cavity therefore for cranial surgeries or for neurosurgery sometimes we can prefer this setting or Fowler's position what is the complication with this position here in this position there will be higher risk of air embolism there will be higher risk of air embolism in this position okay so that is the important risk factor you need to remember that has been a pyq in EPG examination position next two important positions which are important from fmg point of view as well as well as the neat PG point of view so these are two positions the first one that you might have seen a lot of times the number of times you can see a towel roll is placed beneath the shoulder of the patient okay a towel roll is placed beneath the shoulder towel roll please and here you can see why towel roll is placed for two important things there should be extension at the neck joint neck joint is the cervical thoracic joint so extension at the neck or the cervical thoracic joint first thing and second extension at the occipital joint okay so that you get a better exposure to the neck of the patient or better exposure to the oral cavity of the patient so usually this is known as the rose position this classically is known as the rose position and we know Rose position is preferred for three important surgeries and what are these three surgeries first one is called as a thyroid surgery because you are getting better access to the neck second one is what is tonsillectomy both of these are ENT surgeries now second one is tonsillectomy and the third one is adenoidectomy adenoids are nothing but the nasopharyngeal tonsils and when you remove those those are that is called as an indirectly so thyroid surgery tonsillectomy and adenoidectomy we prefer the rose position important is now when there is extension at the neck joint and there is extension at that time to occipital joint what will happen this cervical vertebra the first cervical vertebra known as Atlas is a ring-like vertebra and the second cervical vertebra known as access both of these connect like this right this is the dense of the axis both of these connect like this and if there is hyper extensions if there is hyper extension of the neck during the surgery what will happen this first and second cervical vertebra can dislocate will they dislocate completely no there is a partial dislocation of the C1 C2 joint that is the atlanto axial joint and this syndrome you need to remember is known as the Grisel syndrome so if they ask you what is the complication associated with rose position that has been asked previously in exam and that is what is known as breast syndrome so what is Crystal syndrome it is nothing but subluxation and what do you mean by subluxation it is partial dislocation so it is subluxation of the C1 C2 joint or the atlanto axial joint okay subluxation of the C1 C2 or the acline to axial joint is a gristle syndrome and it is a complication of Rose position during surgery next important is this position what is this position called as this is classically known as the jackknife position this is known as the jackknife position now dark knife position was used in earlier days for which surgeries you can see there is a better access to the buttocks of this patient therefore just jack knife position was commonly preferred for hemoroids so for hemoroidal surgeries we used to place the patient in this jackknife position what is the problem with the jackknife position cap problems all these abdominal organs are pressing against the diaphragm these abdominal organs are pressing the diaphragm so will the patient be able to respire properly no will their lungs be able to expand properly no because the diaphragm is compressed by all the abdominal organs therefore the patient will have asphyxia that is what is the spikes your respiratory distress and due to a specific position as the patient is having asphyxia that is what is called as possessional spryzia okay so please remember what was the complication associated with this jackknife position the patient was suffering from positional asphyxia and that's the reason why this position is obsolete that means not used nowadays for any type of surgery okay that's important Chicago and with all the surgical positions now talking about the next one and that is what is your IV lines okay overlap topic between anesthesia and surgery if I talk about the IV lines or the cannulas if I talk about the IV lines or the cannulas now so they are preferred for administering fluid for administering blood or any type okay when we need to get an access to the veins of the patient we will insert this cannulas gel cause they are also called as or we will insert this IV lines now important is you need to remember starting from the Earth's crust is the ozone layer you need to remember the layers now okay so that will tell you about the color of the cannula so now starting with the 14 gauge camera what is gauge a lot of people are still confused so please remember gauge is nothing but the size of cannula or the size of a needle gauge is nothing but the size of canal or the size of a needle important you need to remember is the gauge of the cannula the number of the gauge is inversely proportional to the diameter of the cannula okay what is the diameter bore okay so please remember the number of the gauges inversely proportional to the diameter what do I mean by this if the number of the gauge increases the diameter of the cannula decreases but how gave S7 is a diameter of the needle the diameter of the cannula will keep on decreasing it will keep on narrowing down that you need to remember over here so as the number of gauge increases the diameter of the cannula decreases therefore 14 gauge cannula will be the widest bore cannula or the widest diameter Wala cannula okay 14 gauge will have y dashboard or wide as diameter whereas the 26 gauge cannula will have the narrowest bore or the nervous diameter the 26 gauge cannula will have the nervous both of the nervous diameter no issues with this anybody that's important now if I talk about the Earth's crust Earth's crust May what is present in the Earth's crust it is the lava and lava is which color orange therefore the 14 gauge cannula is orange color the 14 gauge candle is orange color then what is there we have the soil or the land land is generally which color it is gray color so the 16 gauge cannula will be critical 16 gauge canalized green color next is what lies above the soil of the land we have the grass and the trees and grass are grass and the trees are which color grass and the trees are definitely green in color so that is what is your 18 gauge cannula grass and the trees are 18 uh is 18 gauge in size next is the 20 gauge cannula what drives over the trees trees okay the flower you need to remember it is pink in color so the 20 gauge candle is how much the 20 gauge cannula is pink in color next we have the sky above and sky is which color sky is definitely blue in color so the 22 gauge camera is blue in color next we have the sun sun is which color definitely the sun is yellow in color so the 24 gauge cannula is yellow in color and the last one you need to remember ozone I'm not saying the ozone is violet in color but to remember it is easy okay so ozone you need to remember the ozone is usually Violet in color or it is purple in color okay the ozone has violet or purple in color no issues with this anybody now I'll just explain it to you about three see yellow and violet a lot of people easily remember gray and orange also a lot of people easily remember there is confusion between 18 20 and 22 gauge a lot of times so now one thing that I am saying you need to follow it properly okay now once you are 18 years old you will enter into your college and once you enter into your college you will see Greenery everywhere so once you enter your college you will see Greenery everywhere and that is how you need to remember 18 gauge camera is green in color after two years of college life you will fall into love and Jesse you will fall into love definitely everywhere you will see okay everywhere you'll see that love or hearts are coming and all of those are pink and color so once you are of 20 years old definitely you will fall in love and that will be pink color next is definitely once you have two years of relationship you'll get frustrated okay or the girl will leave you and then definitely what will happen Okay okay so definitely asman or the sky is rich in color that is blue and color that's how you need to remember it okay so these three can be remembered easily important is Orange has the widest board or gray has a wider board so usually what is the flow rate they don't ask you about other candidates but they can ask you about these two so Orange has a flow rate of 240 ML per hour okay whereas gray has a flow rate of around 180 ML okay Gray has a flow rate of around 180 MLS no issues with this anybody that's important now gray and orange Canada generally will be used for gray and orange Canada generally will be used for what please remember when we require more amount of fluids therefore when we need to give a lot of fluid to the patient we prefer the wider bore or wider diameter cannulas that is orange and green so here they are required for Rapid resuscitation what do I mean by rapid resuscitation that means resuscitation is nothing but the protocol that you follow for saving a life of a patient that is what is resuscitation okay so a patient comes to you after trauma when a patient comes to you after trauma with excessive bleeding and the patient is in hypovolemic shock you need to give a lot of fluids to the patient and those lot of fluids if you need to that you if you need to give to the patient that is what is called as rapid transfusion and definitely rapid transfusions will be done either with the help of orange Canada the best one if that is not available the gray cannula green one is preferred for adult meal green one is preferred for adult male or during surgeries pink one is preferred for an adult female so females like pink therefore pink one is used for adult female blue one definitely is used for children blue one is definitely used for children yellow one is generally preferred for infants yellow one is preferred for infants whereas the violet or the purple one as you can see it has the narrowest bore who has smallest veins definitely the new names so violet or the purple one is generally preferred for the new knits it is generally preferred for the units yes 17 gauge it is there it is white in color in between both of these you have a 17 gauge Canada which is not commonly used therefore we don't count it over here it is 17 gauge is white color cannula no issues with this anybody so that's what you need to remember over here guys okay now important is guys you need to remember this condition what is this so for example if a patient was having a cannula inserted for a very long duration of time so what will happen now there will be inflammation of that particular vein in which you have inserted the cannula an inflammation of a vein is what is called as thrombophlebitis so if they ask you what is the most common complication of IV line so the most common complication of IV line is a superficial thrombophlebitis it is usually superficial thrombophlebitis that you need to remember okay that has been asked please remember the most common complication of IV line is definitely superficial thrombophlebitis what should be done you need to remove the IV line from that side and you can use another site if you need the cannula okay you can use another vein for cannula insertion that's important very good next is this one what is this tube anybody this tube as you can see is what is your nasogastric tube this is what is your nasogastric tube okay you will insert this tube with the uh from the nose and it will go till the stomach therefore it is known as nasogastric tube okay also known as your rice tube it is also known as rice tube and why nasogastric tube is inserted in a patient nasogastric tube is inserted in a patient to provide nutrition to the patient so you will say why sir can't the patient eat orally no that's the problem now if the patient is not able to eat orally that's the reason why we are directly delivering the food into our stomach and that is usually done with the help of this nasogastric tube okay this is RT or rice tube and nowadays as they are approaching towards the next pattern they are going to more ask you about these clinical things okay definitely they are going to ask you about the topics and the diseases and all of that but more of them they are inclined towards this clinical aspects of surgery so important is nasogastric or the rice tube important is you will insert this rice tube by the nose and the question was what is the best position to insert the rice tube so important is you need to remember the best position to insert the rice tube the best position to insert the rice tube is usually the sitting position yes the position is sitting position and with the neck slightly flexed you'll also patient of slightly Flex the neck okay not complete flexion but just slight flexion of the neck and then you will take some lignocaine jelly on your hand you will cover this tube with the lignocaine jelly and then you are going straight from the nostrils okay perpendicular to the nostrils see the jaw get them take it and then you will ask the patient to sip or you will ask the patient to swallow as the patient swallows definitely it ensures that the tube will go into the stomach only not anywhere else if the patient keeps on swallowing the esophagus will open up and therefore the tube will only go into the stomach okay so patients when the patient will swallow definitely it will become much easier with neck slightly flexed that has been a previous year question now you will see how why I'm wasting time on this because this has the previous year question this was a previously question that you need to remember no issues with this anybody shallow moving further now talking about other type of nutrition one type of nutrition I've told you is enteral nutrition so there are two types of nutrition just understand for those who don't know there are two types of nutrition guys one is enteral nutrition second is Parental nutrition what does the basic difference between entrance and parental nutrition so enteral nutrition is the one where the food will be absorbed by the intestine other absorption of food is taking place by the intestine that is what is called as enteral root of nutrition whereas if the intestine is surpassed or the intestine is bypassed absorption of food does not takes place by the intestine that is what is known as the parental root in Parental root we are directly delivering the food or we are directly delivering the fluid into the veins of this patient so we are directly delivering the food into the blood of this patient that is what is known as parental root again yes yes it will be more than enough for fmg I'm covering every other aspect please remember that if absorption has not taken place by the intestine when we deliver directly into the blood that is Parental group okay now enter the root is definitely preferred why because it is more physiological root it is cheaper route so enteral roots are what first oral root definitely there is better the best route will be the oral root the patient is eating by himself that's the overall route second if the patient is not able to eat orally what do we insert definitely we insert the nasogastric tube so usually nasogastric tube or rice tube is also an example of enter Because here the food will be delivered into the stomach but finally absorption takes place by the intestine only so nasogastric tube is also an enteral root next is neither jejunal tube we insert a longer tube okay that is what is the nasogenic tube then also the intestine will be responsible for absorption so all of these are enteral Roots whereas if I talk about parental root here the food or the fluids will be directly delivered into his blood vessel and which blood vessels mainly the veins okay mainly the veins important is if I talk about parenteral nutrition which kind of fluids or which kind of solutions will be given to the patient yes because the patient is not eating anything the patient needs more energy and all that energy you will give by a sugar Solutions so for Parental nutrition we generally prefer giving sugar Rich Solutions we generally prefer giving sugar Rich solutions to the patient what is the best route please remember what is the best route for parental just a minute what has happened hold on correct sure so what is the best route for Parental nutrition so the best route for Parental nutrition is the central line best route for Parental nutrition is the central line so what do I mean by central line please remember here we insert a central line or here we insert a catheter directly into the central veins of the patient which are the central veins the three veins which are preferred for central line insertion I'll talk about them later as well one is the ijv internal jugular Wing second is the subclavian vein the one which lies below the clavicle subclavian vein and third is in the groin that is your femoral vein okay so here if we insert a catheter that is what is called as the central line insertion that is the best route to deliver parenteral nutrition but if that is not an option you can answer it as pick what is pick pick a line is peripherally inserted central line your PICC line is peripherally inserted central line and if that is also not an option the least preferred one which is there is the peripheral IV line that we discussed now the cannulas so peripheral IV lines are the cannulas that we have discussed right now so peripheral IV line is the least preferred route for Parental nutrition why because if you give sugar rate Solutions why are these peripheral IV lines they will undergo inflammation please remember if you are giving sugar rip Solutions the other sugar rape Solutions if you give via peripheral IV lines there will be inflammation of the peripheral veins and that we discussed it is called as thrombo phlebitis so due to the increased risk of thrombophlebitis the peripheral IV lines are the least preferred route for Parental nutrition the best one is central line insertion what are the indications of Parental nutrition so if you are delivering anything into the intestine of the patient or anything into the stomach of the patient but the intestines have lost its motility what is the motility in intestine called as peristalsis so if the intestine of the git has lost its motility so definitely will the food be able to pass further no the food is not able to pass further so that's the important thing in that condition we cannot prefer a enteral root okay so parental root is preferred when the intestines have lost their motility or intestines have lost their peristalsis so in that conditions we will prefer parental nutrition and that condition is known as a prolonged paralytic ideas okay that condition is prolonged paralytic ideas so paralytic ideas means intestine have lost their motility or peristalsis okay if another indication will be acute severe pancreatitis yes in cases of acute severe pancreatitis initially we keep the patient NPO nil per oral and in that condition we need to give fluids to the patient via the IV root itself okay so that is what is acute severe pancreatitis next definitely in acute episodes of inflammatory bowel disease why in acute episodes of inflammatory baby disease we are preferring parenteral nutrition because inflammatory bowel disease what is inflamed the bowel is inflamed right so as the bowel or the intestine is inflamed can they work no they cannot work so will there be absorption of food no there will not be any absorption of food therefore acute episodes of inflammatory bowel disease we cannot prefer the enteral root we need to give nutrition via the parental rule so at least remember this and the third one or the fourth one you need to remember is short bowel syndrome if a patient underwent a trauma due to which major part of his intestine was removed major part of his intestine was resected the part of the intestine which is Left Behind now it is a very small bowel or a very short bowel in that condition also you will prefer a parental root in the patient next is what was the best route for parenteral nutrition the best route for Parental nutrition was the central line insertion as you can see over here this is how a central line is inserted you can see a long catheter and here the vein which is preferred is the internal jugular vein for a central line insertion so as I've told you there will be three sides for central line insertion which is the best site for central line insertion so the best site for central line insertion is the subclavian vein the best site for central line insertion is the subclavian vein which lies two fingers below the clavicle but why is this subclavian mean not preferred regularly why it is not the most common site the reason is because it needs expertise it needs skills because if you are inserting a central line in the subclavian vein what can happen What Lies below what lies in the thoracic cavity over your belongs and I hope all of you are quite aware if you are inserting a catheter over here definitely that needle can injure the lungs also or it can mainly injure the covering around the lungs and what is that covering along the lungs called as Laura and if the pleura is injured definitely what will happen a lot of air will collect around the lungs and that excess of air will pressurize the lump this excess of air around the lungs will pressurize the lung it will not let the lung expand freely lung expanded the lung is not able to expand and that is what is called as pneumothorax so please remember the most important complication which is associated with subclavian vein insertion a subclavian Bean Centerline insertion is pneumothorax okay so it does pneumothorax next what is the most common site for central line insertion the one that I've shown in shown you in image and that is what is called as igb internal jugular vein is the most common site preferred because it is easily accessible next is what is the least common site so least common site preferred for a central line insertion is the femoral vein and all of these are one liners which have came in come in your exam already all of these are one-liners the play vitamin is the best site most common is igb least preferred is and the complications have also been asked please remember and what is the complication associated with subclavian vein insertion it is pneumothorax and they have asked why female vein is the least preferred site for central line insertion Q female prefer so female vein is the least preferred site the reason being this female vein lies in the groin region and that groin region is usually unhygienic that's the reason why there will be higher chances of infection okay there will be higher chances of infection or there will be higher chances of thrombosis so if they ask you which root of central line insertion will have the highest chances of infection and thrombosis you need to answer it as femoral vein and that is the reason why it is the least common or the least preferred site for central line insertion as well next if I talk about these two important step laws which and one of them have come your come in your exam recently in fmg Jan 2023. he gets a lot of people are still feeling topics so please remember I am teaching you topics which are left everywhere and that's my duty as well okay so important thing is usually this image had come in the recent examination so we need to differentiate between these two important staplers the first stapler that we use in surgery is known as a circular stapler okay this one is a circular stapler and circular stapler is preferred for which surgeries the one that we come on commonly perform nowadays and that is what is called as stapler hemorrhoidopexy when you are treating hemorrhoids in a patient for stapler hemorrhoid opexy if they ask you which which stapler is used your answer should be a circular stapler and second surgery that will prefer in cases of sigmoid colon cancer it is called as lar low anterior resection in both these surgeries we prefer the circular stapler next one this one as you have over here in this image this is what is called as your linear stapler which was there in fmg giant 2023 examination this linear stapler please remember is preferred in with surgeries so linear stapler is preferred in gastrointestinal surgeries okay the Indian stapler is preferred in gastrointestinal surgeries like a dual man's procedure that you will discuss in zenker's diverticulum over there we can prefer this linear stapler next is this dream now after a surgery if you feel there can be collection of a lot of fluid over the at the surgical site okay so better is to insert some drain after the surgery cue because if you have not inserted a drain after surgery and if there is fluid accumulation at the surgical site are you again going to open up the patient for that no right you're not going to open up the patient for that that's the reason why if you are suspecting fluid collection better is to insert some drain okay and when the output will be very less you can remove the drain this drain which is there which is inserted commonly after the surgery and this is what is known as a romovac suction ring this drain which is inserted after a surgery is known as a romoac suction drain and this Romo wax suction why suction because it works on the principle of negative pressure or vacuum we press this okay we press this and then we fix the suction and then we release it so a negative pressure or a vacuum is created in the suction okay and therefore if there is any fluid collection it will be sucked out or it will be pulled out so it works on the principle of negative pressure and it is used after with surgeries so it is generally preferred after mrm what is mrm modified radical mastectomy that is after removal of the breast the most common complication I hope all of you are quite aware that was a previous year question again what is the most common complication after mrm or modified radical mastectomy it is seruma what is seruma collection of serous fluid after a modified radical mastectomy therefore after mrm we need to insert a removal suction drain in the patient TK it can also be inserted even after a lymph node dissection okay so that's the important thing you need to remember next one talking about few important surgical instruments now talking about few important surgical instruments the first one that we have in the image usually it is called as the pro octoscope procto is another name for proctum is another name for rectum okay and scope is the instrument that is used for examination so usually this instrument that is used for examination of the rectum is what is proctoscope now usually proctoscope is inserted via the anal Canal by taking some lignocaine jelly and you'll ask the patient to relax as anal sphincter so you can easily insert the proctoscope then you will remove this obturator and then you'll slightly bring out this proctoscope okay while you are bringing out this proctoscope you are examining the rectum of the patient and what you will be able to identify you will be able to identify any hemoroids in the patient piles okay any piles or hemoroids in the patient can be identified with the help of a proctoscope important okay or any rectal polyps if they are present any rectal polyps so important is investigation of choice for hemorrhoids is proctoscopy investigation of choice for hemorrhoids is proctoscopy that's important to be remembered yes no fancy radiological investigation is required but whereas absolutely contraindicated now you are inserting such use surgical instrument in the anal Canal of this patient and if the patient is having excessive pain in the anal Canal is the patient going to let you insert this proctoscope so that condition is what is called as anal fissure okay so in cases of anal fissure definitely don't try to insert proctoscope otherwise you will get a kick strong kick from the patient next one is this one now important is these are all the retractors what do I mean by retractor guys so please remember when you have given an incision okay when I am giving a skin incision first of all definitely I need to separate the skin so that I can get a proper view of the underlying structures and then I'll give another incision on the subcutaneous tissue then again I'll retract these structures okay so every incision after every incision you will retract the tissues you will try to separate the tissues that is what is called as retraction and that separation of tissues to get a better surgical view is done with the help of retractors itself now the retractors that we commonly use the most common one and which has appeared in the examination also is this reverse L shape for a retractor and that's how you need to remember this reversal shape retractor is known as laginbox retractor this is known as the lag and backs retractor okay it is known as the laginbox retractor the next one that you have over here okay the next one which is completely D shaped very concave this is what is called as your doyans retractor and important is you need to remember doyance retractor is used to retract or used to hold back with structure concept structures so it is generally preferred to separate to retract your bladder urinary bladder the Doyle's retractor is used to retract your urinary bladder next one that you can see over here it is a square blade which is there in this retractor okay and it has a curved at the end as well this is known as the Morris retractor it is known as the Morris retractor to retract a huge organ like liver for example to retract or to bring back the huge organ like a liver definitely we will use this Morris retractor okay important is that next is sarkari question of your exam and it is this instrument what is this instrument anybody answer I need answer for this one now it is a very common sarkari question of the exam answer it anybody have you slept or what hopefully not so this is what is characteristically known as your Humvees knife guys okay this is what is known as your Humvees knife and please remember this Humvees knife is it it is usually used to raise a skin graft when we need to take a skin graft from the patient's body so that patient uh though so the skin graft that is taken or raised from a patient's body it is usually done with the help of this knife known as the Humvees knife a sarkari question of your exam to raise the skin graft definitely we use this Humvees knife and in this Humvees knife we can use two kinds of Blade depending on how much thickness of graft we need if we need a partial thickness skin graft the blade that we commonly insert over here it is known as a Theos Blade the blade that we commonly insert is a theory blade which is used to take a partial thickness skin graft also known as a split skin graft so split skin graft is another name for partial thickness skin graft will see in both next if we need to take a full thickness skin graft to take a full thickness skin graft the blade that we insert is known as the wolf piece blade okay so to take a full thickness skin graft we use the Wolfies blade along with the Humvees Knight no issues with this anybody next one are these two important forceps and what are these two important forceps so what is the role of forces first of all the function of the role of forceps during a surgery is to hold any structure okay during a surgery we use this forceps okay so the first forceps that you can see these are the two rings the first and the second ring okay this is what is called as a ratchet and what is a ratchet so Rashid is a locking system with the help of which we can lock the forceps and it will not displace okay so we can lock the forceps with the help of this ratchet usually next this is called as the joint usually okay this is known as The Joint this is what is called as a blades and you can see the end of the blades over here these blades are curved over here okay the end of the blades are usually curved over here and definitely both the blades not having penetration what do I mean by fenestration fenestration whole okay so both of these curved blades are having hole at the end okay so please remember there are curved blades which are there and these curved blades are definitely having fenestrations or holes so this type of forceps will be used to hold tough structures or tubular Hollow structures delicate structures so please remember there's forceps that is there in the image again commonly asked in your exam is known as the Babcock's forceps this is what is called as your Babcock's forceps and please remember important thing that Babcock's forceps is generally used to hold delicate structures okay it is used to hold delicate structures generally okay next one is this delicate structures like bowel ureter wash ref okay your seminiferous tubules okay sorry formatic chords that is your vast reference ductile's difference all these tubular structures which are Hollow okay to hold every kind of structure you can use this forceps next is this forceps again the blades of this forceps as you can observe they are also curved but what is the difference you have got these tooth at the end of these forceps you have got these two at the end of these forceps so here we do not have any finished rations rather we have tooth ends usually okay we have tooth ends at the plates and this is characteristically known as the Alice tissue forceps this is what is known as your allies tissue forceps okay so if I talk about the early tissue forceps now it has the tooth and this tooth will definitely help in foam grip strong grip your strong holder so this early tissues forceps is definitely used to hold which kind of structures it is used to hold tough structures like the fascia it is used to hold tough structures like the fascia aponeurosis sheath the tendon okay for them definitely we use this alleys tissue forceps next important we need to remember is this one and what is this you can see these are thick scissors you can see there is no Ratchet or no Locking System now so this is what is a sensor okay so this is what is called as the Mayo scissor and Mayo scissors are the thick scissors or very heavy scissors and if heavy scissors are there definitely they are used to cut what they used to cut tough structures they can also be used to cut sutures as well but definitely they are preferred for using they are preferred to cut any tough structures like again the fascias usually okay to cut the fascias we prefer this Mayo scissors only and last important one this is what is called as your needle which needle this is known as your various needle and this various needle important is it is used during which surgery so please remember this various needle is generally preferred during a laparoscopic surgery whereas needle is used during a laparoscopic surgery why now I hope all of you are quite aware laparoscopic surgery may we give a complete incision or what no we only give small small incisions and we insert our laparoscopic insert we insert our laparoscoping instruments from this small small incisions to get to insert a laparoscopic instruments from here important is guys if you're inserting this laparoscopic instrument they can immediately injure some structures in the abdomen therefore there should be some Gap or there should be some space between the abdominal organs and the abdominal wall to create the space we insert a gas and what is that gas inserted in the abdomen or in the peritoneal cavity that has been a question the most common gas which is used to create a Nemo peritoneum what is Nemo that is gas where do we insert a gas in the peritoneum so the most common gas that we insert usually in a laparoscopic surgery and that was a previous year question is the carbon dioxide gas okay so the gas which is used to create a Nemo peritoneum is the carbon dioxide gas and for insufflation or to insert this carbon dioxide gas within the peritoneal cavity we use this various needle itself TK so therefore it is a very important image that you need to remember where is needle it is used in laparoscopic surgeries to create an email peritoneum and the Nemo peritoneum is created with the help of a carbon dioxide gas no issues next if I talk about is this one these two instruments are known as cauteries yes nowadays I hope all of you are quite aware only we give the first incision the skin incision with the help of a blade surgical blade otherwise all the other incisions are taken or are given with the help of these cauteries itself why because cauteries will not only give an incision but they will also burn the area and as they burn the area somewhat definitely they will not cause excessive bleeding if you are giving direct incision with a blade there will be more bleeding but if you are using a blade if you are using a cautery to create an incision or to make an incision there will be less amount of bleeding therefore cautery is a commonly preferred there are two types of cauteries you need to remember fmg exam may be though important okay so the first one is the monopolar quadri the first one is a monopolar quadri and the second one is known as the bipolar cautery the second one is known as a bipolar cautery over here so monopolar why because you can see there is only a single end okay the tip of this monopolar cautery is like a pen or it is like a Bobby tip okay so there is only a single one therefore it is called as monopolar but here you can see in this cautery the end which is there there are two ends right so there are two electrodes over here therefore it is called as a bipolar quadrant okay here the ends are like prongs here the end is like a pen okay that's the basic difference important is monopolar core tree always requires a cautery pad why it requires a cautery pad always important is please remember because if we connect this monopolar quadri to the cautery machine so the electricity will come via this monopolar cautery electricity or the electric current comes via this monopolar thought tree it goes to this step and then it goes into the tissues and it cuts the tissues current or the heat cutting the tissue is what is cauterization so it will cut the tissue but then this current will pass via the patient's body okay then this current will pass via the patient's body once it has cut the tissue and then it will exit out now otherwise okay the quarter will not work Q because in physics you might have studied I am not going into details but the electric circuit should be complete for the current to flow so here also the circuit should be completed so the current will come back from the patient's body into the cautery machine and that is usually comes back with the help of a cautery pack so you need to stick a contrary part to the patient's body usually it is thick uh usually the contrary pad is placed over the thigh of the patient okay so that's the important thing quadripad is required for a monopolar quantity is it required for a bipolar Pottery no the reason is your important is please remember here the current comes via one electrode it cuts the tissue and it goes back via another electrode okay so here the current does not pass via the patient's body that's the reason why we do not require any cautery part in case of bipolar cautery so that's the basic difference first one next important as the current is passing by the patient's body in cases of monopolar core tree therefore there is a risk of arrhythmia because this current can interfere with your current of your heart also know the rhythm of your heart and therefore monopolar core tree is contraindicated in patients who are having pacemakers implanted so gin patients May pacemakers not used in patients who are having pacemakers whereas bipolar cautery can be used in patients who are having pacemakers okay important is here you can see in a monopolar cautery there are two buttons the yellow button which is there it is used for cutting okay the yellow button is used for cutting whereas the blue button is used for coagulation the blue button is used for coagulation whereas if I talk about the bipolar quality bipolar cautery you can see there is no button over here because the only function that the bipolar quadri can perform is coagulation is only responsible for coagulation that's important okay so these were the basic differences you need to remember about the cauteries next if I talk about the surgical blades as I've told you cautery are not used to make skin incision why cauteries are not used to make skin incisions because if we use core trees to make skin incisions electric current they are using heat therefore they will be born over the Skins there will be burning scars over the Skins if you use the cot tree that's the reason why to make skin incisions we still prefer the surgical blades important among the surgical blades are the two most important ones that is 11 and number number 11 and the number 12 plate the number 11 blade you can see it is a pointed blade okay the number 11 blade is a pointed or a triangular blade at the tip this blade is what is known as the stab blade white is known as the star blade so the number 11 blade is known as the star blade because it is used to mix tab incisions okay the one that we do perpendicular okay that is what is the stab incision so it is used to mix tab incisions and where do we mix stab incisions usually to drain an abscess what is an abscess pass collection to drain a pus collection definitely the incision that we make on the skin is a stab incision so definitely for incision and drainage of an abscess for I and d and that doesn't mean a previous a question again for incision and drainage of an abscess which is the number of Blade that is used it is a number 11 blade or the star blade which is used next is the number 12 blade so you can see number 12 blade is a curved blade right so this number plus a 12 blade is used for cutting sutures okay to cut the sutures the blade that we use is the number 12 plate whereas all the other blades whether it is number 10 15 18 20 21 22 23 24 all of these blades are used to make skin incisions various types of skin incisions and if they ask you that was a previous equation in need PG T which is the sharpest portion of the blade the single one liner that you need to remember the sharpest portion of the blade is not the tip that was a mistake that a lot of people did so the sharpest portion of the blade is the belly okay it is the tummy the sharpest portion of the blade is the tummy or the belly okay does the belly of the blade which is the sharpest portion and always hold the blade perpendicular to the skin so that the margins row and the margins are not inverted they are inverted margins okay the margins are inverted and this is what so you do not use the blade directly right so usually you place the blade over here on this handle and what is this handle called as this handle is known as the barred particle handle or the BP handle this handle which is used to mount a surgical blade on top is known as the bad particle handle to lengthen the surgical blade easy on a pen case next important is this one what is this anybody so this one is a needle holder and with the help of a needle holder we are holding the suture needle this suture needle as you can see please remember this suture needle that we can see it is hold in between okay so this is what is the switch done what is the swaged end the end at which the suture is attached or the thread is attached is the switched end whereas the pointed and the other one which is sharp it is a pointed end okay so where do we hold the needle with the help of a needle loader and that was a previous year question so please remember we hold the needle with the help of a needle holder at Junction of how much part from the pointed end at Junction of two thirds from the pointed end okay two third from the pointed end and how much from the switch then one third from the switch stand okay so at Junction of two third from the pointed end and one third from the switch end the needle should be held okay one third from the paged end the needle should be held no shows with this anybody just a minute okay from the wage then and one sorry two thirds from the pointed end and one third from the page Dent you need to hold the needle with the help of a needle holder okay then once you have taken the sutures we'll talk about the sutures okay then finally you will tie a knot right finally you will tile knot and that knots you need to remember these three types of knots at least okay so one knot that you can see in the first image here how many throws are there first we are taking two throws and then it is followed by one throw okay then it is followed by a single throw so if you take two throws and then again one throw so it is the most secure knot it cannot flip easily so definitely it is the most secure knot it will not slip off easily and this is what is called as a surgeon snot this is what is known as the surgeon's knot it is the most secure knot which does not slip easily next one that you can see over here next one that you can see guys okay you can you can follow the blue thread okay so you can see the blue thread is going either above the loop or it is going below the loop okay so here you can see the blue thread both the ends of the blue thread they're going above the loop so if both the ends go above the loop this is what is called as a square knot or a reef knot okay if both the ends go above the loop it is known as the square not or the reef knot it is known as a square not of the reef naught that you need to remember and it is a secure kind of a knot it is a secure kind of knot that means it will not slip off easily but the more secure Still Remains the surgeon's knot next is this one how to recognize this not in the image so you can follow the blue thread again one part of the thread is going below the loop another part of the thread is going above the loop okay so that's important if one part of the thread goes below the loop another part goes above the loop this is the granny is not and we know the granny is not usually grannies use it while making a sweater and therefore these knots will come off easily because these are insecure knot they will slip off easily these are insecure knots again so that's the important knots that you need to remember which has been asked in the exam then if I talk about the classification of sutures okay if I talk about sutures now so there are two varieties of sutures either they're absorbable sutures and if they are absorbable will you need to remove them no they will get absorbed by themselves absorbable sutures and the second is known as non-absorbable sutures the non-absorbable Matlab the sutures that you need to remove okay if you need to remove the suture that is what is a non-absorbable suture if I talk about the next classification the sutures can be either natural sutures which are derived from plants or animals or it can be synthetic sutures which are made out of something okay which are made in the laboratory okay these are synthetic sutures important is if I talk about the first group that is absorbable and natural sutures so absorbable and natural sutures are usually the cadgut and the chromic absorbable natural sutures or the cadgut and the chromic cat gut whereas the non-absorbable natural suture is silk non-absorbable natural suture is silk if I talk about the next one if I talk about absorbable sutures but which are synthetic in nature so the absorbable synthetic sutures will be vikril and the second one is monocryl and the third one is PDS PDS is also known as polydioxinone together at least remember this classification absorbable synthetic sutures are ygrill monocryl and PDS that is polydaxonome whereas if I talk about non-absorbable synthetic sutures non-absorbable synthetic sutures are Proline and nylon non-absorbable synthetic sutures will be Proline and nylon so this is the bare minimum classification of sutures that you need to remember at least remember the stables for your exam ticket next one if I talk about these sutures in detail which have been asked in your examination the only images that have been asked in your examination I am focusing on those type of sutures and they are also very commonly new they are very commonly used during the surgeries as well the first suture that you can see over here this suture which appears yellow in color is what is your catguard suture it is your cardigan suture important is cadgut is a natural or a synthetic suture definitely it is a natural suture because it is derived from animal first thing second is it absorbable on a non-absorbable suture we have seen it is an absorbable suture that means it will be absorbed by itself we don't need to remove the suture so if I talk about what is the absorption time that has been asked within how much days cadgat suture is absorbed so cadgat suture is absorbed usually within a span of 60 days yeah it gets suture is absorbed within a span of 60 days chromic calculate can be absorbed within 90 days okay but CAD guard is absorbed within a span of 60 days important is it is derived from which animal so please remember it is not derived from a cat though it seems it is derived from a cat no it is not okay so please remember cat get suture is derived from the sheep's gut it is derived from sheep's gut okay so just derived from just a minute let's derived from the Sheep's gut ship guards and which layer of the sheep got as we know just like the human intestine or the human gut sheep's gut is also the strongest layer of the sheep gut is also submucosa that is the one liner from Anatomy okay which is the strongest layer of your git answer is so here it is derived from the Sheep guts Saba mucus it is derived from the Sheep guts submucosa that's important okay that has been a previous year question now again one important question which has been asked that cadgut is stored in which preservative so if you open up the cad guard suture that is stored in some preservative and what is that preservative so it is stored in isopropyl alcohol so cadgat suture is stored in isopropyl alcohol yes there is some liquid inside the category suture pack and that liquid is nothing else but isopropyl alcohol okay so CAD guard suture is stored in isopropyl alcohol that is again an important previous year question okay the preservative used for storage of CAD get suture answer is isopropyl alcohol next is this violet color suture and this violet or purple color structure is known as white Grill it is known as vikril which is the most common suture used nowadays okay another name for vikril it is also known as polyglactin so why Krill is also known as polygalactin is it a natural suture or synthetic suture definitely it is a synthetic suture is it absorbable or non-absorbable so it is an absorbable suture it is absorbable suture important is that now why Krill usually is absorbed within what how many days now so if it is absorbable suture there should be a span or duration of absorption so usually vehicle is absorbed within a span of 60 to 90 days why Krill is absorbed within a span of 60 to 90 days important to start and where is Wyclef used so why Krill is not used over the skin it is used below the skin okay so it is used for bowel or bladder repair commonly remember it is used for blava or bladder repair when you need to repair your intestine or when you need to repair your urinary bladder for all the internal structures you can use the vehicle suture very commonly used please remember that okay next is the sky blue color suture and this suture is what is called as Proline suture Proline is also known as polypropylene so don't get confused Proline and polypropylene is one and the same thing now is it a synthetic or a natural suture definitely it is a synthetic suture okay Proline or polypropylene is a synthetic suture absorbable and non-absorbable so it is a non-absorbable suture and whereas proteins which are used so please remember Proline suture is generally used for vascular repair when you need to repair the vessels right vessels repair we use this Proline sutures next the recta sheath repair okay for recta sheath repair also that was a previous need PG question for rectus sheet repair which is the suture preferred it is the proline suture which is preferred next if I talk about this suture over here the black color suture that we have and this black color suture is again a very common to use suture and that is nothing else but your silk suture if I talk about your silk suture important death silk is natural or synthetic definitely we know silk is natural why does natural because it is derived from say silk worm okay silk we know it is derived from cell thread is derived from cell formula just like that Silk suture is also derived from silkworm therefore it is a natural suture and it is absorbable or non-absorbable so please remember silk is a non-absorbable suture you need to remove the suture okay you need to remove the suture this suture is preferred where social suture is generally preferred for skin suturing foreign okay so that's the important thing so therefore it is very common suture which is used next is this one it is known as the nylon suture nylon is synthetic or natural definitely it is a synthetic suture absorbable or non-absorbable so nylon please remember it is a non-absorbable suture important is nylon is also known as ethylon and nylon suture is used where so niron again is used for skin suturing just like Silk sutures we can also use nylon for skin suturing important very fine nylon or very thin nylon is also used for ophthalmological surgeries yes please remember that was a previous year question again for ophthalmological surgeries which is the preferred suture answer is nylon okay nylon is the preferred sutures used for of terminological surgeries and it is also used for tendon repairs it is also used for tendon repair because it is a strong suture it is also used for tendon repairs please remember that okay now if I talk about the needles which are attached you can see the needle is attached to the suture itself so the needles which are attached there are two types of needles if I cut the needle in between okay and if I see the needle either it will have a circular point or it will have a triangular point if it has a circular point it is called as a round body needle if it has a circular point it is called as a round body needle and if it has a triangular point it is called as a cutting or a reverse cutting needle it is called as a cutting or the reverse cutting needle so what is the basic difference where we will prefer a round body needle and where we prefer a reverse cutting needle important is please remember that round body needle could not pass via the tough structures so if you don't if it cannot pass by tough structures can you use it for skin suturing vagara or for tough structures no so please remember round body needle is generally used for delicate structures like the intestine swaggera whereas cutting or reverse cutting needle as it has a pointed end or a sharp end definitely it can be used for tough structures okay so cutting or reverse cutting needle is generally prefer for top structures no issues with this anybody so that's important moving further guys moving further now talking about the once do you want a break so we can start off the brake okay so if you want a break please let me know in the chat box so we can take a break for 10-15 minutes and then we can start 10 minutes break and then we can start with the ones and then we'll continue with trauma further please let me know I hope I am audible to all of you I'm fine with no break you let me know just if all of your mind we can continue further we can continue further for sure then talking about wounds guys if I talk about Okay so okay great job if I talk about once now after once let's take a break okay if I talk about ones guys important test over here there are different types of wounds you need to remember this will also be covered in forensic I am just giving you a brief idea because because we did as surgeons we usually deal with these type of phones regular basis pair so therefore you need to remember about the ones as well so important is this one that you can see the first one this wound is a very superficial wound and this type of injury is what is called as an abrasion this is what is called an abrasion what is an abrasion abrasion is only injury to the epidermis only the injury to outermost layer of skin that is what is known as your epidermis so abrasion is injury only to the outermost layer of skin that is epidermis please remember and abrasions are usually seen during the accident okay usually during a root traffic accident we can see these multiple linear wounds on the skin and that is what is abrasion next you can see over here if you use a heavy weapon just something like a sword or something like a ax okay then this in then this type of wound is formed and this one that you can see over here okay this one that you can see over here is what is called as a laceration this one is what is known as a laceration important about laceration is please remember laceration will have irregular margins laceration has irregular margins if I compare it with a incised one what is an incised you want if I take a surgical blade and if I make a cut okay that is what is called as an incised one so if I compare a laceration with an incised wound incised wound will have regular margins but laceration has irregular margins important is the nerves and the vessels or the hair follicles if they talk about okay the nerves vessels and the hair follicles they are crushed in cases of a laceration they are crushed in cases of a laceration but in an incised wound if I give a sharp cut in a case of incised wound these nerves these vessels and these hair follicles will be cut so that's the basic difference if they are crushed it is restoration if they are cut that is an incised one next is this you can see there are multiple superficial linear Cuts these multiple superficial linear cuts that usually is seen on the accessible parts of body usually over the wrist or the forearm these are called as the suicidal Cuts these are known as the suicidal Cuts also known as tentative cuts other hesitational Cuts so these are known as suicidal wounds or suicidal Cuts or tentative cards hesitational Cuts as well again multiple superficial linear cuts next is this one what is this type of a one called as this type of a wound is what is known as de-gloving this type of a wound is known as a de-gloving injury or it is known as a oval gen injury this is a de-gloving or an ovulsion injury see over here if a flap is formed okay if due to some injury a flap of skin is separated a flap of skin is separated from the underlying structure so these are my underlying structures and a flap of skin is separated from the underlying structure this type of injury where a flap of skin is separated is known as de-gloving or a Volcan injury important previous year question is the plane of separation is between which two layers so the plane of separation is between the subcutaneous tissue okay the plane of Separation in a d gloving or an avulsion injury is between a subcutaneous tissue and the Deep fascia the plane of separation is between a subcutaneous tissue and the Deep fascia okay in the case of degloving or an avulsion injury okay important is next one is this this is what this you can see for example if you get a blunt drama somewhere okay and after that you get these kind of discoloration over the skin this kind of bread brown or bluish or blackish at times there's discoloration that you get this is what is called as a contusion this is what is known as a contusion and contusion is also known as a bruise important is contusion is also called as a bruise important is why there is a contusion of bruise after a trauma usually it is due to collection of blood yes it is due to collection of blood so bruise or contusion is nothing else but collection of blood so you will say so why we don't call it a hematoma so hematoma is the collection of blood which feels like a tumor which is huge huge collection of blood which feels like a tumor that is what is the hematoma here you can you feel it like a tumor no okay this is what is the contusion of a bruise that is only minimal collection of blood due to rupture of small small vessels like the venues okay now next is this one you can see the skin all the underlying structures they have been completely damaged structures this is what is called as a crush injury this is what is known as your crush injury and Crush injuries are usually seen during what Crush injuries are usually seen during road traffic accidents these are crash injuries and we know in Crash injuries all the structures are severely damaged okay they are crushed completely okay so you need a flap to cover the crush injury properly you need a skin flap next important is this and that is what is cars okay so if there was one in a patient if there was one in a patient please remember definitely after a wound there will be one healing okay and as the wound healing will occur what will happen at the side of the wound okay at the side of the wound what will start depositing what will start depositing the fibroblast will start depositing or the collagen will start depositing okay so if there is one healing definitely when there is wound healing the fibroblasts or the collagen starts depositing at the site and that is what is known as one healing or one repair please remember that okay so usually if there is deposition of collagen or fibroblast at the one side that causes healing important is can anybody tell me faster which is the first collagen to appear during one healing which is the first all of these are previous year questions which is the first collagen to appear during wound healing which is the first Collision to appear during one healing Pastor answer this question and second also answer that which is the most abundant collagen in a scar which is the most abundant collagen in a scar so what is the scar as I've told you we are going to discuss about a scar star is nothing but outcome of an wound okay the outcome of a wound is what is known as a scar in simple terms outcome of a wound is known as car after one dealing what appears is what is a scar so please tell me these two important one-liners first collagen to appear during one healing very good answer is Type 3 collagen first collagen to appear during one healing answer is Type 3 collagen previously question and the most abundant collagen in a scar the most abundant collagenous car answer most abundant collagen in a scar very good it is type 1 collagen the most abundant collagen in a car is a type one collagen important you need to remember next if I talk about the scar usually the scars can be of two types one is called as a hypertrophic Scar and second is a keloid skull now if you see that the scar if it is limited within the wounds if the scar is limited within the margins of the wound if the scar is limited within the margins of the wound it is known as a hypertrophic scar but if it grows beyond the margins if it grows beyond the margins it is what is called as a colloid keloid scar if the scar grows beyond the margins it is what is called as a keloid scar important is hypertrophic scar is more commonly seen in which population so hypertrophic scar is more common in children but whereas keloid scar is more common in younger population that is 10 to 30 years of age colloid scar is more common in younger population between 10 to 30 years of age and that to females make females make alloid is more common important is occur in every patient no keloids car has a familial predisposition what do I mean by this family history okay so only patients who have a family history will be having a higher risk of keloid scar formation okay whereas no familiar Association and seen in cases of hypertrophic scar hypertrophic scar can be seen in any and every patient okay so that's the important thing next keloid scar is more common in which race so you need to remember keloid car is more common in the black Rays or we can call it as the afro-caribbean race okay so keloid scar formation is at a higher risk in the black or the afro-caribbean race whereas no such genetic predisposition or no such racial in predisposition is seen in a case of hypertrophic scar what is the treatment for hypertrophic SCAR or hypertrophic scar nothing has to be done or we can just massage the hypertrophic scar with the help of moisturizing cream that's it it will go by its own but if I talk about a keloid scar keloid scar definitely needs a treatment and what is the treatment most commonly used for keloid scar the management of the treatment for a keloid scar you need to remember here we will give a intracelloidal injection within this keloid we need to give an injection we will give a intracelloidal injection of a steroid and what is that steroid known as triumphsinolone a previous year question which has been commonly asked okay so intracelloidal injection of triumphs in alone has to be given that is the most common treatment used for but if they ask you what is the best treatment for a keloid's car then the answer cannot be intracelloidal injection okay if they ask you what is the best treatment for a keloid scar then the answer cannot be intracelloidal injection of triumphant alone then your answer should be surgical excision then your answer should be surgical excision so you will say so even after surgical excision can there be chances of recurrence yes there can be chances of recurrence even after surgical excision that's the reason why usually after surgical excision the patient has to undergo a interstitial radiotherapy okay we will place a radioactive substance like Cobalt in the tissue okay so interstitial radiotherapy that's the best answer to be given for best treatment in a case of keloid scar so surgical excision followed by interstitial radiotherapy is the best treatment option for keloid scar but the most commonly used is definitely the intra colloidal injection of try and sinolone no issues with this anybody next if I talk about these what are these so these are various types of ulcers which are commonly asked in your examination their top most favorite and usually they will ask you about the ulcers in the leg region itself okay so they are very commonly asked in the first image you can see there are multiple ulcers okay there is not a single ulcer there are multiple ulcers and The Superficial or deep so we can see they are shallow or they are very superficial okay the multifacial multiple they are shallow or superficial ulcers so multiple or superficial ulcers usually seen in the leg region and what is the most common side the most common site for these type of ulcer is definitely the greatest area of leg okay the area above the medial malleolus okay so it is the greatest area of leg which is the most common side the area which lies above the medial malleolus it is the most common site again a py queue okay and these ulcers where there are multiple and shallow ulcers these are an example of a venous ulcer okay these are an example of venous ulcer so you will say Sir only superficial ulcers will tell us about that no you also need to see the margins if it has sloped margins if it has slope or sloping margins so venous ulcer or multiple shallow ulcers with sloping margins usually seen on the greatest area of leg that is the venous ulcer second answer that you can see in the image is what is the deep ulcer okay there is a single deep ulcer and which type of margins are seen such margins that is what is called as a punched out margins so deep ulcer with punched out margins if it is there in the image or if they mention in the question so deep ulcer with punched out margins okay so definitely this is the case of an arterial ulcer okay this is what is the case of an arterial ulcer so the margins are very important guys to make a diagnosis sloping margins Venus ulcer punched out margins in a deep ulcer usually an arterial ulcer and in ulterior ulcers please remember the patient commonly has pain why because the arterial ulcers are due to artery blockage and if there is blockage in artery or there is an obstruction in the artery it will be decreased blood supply to the nerves also in that area that causes pain in the patient okay so it is associated with pain next we can see over here please remember these are called as the trophic ulcer the one which are usually seen in the sole of the foot they are called as a trophic ulcer okay so one of the subtypes of a trophic ulcer is usually seen in the one of the subtype of a trophic ulcer is seen in the heel area and that is what is known as a pressure sore the pressure sore is due to excessive pressure which is exerted on the pressure points okay so trophic ulcers are usually seen in patients of diabetes mellitus or leprosy trophic ulcers are usually seen in patients of diabetes mellitus or leprosy and important is Tropicals are painful or painless they are painless why because diabetes mellitus patients are suffering from neuropathy and leprosy patients are having neuritis so in both the conditions the ulcers the tropical cells are painless usually okay so there will be painless ulcers but which kind of margins will be there so these are painless ulcers which are having please remember which are having again punched out our margins yes here also the ulcer will have a punched out margin so painless ulcer with punched out margins what did I tell you arterials are painful okay but trophic ulcers are painless both of them are having punched out margins so that will help you to differentiate painless is arterials are sorry painless is a trophic ulcer and painful is an arterial also again important is that to be remembered and second important thing that you need to remember over here these are non-healing ulcers they will not heal you might have seen a patient of diabetes getting ulcer that ulcer does not heal on time so it is a non-healing ulcer okay and see all these ulcers treatment is always dressing proper dressing should be done proper one hygiene should be maintained next the last one that you need to remember I'll talk about pressure so separately as well this last ulcer that you have in the image okay this is what is called as a marginal in salsa a very common ulcer which is commonly asked in your exam okay this is what is called as a margarine salsa if I talk about the margins ulcer guys important is marjolins Ulcer is a painful or painless ulcer it is a painful ulcer first important thing it is a painful ulcer next where it will be common it will be common at the site where there was a burn scar so okay and if there is a burn scar over there so definitely at the site of burns car marginal ulcer is more common so margarines also should have a past history of burns it usually has past history of burns usually and what is the risk factor in a marginal salsa the risk factor in a marginal in sulcer is there will be higher risk of squamous cell carcinoma yes and that has been a question which type of ulcer has highest risk of squamous cell carcinoma so only ulcer which has the highest risk of squamous cell carcinoma is marginal in salsa yes margarine salsa can pour the progress into squamous cell carcinoma that is the reason why here the treatment is not only dressing here we need to go for a surgical excision here we need to go for a surgical excision of the ulcer why local excision should be done that should be done important please remember this the philatic ulcer please remember cephalitic ulcer also has punched out margins usually okay next is this what is this so you can see there is infection of the pulp space of finger so this is what is called as the pulse face this is the nail and this is what is called as a nail bed okay so these two infections are different so if there is infection of finger pulp space if there is infection of finger pulp space this is what is called as a fellow if there is infection of the pulse face of finger this is what is called as a fellow is it a bacterial or a fungal infection so it is a bacterial infection please remember it is a bacterial infection usually that is what is known as a fellow please remember okay so fellow is usually a bacterial infection which occurs in the pulp space of finger but if they say there is a viral infection which occurs in the pulse space of finger usually due to herpes simplex virus then that is what is called as a Whitlow herpetic Whitlow so please remember both are infections both are infections in the pulp space of the finger but if it is bacterial in nature it is called as a fellow but if it is herpetic or if it is viral in nature it is known as a vitro so that's the basic difference next is this infection over here you can see this is not the infection of a Fingal pulp this is the infection of nail bed so if they give you this image infection of nail bed that is the most common infection of hand please remember this infection is the most common infection of hand this is the most common infection of hand so this infection of nail bed is the most common infection of hand and that is what is called as paronychia that is what is called as paronychia you can see there is inflammation redness swelling and all of that along with that you can see pus collection is also there the management of paronychia is not only by giving antibiotics or by draining the pus antibiotics and drainage should be done only but along with that in majority conditions we also need to go for a partial nail excision over here you also need to go for a partial knee laxation and that is important to be remembered okay this has been asked as well take a partial nail excision has to be done in a case of paronychian most of the condition next up if I talk about this type of a wound what is this type of a wound usually on the shin or the leg area of the patient and it is commonly associated with the condition that is called as IBD what is IBD I have told you IBD is inflammatory bowel disease and this condition IBD or inflammatory bowel disease can be of two types it can be either Crohn's disease or it can be ulcerative colitis this type of a wound or an ulcer it's commonly associated with ulcerative colitis it's commonly associated with ulcerative colitis and second condition where it can be seen as rheumatoid arthritis so in these two conditions this infection which is seen in the leg of the shin area this infection is what is called as bioderma gangrinosum a previous year question again this is called as bioderma gangrinosum that too has been asked twice in the examination guys bioderma gangranosum and pyoderma gangrenosum is again an ulcer so you will say Sir again how to differentiate this ulcer so please remember this ulcer which is there it has undermined edges what do I mean by undermined inward edges so this also as you can see the edges or the margins of this ulcer are inwards they are undermined so if there is undermined edges of an ulcer okay so undermined edges of an ulcer in the leg of the skin area it is likely suggestive of shankroid so you will say Sir undermined edges also seen in other conditions yes they are they are also seen in case of a tubercular ulcer but various tuberculos are also more common usually in the neck region tubercular ulcer is usually more common in the lymph nodes area around lymph node so tubercular also also has an undermined edge but it is common in the neck region second it is seen in pyoderma gangrenosum which is seen in the shin or the leg area and it is associated with these two conditions and third important where we can see this undermined edges is usually the shankroid I hope all of you have studied Dharma so in that you have studied that painful genital ulcer occurs due to hemophilus Dupri that is known as chancroid over there also we can see a generator ulcer with undermined edges okay so I'm covering all the topics right so that is what is called as integration and that is how you need to study next one you can see again a previous year question multiple times asked once they have given the image another time they have mentioned the diagnosis clearly and this condition you can see multiple red patches all over the body of the patient and they are changing their site from one side they are going to another site so this is what is called as migratory necrolytic erythema this is what is called as necrolytic migratory Aroma or migratory necromite arithmet is called as migratory necrolytic erythema erythema is nothing but red patches or red rashes over the body and why migratory because it keeps on changing sites from one side to another okay and they have asked thus migratory necrolytic aridma is associated with which condition or which malignancy so please remember this migratory necrolytic arisma is commonly associated with a pancreatic cancer and pancreatic malignancy and that is what is called as glucagonoma that is what is known as glucagonoma twice asked question in your exam again so this was also a recent PG question and also came in the previous examination of fmg glucagonoma is commonly associated with this necrolytic migratory erythema next is this one here you can see there is a widespread infection in the leg of this patient and you can see some balloons also right blephs are formed and these blephs contain nothing but gas okay these contain gas so this is the case of gas gangrene this is the case of gas gangrene I hope all of you are quite aware now gas gangrene is due to organism and what is the most common cause of gas gangrene okay I'm waiting for your answer now this is a very easy question all of you should be able to answer gas gangrene what is the most common cause of gas gangrene now gas gangrene white is called as gas gangly because this organism of this bacteria which is there it produces a lot of gas and here this infection can also spread to the whole body of the patient the patient can land up into sepsis there can be damage to all the muscles as well my own necrosis and the patient can also die in cases of gas gangrene that's important okay so usually diagnosis can be done with the help of a biopsy and a culture biopsy and culture are required to make a diagnosis in a case of gas gangrene okay what does the most common cause very good which species of colostridium very good it is clostridium perfringence previously called as prostodium Valkyrie so calcium perfringence is the most common cause of gas gangrene that you need to remember next is this condition both these conditions are necrotizing fasciitis both these conditions are necrotizing fasciitis what do I mean by necrotizing fasciitis so fascia it is in literal terms I hope all of you are quite aware it is it is nothing but inflammation inflammation of what inflammation of the fascia so if there is inflammation of the fascia definitely it is called as fasciitis but when the fascia undergoes necrosis that is what is called as necrotizing fasciitis so it is such a severe infection where the facial is undergoing necrosis that is called as necrotizing fasciitis there are two variants of necrotizing fasciitis if the necrotizing fasciitis is seen in the scrotum this is what is called as the forniers gangrene if necrotizing fasciitis is seen in the scrotum that is what is called as forniers gangrene a previous year question of fmge okay that is the previous year question of fmg but if they say and if they give you this image which was given in the recent neat PGA examination 2023 if there is necrotizing fasciitis of the abdominal wall so necrotizing fasciitis of the abdomen please remember this is what is called as the melanese gangrene okay necrotizing fasciitis of the abdominal wall is what is called as the melanese gangrene okay so these are the important two terminologies you need to remember necrotizing fasciitis of stratum foreigners gangrene necrotizing fasciitis of abdominal wall melanese gangrene okay next if I talk about sepsis guys we are talking about once now so I'll just finish it off sepsis if I talk about sepsis is nothing but combination of two things what is sepsis so if you can see a known focus of infection for example if a patient is having some infection over here the patient is having an ulcer over here or the patient is having some boil over here that is a foreign there should be known focus of infection but along with known photograph of infection to diagnose sepsis there should be another thing as well I hope all of you are quite aware whenever a patient suffers from infection the body tries to protect and how what is a protective response of body known as the protective response of body is called as inflammation but inflammation yes inflammation is a protective response of body but and when it is in the limits it is fine or it is rather beneficial for the body but when the inflammation goes out of control when the information will go out of control that will be damaging the body okay and that out of control inflammation is what is called a source what is known as Source systemic inflammatory response syndrome if there is a known focus of infection infection along with that there is source that is in systemic inflammatory response syndrome that means the inflammation has spread to multiple organs in the body okay so all of these factors together is what is called as sepsis in a patient okay yes in systemic inflammatory response syndrome the patient can either have hypothermia that means the temperature of the body can be either less than 36 degree Centigrade or more than 38 degree Centigrades the patient's respiratory rate will be high the respiratory rate will be more than 22 breaths per minute the systolic blood pressure of the patient will be low less than 90 millimeters of mercury so all of these factors at least two of these factors makes a diagnosis of source and if Source infection that is what is sepsis what is septic shock then so septic shock is nothing but sepsis plus hypotension so a lot of people will feel a question let me tell you all of these questions have been asked these are simplest definitions and that you need to know right that you need to know yes as doctors you need to treat sepsis as well now so you need to know what a sepsis first of all septic shock is what septic shock is nothing but sepsis along with hypotension or decreased blood pressure along with hypertension or decreased blood pressure is what is called as septic shock very good and that's that hypotension or that low BP if it is not corrected by fluids then we can make a diagnosis of septic shock that means the hypotension or the low blood pressure which is not responding to fluids that is what is the case of septic shock next assessment of septic shock or sepsis in a patient is usually done by help of a score and that score is what has been asked in the recent fmg examination as well as recent need pj examination and that is what is known as the sofa score okay so so far what is the full form of sofa that has been asked again the sofa is nothing but sepsis related so far is nothing but sepsis related or sequential okay sepsis related or sequential organ failure assessment score it is sepsis related or sequential organ failure assessment score again that is what is known as the sofa score and that will help you assess that how much severe the sepsis is in the patient or how many organs have been damaged due to sepsis in this patient okay so sepsis related or sequential organ failure assessment score but sepsis are sorry a sofa score the traditional or the conventional sofa score is there are many factors in the conventional sofa score therefore in cases of emergency we follow nowadays the Q so far what does the q small q stands for Q stands for quick so it has quick sequential organ failure assessment score that is known as the Q so far and the three parameters of the queue sofa score has been asked in the recent need PG as well as in recent fmg examination the queue sofa score you need to remember it has three parameters remembered by the mnemonic bar and the three parameters of the sofa score are remembered by bar where B usually goes for systolic blood pressure B goes for systolic blood pressure when the systolic blood pressure of this patient is low less than 100 millimeters of mercury at least remember the parameters don't remember the criteria address remembers systolic blood pressure and a goes for altered mental status okay a goes for altered mental status and how do you assess mental status of a patient yes you assess it with the help of a score called as GCF Glasgow comma score so sometimes they can mention altered mental status sometimes they will mention GCS so both of them are fine and lastly our R stands for respiratory rate R stands for respiratory rate okay so if the respiratory rate of the patient is more than 20 breaths per minute that is the third parameter of a q sofa score okay so important is Q so far score has three parameters remembered by the mnemonic Bar B goes for systolic BP less than 100 a goes for altered mental status assessed with the help of a score known as GCF or Glasgow Coma score and R goes for respiratory rate where there will be a higher respiratory rate more than 20 breaths per minute that is tachypnea next if I talk about some surgical swellings important ones this surgical swelling that you can see usually over the lateral or the outer cancers of eye okay this is what is called as a dermoid cyst this is what is known as a dermoid cyst the same image had come earlier in examination as well okay so this is the case of a dermoid says please remember while dermoid sisters form nothing but the epithelial elements if they get trapped along the lines of embryonose fusion simple terms only if the epithelial elements they get trapped somewhere in the body that forms a dermoid cyst so dermoid means nothing else but entrapment or collection of some epithelial elements that is what is a dermoid zest important is what is the treatment of a dermoid cyst guys the important as treatment usually of a dermoid cells is nothing but surgical excision that was another previous year question once they only asked you to make a diagnosis other time they ask you what is the treatment of the above given condition answer is surgical excision okay and the most common side which is shown in the image is the same one it is the lateral or the outer cancers of eye only most of the times okay next is the swelling over here what you can see there is some swelling small small swellings over the scrotum of this patient rather it is not single but multiple swellings over the scrotum of this patient so this swelling can also appear on the scalp of the patient it can not only be present over the scrotum but sometimes it can also be present over the scalp why what is common between these two sides scalp and scrotum is so in both these sites we have hair follicles in both the sides whether it is your scalp or whether it is your scrotum we have hair follicles and what opens along with the hair follicles I hope all of you are quite aware along with the hair follicle a gland opens on the skin all along with the hair follicle a gland always opens and that gland is what is called as your sebaceous gland that gland is what is called as your sebaceous gland so if the hair follicle duct or the sebaceous duck gets blocked then we can get this type of a swelling and this swelling arises from the sebaceous gland itself and therefore this type of assist or a swelling which is formed is known as a sebaceous cyst okay this is what is the case of a sebaceous cyst important as sebaceous cyst is more common in the scalp or the scrotum because it is nothing but swelling arising from the sebaceous gland and we know sebaceous gland always opens along with hair follicles so when the hair follicular duct gets blocked that causes formation of a sebaceous cyst okay treatment over here is again a surgical excision treatment over here is again a surgical excision of a sebaceous cyst please remember that okay very good next important is this swelling which has come a lot of times in the neat PJ examination and it can anytime come in your fmg examination what you can see the patient is having a cheek swelling over here but important another feature is this cheek swelling is also elevating the lobule of the ear okay so if the ear lobule is lifted up due to a swelling if the earlobeals due to the swelling cheek swelling this is what is the characteristic or the Hallmark feature of a parotid swelling this is what is the characteristic feature or Hallmark feature of a parotid swelling so how to differentiate a parroted swelling please remember what is the Hallmark of a parotid swelling is important the Hallmark of a parotid swelling is usually the ear lobule is lifted up lifted up in a case of parotid swelling why there will be a swelling arising from the parotid gland it can be just a infection on the parotid gland that is parotitis and pyrotitis has commonly seen in children during an episode of mumps so in the case of mums it can happen or it can also arise due to a parotid tumor and the most common parity tumor we know it is pleomorphic adenoma okay so in both these conditions there can be this paradise swelling and please remember this is the way to differentiate parody swelling from all other cheek swellings so parotid always causes lifting up of the earlobul next is the swelling over here this swelling which is seen in the Floor of mouth Yes the swelling which is seen in the Floor of mouth this is what is called as a granula and what is granula lanula is nothing it is cyst what is the cyst in simple terms okay cyst means sac and that Sac contains some kind of fluid inside it okay so here you can see a Sac or a cyst which is there which is present in the Floor of mouth a cyst present in the Floor of mouth and what does this cyst contain this cyst contains a lot of mucus inside it okay this cyst contains a lot of mucus inside it so a mucus containing cyst okay a mucus containing cyst in the Floor of mouth is what is known as granular and the granular you usually involves which gland so please remember the granular generally involves the sublingual salivary gland granular commonly involves the sublingual salivary gland okay and if I try to flash a torch from here if I try to flush a torch what will happen the whole swelling will glow up okay the whole swelling will blow up okay due to the light of the torch and that is what is called as which test that test is known as the trans elimination test last test is what is called as the trans elimination test so the trans elimination test is positive the trans elimination test is positive in cases of granula trans elimination test is also positive in other swellings and what are those other swellings so please remember this trans elimination test that means when the swelling will glow with light after flashing a torch this trans elimination test is positive in cases of granula it is positive in cases of a neural tube defect known as meningocele when there is only meninges and CSF inside the cavity meningocele third important it is also positive in a case of hydrocele okay hydrocele which is a swelling arising in the scrotum and fourth it is also positive in cases of a and Post Road lateral neck swelling known as cystic hygroma so cystic hygroma hydrocele granula and meningo seed are the four conditions where you need to remember these swellings are brilliantly trans illuminant what is the treatment so treatment is please remember usually it is the cyst excision the cyst or the sock which is there not you need to remove that sauce so cyst excision along with sublingual gland excision yes you also need to remember the sublingual gland otherwise again there will be granular formation so sublingual gland excision should also be done no issues with this anybody so that was all about your wants and the swellings as well we have covered so next will be trauma so let's take a break okay let's take a break and then we'll start with trauma because I want all of you fresh for trauma again thank you so much shall we start I'm on Audible please let me know if the audio visuals are clear please let me know if the audio visuals are clear guys hopefully the audio visuals are clear no you can begin then can we restart please let me know give me a thumbs up in the chat box so I can just begin now Audible yeah good job now starting with trauma now okay a very important and interesting topic that you need to remember and that is what is trauma so if I talk about trauma guys important is the first thing that you need to remember why is trauma so so much important because we know a lot of people nowadays are facing road traffic accidents every day right and they sustain a lot of trauma and then they come to the emergency they are brought to the emergency and usually the frontliners who deal with them are mostly the surgeons right so usually they are the emergency medicine people or the surgeons who have to deal with them and definitely the authoritations as well now important is you need to remember trauma why because a lot of deaths occur after trauma now if they ask you what is the most common cause of death after trauma if they ask you what is the most common cause of death after trauma now there are usually three types of deaths which occur please remember after trauma if there is immediate death on spot okay that is what is called as immediate death if the patient dies on spot itself that is called as the immediate death and the most common cause of immediate death as well as overall also the most common cause of death after trauma is usually a severe head injury the most common cause of on spot death or immediate death after trauma is usually a severe head injury that's important other cause can be transaction or injury to the main main blood vessels of your body injury to the mean blood vessels of your body as well so that can be immediate causes of death or the early causes of death early causes of death after trauma what is the only cause usually only causes that means the patient dies within one hour of trauma so if the patient dies within one hour of trauma usually the causes of death can be multiple okay so few causes you need to remember so one of the cause can be Airway obstruction yes the patient's Airway was completely blocked okay so one of the causes can be Airway obstruction other cause can be pneumothorax in the patient okay other cause can be pneumothorax in the patient as well again apart from that the patient can also have cardiac tamponade yes the patient can have a cardiac tamponade that can lead to death or the patient had a circulatory arrest that means the patient went into shock severe shock so the patient had a acute circulatory arrest there was a severe shock in the patient or sorry or the patient had a severe tracheal bronchial injury okay the patient had a severe bronchial injury as well or the patient had a massive hemothorax what is hemothorax collection of blood in the thoracic cavity where thoracic cavity May exactly around the lungs that means in the pleural cavity when there is excess collection of blood in the pleural cavity that is what is hemothorax when there is excess collection of blood in the pericardial cavity that is what is cardiac tamponade okay so these are the important causes of death after trauma within the first hour of trauma okay so that's you need to remember so usually if they ask you what is the golden R after trauma so please remember your answer should be the first hour after trauma is considered as golden R after trauma because if we give medical help to the patient within this one hour of trauma if we give medical help to the patient within this one hour of trauma most of these deaths can be avoided okay most of these deaths can be avoided so that's the important thing that's the reason why the first R after trauma is called as the golden R after trauma and platinum minutes are so Platinum minutes are usually the first 10 minutes after trauma are known as the Platinum minutes usually foreign basically if a patient for example okay there was a bus accident or a train accident in a specific area and that area is usually in the periphery okay it only has a very small small Hospital over there it has very small hospitals there is only a single government Hospital over there now what will happen there will be a lot of people who require medical help that too at the same time all of these people will flood the hospital at the same time and we will not be able to manage all the patient at once definitely because the workload will be limited okay the workforce will be limited that's the reason why we need to segregate the patient we need to categorize the patient once in Hindi so please remember bus accident your train accidents means nothing else but it is segregation of patient price means nothing but segregation or we can say separation we can say categorization also so price is nothing but segregation of patients when usually during a case of mass casualty what I described right now like a bus accident or a train accident is a case of mass casualty when many people require help at the same time or in a case of disaster for example floods earthquakes that you might have studied in PSM so it's one and the same thing over here as well okay so in the case of disaster when a lot of people require medical help at the same time so that is segregation of patients in a case of mass casualty or a disaster based on two parameters and what are these parameters so one is likelihood of survival and second is severity of injury likelihood of survival means what which patient can be saved okay and second is severity of injury these patients are divided yes first is definitely which patient can be saved that means konsa patients likelihood of survival and second concept patients are the severely injured that is called a severity of injury both of these parameters definitely are taken into consideration when we need to segregate the patient but important among them one factor if they ask you then answer should be likelihood of survival why because likelihood of survival is the better Factor just pay we will categorize or we will segregate the patient followed by severity of injury both are factors both parameters are definitely taken into consideration but the major factor which is taken into consideration is likelihood of survival that means constipation please remember that okay don't worry abhinandan please remember whatever I am saying in Hindi is I've already spoken in English as well please remember whatever I'm speaking in English that I am repeating in Hindi for those people who are finding it difficult to follow up and follow up with meaning in English Okay so we need to take care of both of them right I am using both the languages you don't have that fear that I am saying something different and no please remember I'm seeing this and repeating the same thing in Hindi also okay but we need to consider everyone over here right so that's the important thing so that is what is trial so once they have only asked you the definition of tribes the trash is nothing but segregation or separation of patients into various color-coded categories based on likelihood of survival followed by severity of injury in various color-coded categories and what are these four color coded categories in which we will categorize a patient the first one the highest priority is given to the red category the highest priority is given to the red category so please remember the red category is given the highest priority and definitely here we have patients who required some urgent intervention okay who require some urgent Intervention which kind of patients usually the patients who are gasping for example or the patients who are having huge blood loss so the patients who require basic resuscitation so immediate basic resuscitation they are the patients who come in the red category or the patients who require a limb or a life-saving surgery the patients who require a limb or a life-saving surgery if the patient is requiring a limb or a life-saving surgery that is what is the red category surgery that is red category patients no issues with this anybody next is what is the yellow or the blue category patient so if I talk about the yellow or blue some places have the yellow category some places have the blue category so it's one category only so yellow or blue category these patients are given high priority these patients are given high priority and which are these patients these are the patients who now don't require resuscitation these possibly may require resuscitation okay resuscitation so the patients who possibly might require resuscitation or the patients who require a limb or life-saving surgery the patients who require a limb or a life-saving surgery in a span of 6 to 24 hours okay in a span of 6 to 24 hours not immediately within six hours but yes within span of 24 hours they might require a limb borrow life-saving surgery okay next the third category is what is the green category and what are these green category patients so these green category patients are low priority patients green category patients are low category patients who are these patients those patients who are having some minor injuries only okay the patients who are having only minor injuries they are categorized in the green category so these are chaltas as a patient okay the patients who are walking easily these are known as ambulatory patients okay so the patients who can walk when we are having minor minor injuries are known as ambulatory patients and they are categorized in the green color category okay so ambulatory patients or patients with minor injuries they can say or they can say walking wounded patients okay they are wounded definitely but they have are have they are having very small wounds therefore they are easily walking as well and the last category which is given the least priority okay they are treated at last so the ones which are giving the least priority are the black color-coded category okay they are known as the black colored cat black category patients they are given the least priority and please remember why I said that the variety of injury is the second most important factor because if severity of injury would have been the most important factor then black color coded category should have been the most preferred category or the most prioritized category so that's the important thing now now you understand me so please remember black color coded category is the least prioritized category they are given least priority because these are the most severely injured patients who cannot be saved so which are the patients in black color category usually these are the dead patients or these are the Maori Bund patients okay who are about to die or they are unsalvishable patient and that was the term which was used unsalvageable that means the patients who could not be saved even after your best efforts you cannot save the patient these patients will be called as unsalvageable patient okay so dead moribond or unsalvageable patients are categorized in the black category no issues with this anybody so this is what is called asteroids a very important question of your examination next if I talk about once definitely a patient is categorized at the site of injury or that the site of accident itself or if the patient has not been categorized once the patient is brought to the hospital you need to categorize the patient or you need to perform the triage of a patient okay then you know which patients should be given the most priority and we should be given the least priority okay now once you start the resuscitation of the patient what does do what do I mean by resuscitation I have told you all the things that you do to save a life of a patient okay so the protocol or the guidelines that you follow to save the life of a patient is what is called as resuscitation in short okay now that resuscitation in a case of trauma is usually done with the guidelines and these guidelines are usually known as atls guidelines or atls protocol what is atls you need to know the full form atls is nothing but Advanced Trauma Life Support atls is nothing but Advanced Trauma Life Support please remember that okay so Advanced Trauma Life Support is definitely the guidelines that you need to follow while saving the patient who has come to you after a trauma okay so that is what is Advanced Trauma Life Support important is what is the sequence which is followed or resuscitation in a case of atls protocol so if you are performing resuscitation in a patient if you are trying to save a life of a patient after trauma okay you are following some guidelines those guidelines are called as atls protocol now what is the sequence to be followed will you give highest priority to Airway or will you give highest priority to the circulation of this patient so is it a b c d or is it c a b what is your answer but I need answers now what does the sequence for resuscitation that was a previous year question again what is the sequence for resuscitation according to atls protocol what is the sequence of resuscitation guys sorry let me know once the sequence of resuscitation which is followed anybody hello I'll tell it to you so this has been asked it is a b c d e yes Airway has to be given the highest priority followed by breathing followed by circulation followed by disability followed by exposure okay so please remember what does this ABCDE stand for so please remember a stands for Airway management you need to take care of the airway of this patient Airway management P stands for breathing management okay you need to look out for any problems in breathing of this patient C stands for circulation management C stands for circulation important previous year question what does b d what does d stand for in a atls protocol or in a sequence of resuscitation that has been a question in FMJ examination so we know now d stands for what d stands for disability management okay so d stands for disability management it does not stand for any dehydration or anything else okay so d stands for disability management was a pyq and lastly e stands for what e stands for exposure with environmental control so e stands for exposure with environmental control I'll talk about these don't worry about that okay so e stands for exposure with environmental control now you will see sir Cab's protocol is followed where now so please remember c a b is the protocol where circulation is given the utmost priority this sequence is generally followed if a patient has underwent a cardiac arrest that means you are standing on an airport and there a patient suddenly collapsed okay so the patient was suffering from Cardiac Arrest there was no pulse in the patient no breathing efforts were seen in the patient TK so such a patient who is under Cardiac Arrest the protocol that we follow is not the atls one then the protocol is known as a BLS protocol that is known as basic life support basic life support or it is called as ACLS that is Advanced cardiac life support okay so BLS or the ACLS protocol is followed please remember if a patient has underwent a cardiac arrest and then the sequence which is followed then the utmost priority should be given to circulation management and we immediately start chest compressions on that patient so that is the topic of medicine and anesthesia you will discuss it over there no issues with this let's continue with Ramana ATL so if I talk about surveys in a patient of so usually as we initiate the etls protocol okay as we initiate or as we start the etls protocol in a patient we need to do two types of surveys and what are these two types of surveys one is called as a primary survey and what is done in a primary survey resuscitation is done in a primary survey and which sequence is followed that we have already discussed it is a b c d e okay so primary survey is nothing but the survey which is done for resuscitation that is the sequence followed as ABCD the next one that we do is called as a secondary survey the next one that we do is the secondary survey in secondary survey we do important two things one we try to collect the history of a patient and that history is what is called as the ample history we try to collect the history of a patient known as ample history a stands for what so please remember over here the a stands for allergies okay if the patient is having any kind of allergy if the patient could not speak because if the patient is in trauma if the patient is in coma or he is unconscious then you should ask the attendance of the patient okay or whoever has brought the patient to the emergency okay so you need to see whether the patient has any kind of allergies second you need to see whether the patient is having any medical condition that means if the patient is suffering from any diabetes mellitus hypertension or anything else or if the patient is taking some medicines if the patient is currently taking some medications then P stands for what P need to stand for any past history of the patient that means whether the patient has underwent any surgery in the past surgery should be taken or P also stands for pregnancy if it is a female in the reproductive age group you also need to take the history of pregnancy in the patient l stands for what usually L stands for last meal because in most of the cases of trauma we need to intubate the patient okay so that's the reason why we ask about the last meal of the patient as well please remember that okay so last meal of the patient should be asked because if you need to take the patient for intubation or for surgery we need to give anesthesia and if we give anesthesia the risk of aspiration will be very high okay so that's the reason we need to asked about last meal and if for events which have caused trauma the events which has caused drama you need to ask about that as well and second thing that you do in a secondary survey okay apart from taking the ample history the second thing that you do is usually search for all injuries okay search for all injuries because in the primary survey you are busy saving the life of the patient okay you are busy resuscitating the patient once you have saved the life of a patient Now search for all other injuries that the patient has sustained injury patients but look everywhere to search for these injuries okay so now if I talk about one by one a stands for Airway management so usually Airway management is not done alone we also go for cervical spine production along with Airway management we also go for cervical spine production when do we give cervical spine protection when we suspect that the patient has sustained a cervical spine injury that means in that condition we need to give utmost priority to the cervical spine production please remember yes cervical spine production precedes over Airway management yes very important okay cervical spine production even before Airway management reason is if there is a cervical spine injury for example if there is a cervical vertebra fracture in a patient after trauma what will happen if this cervical vertebra fracture is there okay and if we try to extend the neck of the patient if you try to extend the neck of the patient what will happen now this fractured cervical fragment the structured fragment of the cervical vertebra go and hit the medulla oblongata it goes and hits the medulla oblongata and we know medulla obligators a very important organ of your body which contains the vital centers of your body your respiratory Center and the cardiovagal center both are located in the medulla oblongata if the medulla obligator is injured the patient will die on spot okay so that's the important thing you see the a that's the reason why cervical spine production is given the utmost priority even before Airway management and in cervical spine production what should be done we should try to immobilize the cervical spine we should not move the cervical spine immobilization of the cervical spine is done usually how that should be done usually you should transport the patient on a hard surface and you should strap the patient usually okay so that the patient should not move okay or you can just stabilize the cervical spine of the operation okay so that should be done immobilize the cervical spine for that generally we apply a hard cervical collar and that hard cervical collar that we apply is also known as the Philadelphia color around the neck of the patient we apply a hard cervical collar known as the Philadelphia column no issues with this anybody that's important then if I talk about Airway management if I talk about Airway management guys when are you going to manage the area of a patient when you feel that the airway is blocked or the Airways obstructed how do you get to Nokia the airway of the patient is obstructed so there are some danger signs which can tell you that the patient's Airway is blocked and what are these danger signs which are going to tell you the patient service block first important is the patient is unable to speak so if the patient is unable to see speak that means there can be some obstruction in his Airway first thing second important sign if the patient GCS is very low that means a GCS of less than equal to 8 the Glasgow comma score of less than equal to 8 which is also suggestive of severe head injury in that condition also you need to manage the airway of the patient third important if the patient is in coma comatose patient okay so comatose patient is also at a risk of having some Airway obstruction as well okay or there can be aspiration as well important next one if there is any facial trauma so if there is any facial or neck trauma there will be higher chances of Airway obstruction in this patient as well okay so any maxillofacial injuries in the patient okay neck injuries in the patient okay so all of these are signs danger signs that you need to manage their way and for Airway management what is the definitive area of choice if a patient comes to you with some Airway obstruction first of all what should be done if a patient is having some problem with Airway if there is some Airway obstruction guys if there is some Airway obstruction you will try to clear the airway right you will try to clear their way that means if there is some foreign body in their way you will try to remove that foreign body particularly okay so important is that but if there is no foreign body there are a lot of secretions in their way what do I mean by secretions a lot of blood is present a lot of fluid is present in the area of this patient due to which he is not able to breathe or not able to speak so definitely you will do suction of all these secretions all of these secretions should be removed that is suctioning should be done and even after that the patient's Airway is not opened up properly then you will go and perform these manures and these manures have been given in the recent need PG examination and they have also appeared in the FMJ examination earlier so this was the recent need pj exam question okay so which is the manual followed in a case of atls protocol this manual to open up the airway of this patient so you can see when this maneuver is performed the airway is straight now okay the airway will be straight in this patient this manure is known as what are we doing we are tilting the head of the patient and we are lifting the chin of the patient this is what is called as the hey tell it on a chin left manure this manure is known as the head tilt and a chin left manure so that should be done okay so head tilt and a chain left manure should be done in a patient to open up the airway properly the next one that you have is called as a jaw thrust manure here you will give a sudden jerk or a sudden thrust to the jaw of the patient so that if the airway is blocked also it should open up okay so this is known as the jaw thrust manual so these are the two manuals that we can perform to open up the area of the patient properly no issues with this anybody that was about your Airway obstruction okay then definitely if the patient's Airway is blocked or the patient is not able to breathe properly okay we will also assess the breathing of the patient we will see what is the rate of breathing that is respiratory rate we will see if the chest is rising equally on both the sides or not or if the patient is having a deep breathing or not or only the patient is having that is a shallow breath okay on we will try to assess there is enough oxygen saturation of the patient or not with the help of a pulse oximeter okay so breathing and management should also be done breathing breathing assessment should also be done if the patient is not able to breathe properly then definitely we need to insert an airway from outside and what is that definitive Airway of choice what we generally do if a patient is not able to breathe definitely we try to insert some endotracheal tube okay so we try to insert a endotracheal tube inside the throat of the patient or inside the area of this patient and where this tube goes this tube goes till the trachea it crosses the vocal cords and it is go it will go till the trachea so therefore it is known as the endotracheal tube okay that's important so definitely we will go for an incubation endotracheal intubation to be specific we'll go for an endotracheal intubation now I hope all of you will cover it in anesthesia also the laryngoscope which is used for endotracheal intubation it is a curved blade laryngoscope in a case of adult called as MacIntosh laryngoscope and a straight blade laryngoscope in of Pediatrics known as The Miller's laryngoscope that you might have studied if I talk about endotracheal intubation that means insertion of endotracheal tube into his Airway okay that is the definitive area of choice in a case of Airway obstruction or in a case of breathing problems in a patient if it is not possible why Endo tracker intubation will not be possible because to insert a endotracheal tube the vocal cord should be visible right but if you are not able to see the vocal cords only why because there's a lot of blood in the throat of this patient therefore vocal cords are not at all visible or if there is a lot of swelling of the airway yes there's a lot of swelling of the larynx and that is the reason why the vocal cords are not visible or if the patient is having a maxillofacial injury therefore there's a lot of bleed and again the vocal cords are not visible or if the patient is having a cervical spine injury and I've told you if a patient is having cervical spine injury can you extend the head of the patient or extend the neck of the patient no because there will be risk of injury to the medulla oblongata that is the reason why if a patient is having a cervical spine injury you cannot extend the neck and if neck could not be extended definitely in the trickle intubation is very much difficult or if the patient is having a very short neck okay in all these conditions definitely intubation is not possible or if you try it but you failed okay if endotracial intubation fails then definitely what are the two Airways of choice that we have so usually we have some emergency area of choice which will not take time which will be a very rapid procedure and second it will be time taking but it will be the best procedure that is the definitive area of choice if Endo tracker intubation fails definitely please remember either we will go for emergency procedure and that is what is called as needle cricothyroidotomy what do I mean by this now needle cricothyroidotomy you might have studied in ENT there is a cricothyroid membrane over here on the neck whereas this between the thyroid cartilage and between required cartilage we have a memory known as cricothyroid membrane on this cricothyroid membrane if you are inserting a needle a wide bore needle okay what will happen some amount of air can at least pass by that needle that process is what is called as needle cricothyroid Autumn important is needle cricothyrodotomy cannot be done in smaller children okay which children usually it is contraindicated in children less than 12 years of age why because you can see this Cricut thyroid membrane lies very close to the subglottis of the children okay subglottis is the lower most part of larynx it lies close to the subgrotis if you insert a needle over here there will be edema at this side and that edema will cause subrotic narrowing that is called a subglottic stenosis and the airway can close again so therefore it is contraindicated in children's less than 12 years of age due to the risk of subgrotic stenosis due to the risk of subgrotic stenosis that's the important thing okay but if they ask you important is what is the definitive area of choice so you will say Sir why needle Cricut that thyroid atom is not the definitive area of choice so as I've told you it is only a needle which is inserted over here and it is like very small amounts of air can go at least it can keep the patient alive for a span of only two to four hours okay otherwise there will be subrotic stenosis there also in a span of two to four hours that Airway is going to close so for definitive management definitely or the definitive Airway we will go for another method and that another method is what is called as tracheostomy that means this time we are not going to make an incision or insert a needle over here we are going to make an incision over the trachea I hope all of you are quite aware trachea is made up of multiple cartilaginous rings and in between the Rings we have some membrane okay so we are going to give an incision over the membrane over here we are going to give an incision over the membrane and then we are going to insert a tube and that tube is what is called as a tracheostomy tube okay so the definitive Airway of choice will be tracheostomy if the endotracheal intubation fails or if it is not possible tracheostomy once we do what is the best site for trichostomy between which rings so that's important again important question so the best site for tracheostomy I hope all of you are quite aware it is mid tracheostomy which is done between the second and the third tracheal Rings the best site for tracheostomy is between the second and the third tracheal Rings usually that's the best site for your trachostomy no issues with this and tracheostomy CB there was a question in recent examination and even in fmg as well therefore these are important topics to be remembered as I've told you now there will be a lot of topics which are clinical based okay so now if I talk about regards to me as I've told you here we can insert two types of tubes either it can be a cuffed tracheostomy tube or it can be an uncuffed tracheostomy tube okay cuff is nothing but this balloon which is there okay this cuff or the balloon which is there now please tell me guys this cuff what is the role of this cup that has been asked you can see nowadays the endotracheal tubes also have a cuff the endotracheal tubes also have a cuff and that has been a very important question and a repetitive question of exam what is the role of a cuff or balloon okay so please remember is it used for fixation of the tube is it used for fixation of the tube this is the cuff we inflate the cuff okay in a trick endotracheal also and in a tracheostomy tube also we have this cuff okay so please tell me what is the role of this cuff tubes what is the role of the cuff tubes whether it is a tracheostomy tube or endotrichial tube what is the role of a cuff tube very good very good it is used to prevent aspiration it is used to prevent aspiration because once you have inserted endotracheal tube in a patient okay once you have inserted endotracheal tube in a patient okay and the patient is kept on ventilator now the patient should not start breathing by himself therefore the patient is given anesthesia and the patient is given muscle relaxants now as these muscle relaxants are given all the muscles of his body are paralyzed including the respiratory muscles okay so that's the important thing now what will happen the laryngeal muscles are also paralyzed that is the reason why definitely the patient will not have any cough reflex or gag reflex so if there is no cough reflex there is no prevention anything can enter into the trachea and finally it can go into the lungs okay anything enter into the trachea and it can finally reach to the lungs of this patient so there will be higher risk of aspiration okay so anything can go into the lungs this is known as aspiration the patient can develop pneumonia further or lung abscess as well that's the reason why usually in patients who are mechanically ventilated that means the patients who are on ventilator they are given anesthesia also now that means muscle relaxants that means usually these patients should be having a cuff tube otherwise there will be higher risk of aspiration in this patient okay so that's the important thing that was the question again one was asked keep cuff tubes are preferred for what purpose so they are preferred for preventing aspiration and second they are used in which patient that was a recent question so they are used usually in Ico patients okay or they are used in comatose patients because the risk of aspiration will be high in this patient so they are generally preferred in ic or comatose patients important is that no no issues with this now if I talk about endotrachial intubation as I've told you only important things endotracheal intubation this endotracheal tube can be either inserted by the oral cavity then it will be called as orotricial intubation that is commonly done so more commonly we prefer orotrical intubation also but sometimes we can also insert this endotracheal tube via the nozzle nose or the nasal cavity as well then it is called as nasotracheal intubation which is very less commonly done and nasotracheal intubation is absolutely contraindicated nasotracheal intubation is absolutely contraindicated if a patient is having a base of skull fracture if a patient is having a base of skull fracture the tube can go directly into the cranial cavity and that's the reason why it is contraindicated in a patient of base of skull fracture so that's important about the airway and breathing management of the patient next if I talk about the circulation management of the patient if I talk about circulation management important is the question has been that means if you see the breeding site you try to control the bleeding of this patient and what is the best method to prevent bleeding the best method to prevent bleeding is by applying direct pressure the best method to prevent bleeding is by applying direct pressure so if you do not have anything what do you do you try to apply pressure with the help of your hand okay that should be done if you have a cloth try to apply the cloth around the bleeding site or if you have a pelvic binder that is usually used in cases of pelvic fracture we know pelvic fracture causes 1.5 to 2 liters of blood loss and that can land up the patient into hypovolemic shock okay excessive blood loss now therefore in a case of pelvic fracture always try to apply pelvic binder if it does that is not available tie a cloth around the pelvis of the patient okay so that should be done so direct pressure is the best method to control Hemorrhage or bleeding in a patient now circulation management is done by what once you have controlled the bleeding definitely you need to start fluids in the patient to prevent any kind of hypovolemic shock in the patient and that is usually done by you need to give a lot of fluids but cautious nowadays we don't give excess of fluids and that has been written in baby as well please remember you usually take IV lines in the patient okay you try to get intravenous access in the patient okay and the question was minimum how many gauge cannula should be inserted in a case of trauma or during resuscitation that was a question minimum how many gauge IV lines or minimum how many gauge cannula should be inserted in a case of trauma or during resuscitation in a patient the minimum if they ask you please remember minimum two 18 gauge IV lines are to be inserted mean minimum two 18 gauge IV lines or IV cannulas are to be inserted and 18 gauge for which color 18 is green in color Yes recommended or please remember the difference what I'm trying to say recommended or orange or gray only because they are responsible for Rapid transfusions that is what we need during a trauma but important is if those are not available if orange and gray are not available minimum which can be used minimum is two 18 gauge IV lines okay minimum two 18 gauge IV lines because from both the sides we will start fluids to the patient okay and how much amount of fluid should be given to the patient okay how much amount of fluid should be given to the patient so usually Berry clearly sees one liter of crystalloid should be given initially it was 2 liters but now atls clearly says it is one liter of crystalloid should be given to the patient and which are crystalloids the crystalloid fluids are nothing else but Ringle lactate or normal saline so lingle acted or normal saline should be given to the patient one liter of crystalloids along with that we will also try to control the bleeding of the patient don't give excess of fluids and no colloids are given immediately colloids are given later on if required apart from this definitely we will try to control bleeding if it is not controlled yet with the direct pressure and that is done by giving injection of tranexamic acid that is usually done by giving an injection of tranexamic acid trenexamic acid is also known as tranexa commonly it is a drug which helps in controlling or stopping the bleed okay here one gram is given in a span of first 10 minutes okay 1 gram is given in the span of first 10 minutes and then next one gram is given over the next eight hours the next one gram is given over a span of next eight hours okay so that is what is done please remember blood transfusion can be given if the patient if you suspect that the patient is in class 3 or class 4 hypovolemic shock okay so in severe variety of shock we can also prefer blood transfusion but initially we will only manage the patient with cholesterolides of fluids okay so if blood transfusion is available then that can be done but only in severe varieties of shop no issue still anybody so that was all about your circulation management next was disability management disability management nothing else has to be done disability May usually you try to manage the disability related with nervous system of the patient okay so in disability management you only try to assess is GCS of the patient that is brief neurological examination of the patient should be done apart from GCS okay so GCS you also need to go for a brief neurological examination of the patient okay and you also check the pupils of the patient that is what is meant by disability Management in the patient you try to manage the disability related to a central nervous system and last is exposure and environmental control what do we do we try to undress the patient we try to completely remove the clothes of a patient for example a Burns patient is coming to an emergency we try to undress the patient and try to see the extent of burn how much body surface area of the patient has been burnt that you try to check and second as you are exposing the patient the patient can land up into hypothermia to try to control the environment that means try to control the temperature of your emergency room or your operation theater okay don't let the patient go into hypothermia that is what is e done with trauma but at least the atrs protocol now talking about various other types as well if I talk about shock over here as I've told you a patient after trauma can have excessive blood loss or massive blood loss and the patient's blood pressure will fall that is called as hypotension and has a heart rate will Spike because the heart will try to compensate by beating faster and that is what is called a shock so what is shock shock in simple terms is nothing but hypoxia at cellular level what do I mean by this definition if there is decrease oxygen supply to the cells that is what is shock okay in simple terms what do I mean by shock if there is decreased oxygen supply to the cells that is what is sharp and why there is decreased oxygen supply due to decreased blood supply to the cells due to decreased blood supply to the cells at times there will be hypoxia in the patient and while there is decreased blood supply due to decreased blood volume in the body most of the times but not all kinds of shock will have decreased blood volume right only decrease amount of blood is seen in hypovolemic shock other shocks method blood volume is not decreased so that's the important thing you need to remember okay so hypoxia cellular level or decrease blood supply to the cells is water shock I have told you the blood pressure of the patient falls usually and what will happen to the heart rate as the body tries to compensate the heart tries to compensate to increase the blood pressure okay it will try to increase the heart rate I hope all of you are quite aware cardiac output will determine the blood pressure of the patient and cardiac output is nothing else but heart rate into stroke volume okay so if the stroke volume of the patient is low that means the amount of blood in the body is low try to increase the heart rate so that the cardiac output increases and so that the blood pressure increases so try to increase the heart rate that is called as reflex tachycardia in the patient okay so decrease blood pressure and increase heart rate is what is suggestion of shock in a patient most common type of shock there can be various varieties of shop just one scene rest you cover it in medicine I'll talk I'm talking about hypovic shock important SC please remember if the heart is not beating at all okay the heart is failed okay so if the heart is not beating will there be blood flow to the organs no so the organs will not get enough of oxygen and that is also a shock so if the heart is not able to pump properly and due to that the patient lines up in shock that is called as a cardiogenic shock shock due to heart is known as cardiogenic shock or if the heart is beating too much faster that is in a case of arrhythmia then also blood supply to the organs will not be enough Q because if the heart is beating faster it is not opening up properly does not receiving blood and if the incoming blood is low outgoing blood is also low and if outgoing blood is low definitely the blood to the organs will also be low and that's the reason why this is also a case of cardiogenic shock next if a patient is having severe infection in the body and the patient lines up in sepsis I told you sepsis can further progress to septic shock okay due to the inflammatory mediators there will be vasodilation throughout the body and all the blood will go to the extreme it is all the blood goes to the extremities so will your vital organs of your body receive enough blood no so the kidneys liver heart they will not receive enough amount of blood and again the body goes into shock okay that is called as a septic shock next if a patient sorry if a patient is having excessive histamine release in the body why excessive histamine release occurs due to Allergy if a patient was allergic to something if the patient eats that substance or the if the patient is exposed to that particular substance there is excessive histamine release that histamine causes vasodilation again there is vasodilation in the peripheries all the blood goes to the peripheries or to the extremities again there is decreased blood supply to the vital organs of body that is what is shock that shock which is due to excessive histamine relief is known as anaphylactic shock okay and the one that I've talked about is definitely is the hypovolemic shock that we are going to discuss so the most common type of shock is due to excessive blood loss from the body so if there is in decreased blood in the body definitely the organs are receiving decreased blood and if the organs are receiving decreased blood the organs are having decreased oxygen also that is what a shock okay so the most common type of shock it is due to decrease blood volume in the body and that is hypovolemic shock and why does hypovolemic shock occurs due to excessive blood loss and excessive blood loss is called as which therefore hypovolemic shock is also known as hemorrhagic shock don't get confused hypovolemic and hemorrhagic shock are one and the same thing please remember this trigger another question which came in the fmg examination if a patient is having an isolated head injury that means the patient is only having a head injury there is no other injury in the body isolated head injury can never give rise to hypovolemic shock why such please remember now if there is any head injury and there is bleeding within the cranial cavity this cranial cavity is a closed compartment this cranial cavity is a closed compartment can it expand in size no it cannot because it is protected by the skull bone which is a very hard bone right therefore it cannot expand in size so if there is any blood if it collects in the cranial cavity it will be limited why because the cranial cavity cannot expand so there will be limited blood loss in a case of head injury okay because the cranial cavity could not expand there is limited blood loss in a case of head injury so please remember if a patient is only suffering from isolated head injury only head injury is there it can never give rise to hypovolemic shock that is the important statement because in FMJ examination the question was among all of the following conditions which condition will have least chances of hypovolemic shock and the answer was subdudal Hemorrhage now we know subdural Hemorrhage is a case of head injury in that there will not be so much amount of bleeding that the patient lands up into hypoolumic shock there will be only bleeding around 300 or maximum 350 ML and hypovolemic shock starts when the bleeding is more than 400 to 500 mL chicken so that's the basic idea so if a patient of head injury is having hypovolemic shock if a patient of head injuries having hypovolemic shock you need to search for other bleeding sites you need to search for other breeding sites why maybe the patient of head injury is having hypovolemic shock you know head injury does not cause hypovolemic shock so please check for an please try for any abdominal trauma because maybe the patient is having internal bleeding in the abdominal cavity or the patient is having internal bleeding in the thoracic cavity or the patient is having any bleeding in the neck okay or in the pelvis so these are the sides where the blood can collect and you are not able to recognize it from outside okay so if a patient of head injury is going into shock please try to look for any other bleeding sites as well okay next is if a patient goes into hypovolemic shock what is the earliest indicator or earliest sign of a shop as I've told you if the blood pressure of the patient starts falling what will the heart try to do the heart try to starts beating faster to compensate okay so therefore the earliest sign or the earliest indicator of hypovolemic shock is tachycardia the earlier sign of the earliest indicator of shock is tachycardia and that is important to be remembered okay that has been a question next important all of these these three statements are questioned previous years what is the best indicator to determine the amount of fluid required in shock please answer this one now okay I'll explain it to you in Hindi those who didn't understand how much amount of fluid is required in the patient that you need to determine with which indicator can anybody tell me that how we are going to decide patient how you are going to decide how much fluid should be given to the patient what is the best indicator to determine or to decide foreign capillary veg pressure okay so pulmonary capillary veg pressure can tell you that how much amount of fluid should be given to the patient if that is not an option the second best answer should be CVP that is central venous pressure okay so second best answer should be central venous pressure so the amount of fluid required in a case of shock will be determined with the help of two things either the best answer is pulmonary capillary wedge pressure not an option go for central venous pressure of CVP as your answer if they ask you what is the best clinical indicator if they ask you what is the best clinical indicator of fluid resuscitation or to assess if adequate fluid is administered in the patient of shock or not which is the indicator that will tell you key adequate fluid is given to the patient or not what do I mean by adequate enough amount of fluid okay so please remember which is the clinical indicator that will tell you enough amount of fluid has been given to the patient okay so which among the following indicators which among the indicators can tell you that enough amount of fluid is given to the patient in resuscitation okay so that has been asked a lot of times this is a sarkari question of your exam and that you need to remember is the urine output why urine output now so please remember if a patient is giving enough amount of fluid there will be enough amount of blood supply to the kidneys and if there is enough amount of blood going to the kidneys definitely the urine produce will be enough in the amount so urine output can tell you if the amount of fluid that you have given to the patient is enough adequate or not okay so that is what is urine output so in adult the urine output should be more than 0.5 ml per kg per hour in adult okay and we know children have more urine output therefore not children it should be more than one ml per kg per hour in a child it should be more than one ml per kg per hour that is what is called as an adequate urine output that is the time we can stop the fluid resuscitation next is important two statements as I've told you till now that shock is nothing but the systolic blood pressure of the patient decreases that is what is shock but there is an exception to this okay so all types of shock men the systolic blood pressure is decreased okay so systolic blood pressure is decreased in all types of shock except one and that is what is called as warm septic shock so these are punch liners okay so that can help you make a diagnosis within a minute okay so warm septic shock is one variety where please remember the patient will have increased blood pressure yes okay only one condition of shock where there is increased blood pressure that is what is warm septic shock okay so for the ones who need to under who want to understand it is due to hyperdynamic circulation in the early phases of sepsis there is a hyperdynamic circulation that means the fluid or the blood goes rapidly from the heart to the body rapidly from the heart to the body therefore the blood pressure is increased okay but as it does not stay at the tissues for a longer duration of time the tissues are not able to get oxygen therefore hypoxia at cellular level that is what a shop so that's important systolic blood pressure has decreased in all varieties of shock except one another answer to this question will be one is a big shock next important one line or statement that I would like to make and that is what is all shocks leads to hypotension and tachycardia I've told you what is hypertension decreased blood pressure and what is tachycardia increased heart rate so all types of shock leads to hypotension and tachycardia but hypotension and bradycardia seen in my shop hypertension and bradycardia is seen in a special variety of shock and that is called as neurogenic shock okay so hypotension and bradycardia is seen in a special variety of shock called as neurogenic shock that's important okay so neurogenic shock there is damage to the spinal cord which part of the spinal cord mainly thoracolumbar region so if there is damage to the spinal cord in the thoracolumbar region I hope all of you are quite aware that from tholaco lumbar region which spinal nerves will come out parasympathetic or sympathetic sympathetic spinal nerves okay so sympathetic spinal nerves will come out and the sympathetic spinal nerves are responsible for vasoconstriction of vasodilation they are responsible for weight constriction okay so they are responsible for vasoconstration they will increase heart rate or decrease heart rate we know sympathetic system that means fight flight and fright so it will cause vasoconstriction to the in the periphery and it will cause increased heart rate as well important is now if there is damage okay if there is damage to the spinal cord this thoracolumbar sympathetic fibers are also damaged if the thoracolumbar sympathetic fibers are damaged what will happen vasoconstriction will not happen so if vasoconstriction is not happening in the peripheries what will happen vasodilation there is vasodilation in the periphery so if there is vasodilation in periphery I've told you in other types of shock also all the blood will be going to peripheries all the blood goes to the periphery build your vital organs like heart kidney and liver get enough blood supply no and that is whatever shock next if the sympathetic fibers are damaged definitely the heart rate will not increase what will happen to the heart rate the heart rate decreases and that is what is bradycardia so that's important okay so please remember hypotension and bradycardia are usual features in a case of neurogenic shock that you need to remember these are two important one Linus next if I talk about head Ramana first starting with head trauma so if I talk about head trauma guys I hope all of you are quite aware our head the outermost layer of the health head is called as scalp the outermost layer of the head is called as scalp then we have a bone and that bone is what is called as skull bone also known as your cranial bone okay the bone that we have inside is known as skull bone and then we have the brain okay so if I talk about head trauma there can be injury to the scalp there can be injury to the skull bone or there can be injury to the brain as well now scalp is abbreviation the layers of the scalp has been asked from Anatomy you need to remember that s stands for skin P stands for dense connective tissue a stands for aponeurosis which aponeurosis neurotica L stands for loose areolar tissue and P stands for periosteum what is periosteum outer covering of a skull bone that is periostic okay so if they ask you which is the most dangerous area of scalp the question was which is the most dangerous area of scalp if they ask you which is the most dangerous area or most dangerous layer of scalp then your answer should be lose areolar tissue and why such so please remember the loose areola tissue is considered as the dangerous area of scalp because it contains important winds and what are these events these are known as your Emissary beams please remember the loose areola tissue as it contains the Emissary veins it is considered as the dangerous layer of scalp and what will happen if the Emissary veins are damaged please remember if the loose alveolar tissue is damaged there will be damaged to the Emissary veins that will cause subdural Hemorrhage that will study but important is more than that these Emissary veins are connected to the main vein of your anterior cranial fossa of the brain this drains into the main vein known as cavernous sinus okay so this anterior cranial poster drains into the main vein known as cavernous sinus and this Emissary veins are connected to the cavernous signs and the infection from here can spread to the cavernous sinus and that can cause cavernous sinus thrombosis in the patient therefore rules areola tissue is considered as the dangerous area of scalp no issues with this anybody that's important then if there is a scalp laceration there will be profuse bleeding okay and therefore what is the treatment the treatment is Emergency Management is applied direct pressure with usually a bandage but definitive management is suturing and the suturing in the scalp is done in two layers one layer that we suture first is the aponeurosis and second layer that we suture above is the skin no issues with this anybody that's important now if I talk about some types of skull fractures over here if I talk about skull fracture the first skull fracture which is over here you can see the fracture line is a straight line that you can see over here okay so this type of a skull fracture is known as a linear fracture or a fissure fracture such type of a skull fracture is known as a linear or a Fisher fracture that you need to remember next one here you can see there was a penetrating trauma in linear official fracture which type of trauma was there for example there was a latte injury or a stick injury to the skull of this patient so usually a blunt trauma was there so if there is a blunt trauma to the head or blunt trauma to the skull definitely will be a linear or a facial fracture but if there is a penetrating trauma to the head of this patient penetrating that means you are using the ax okay for example you are using a and then you are hitting a patient's head it will cause such kind of a fracture what is a fracture like this known as it is known as a depressed skull fracture and this depressed skull fracture also has another name this depressed skull structure is also known as fracture signature it is also known as fracture all our signature okay or signature fracture no issues with this anybody next important usually there was a blunt or penetrating trauma to the skull of the patient but there is not any fracture you can see okay there is only a depression or a dent that you can see this is what is called as a indented fracture it is not a fracture actually it is an indented fracture or a ping-pong fracture it is called as it is also known as a ping pong fracture okay or it is also known as The Ponds fracture it is also known as a point structure so this type of fracture will be seen when when the skull is very hard or when the skull is elastic and soft yes very good when the skull is elastic and soft so it is usually seen in the elastic skull of infants it is usually seen in elastic skull of infants usually okay so that you need to remember next important you need to see these are the two important signs and what are these signs suggest you are so these two important signs are suggestion of cranial fossa fracture if I talk about the cranial fossa fractures if I talk about the cranial fossa fractures guys okay important is there are three cranial forces that we have the anterior cranial fossa the middle cranial sposa and the posterior cranial fossa I am writing important points okay so if they ask you which is the most common part fractured in anterior cranial fossa the most common part fractured in anterior cranial fossa over here it is this plate over here and what is this plate of the Tomato known as crib from plate very good okay so it is the crib from plate it is the crib from plate which is the most common part fractured in anterior cranios fossa which is the most common part fractured in Middle cranial the most common part fractured is the Petrus part of your temporal bone because it is very weak okay it is the Peter's part of temporal bone which is commonly fractured in a middle cranial sposa okay so Peter is part of temporal bone and in posterior cranial force of fracture it is the occipital bone okay it is the occipital bone which is generally fractured no issues with this anybody so that's the important part you need to remember okay now important is in anterior cranial source of fracture guys in a case of anterior cranial fossa fracture the patient will have what so the patient will have fracture of the from plate and the scribbleism plate please remember it is a separating plate between the cranial cavity and between the nasal cavity if this plate is fractured now what will leak out the CSF from the cranial cavity will leak out via the nodes and this is what is called as CSF rhinoria the CSF starts leaking out via the cranial cavity and that is what is called as CSF rhinoria it is usually seen in cases of anterior cranial fossa fracture along with that the patient can also have another important sign and what is that the patient has a ectopic bruise I told you what is a bruise or a contusion it is nothing but collection of blood usually ectopic why because there was injury over here and where is the blood collecting over here okay so that's why it is called as a ectopic bruise so this ectopic bruise which is seen or contusion which is seen around both the eyes this is also called as bilateral periobital or echymosis this is known as bilateral periobital echymosis okay and this bilateral periobital eqmosis which is seen in this patient is what is called as the classical word sign raccoons eye or the pandasai okay so it is known as the raccoons eye or pandasai or the raccoon sign or the panda sign please remember that okay so that you need to remember raccoons or pandasai is a feature of anterior cranial source of fracture it is nothing else but bilateral periobital okimosis and you will see why sir is telling about this periobital ecchymosis because in one examination they asked you this sign they didn't ask you the name but rather they describe the sign and a lot of people were confused they asked you what is battle sign and a lot of people marked it as bruising over massage no it is not sorry a lot of people marketed as edema or mastered no it is not edema or menstrual edema or mastoid is seen in ENT it is no it is known as the grassinger sign seen in cases of sigmoid sinus thrombosis this is nothing but discoloration over mastered or bruising over mastered which is seen and when it is seen in cases of middle cranial fossa fracture so in cases of middle cranial force of fracture mcf fracture there is bruising over the master area okay and this bruising over mastoid is what is called as a battle sign that is bruising over the mastoid and that is what is known as the battle sign no issues with this anybody so that's important to be remembered next in Middle cranial spots of fracture also we will be able to see okay the CSF which is leaking out but the CSF will not leak out wire nodes now mostly it will leak out via the ear and that is what is called as CSF autoria that is known as CSF autoria that should be remembered important okay so that is important to be remembered no issues with this once we are done with the cranial force of fracture or the base of skull fractures I will going I am going to talk about a very important and sarkari question of your exam and that is what is intracranial hemorrhages if I talk about intracranial hemorrhages guys now what is the Hemorrhage as I have told you already it is bleeding where is the bleeding within the cranial cavity and therefore within the cranial cavity and therefore it is known as intracranial hemorrhages now important is any type of head injury what is the investigation of choice for head injury the investigation of choice for head injury is definitely a ncct head that you need to remember okay so investigation of choice over a head trauma or a head injury is the ncct head ncct Matlab non-contra CT scan of head okay it is a ncct head now once we have performed the ncct head in a patient of head trauma there can be two things either we can see something which appears white and anything which appears white on a CT is called as what anything which appears white on a CT is called as hyper density if you are able to see something wide or hyper density that is what is suggestive of a bleeding or a hemorrhage that is what is suggestion for bleeding or Hemorrhage but if something appears black on a CT if something appears black on a CT that is called as hypodensity that is known as hypodensity and hypo density or blackish appearance is what is suggestive in fact what do I mean by in fact decrease blood supply causing necrosis that is what is an infact yeah so these are the two things in cases of trauma we are concerned about this Hemorrhage usually now let's talk about the four types of intracranial hemorrhages a very sarkari question okay the first type of intracranial hemorrhage we have done ncct of this patient and then we get this type of a hyper density right now fiber density we get this type of hypertensity which kind idly shape idli or we can call it by convex don't know that I'll say convex okay by convex shape okay so if we are able to get a buy convex opacity if you are able to get a buy convex or it looks like a lens also now so it is also known as a lenticular opacity or hyper density whatever call it okay so by convex or a lenticular opacity or hyper density is suggestive of idli so EDH that is so it is suggestive of e d h what is EDH extra Dural Hemorrhage that means that is bleeding but outside the dura matter I hope all of you are quite aware there are three meninges around the brain innermost spirometer then arachnoid matter then the durameter this bleeding is outside the Euro matter that is extraordinary Hemorrhage so extra Dural Hemorrhage the incity shows a by convex or a lenticular opacity which is the most common vessel which bleeds over here the most common vessel which breeds over here is the MMA that is mixed that is the middle meningeal artery Okay so it is the middle meningeal artery and where does the middle meningo artery lie usually beneath this Landmark what is this Landmark you might have studied an anatomy called as this is what is known as the Tyrion okay so the middle meningo artery usually Lies Beneath this Tyrion okay therefore most of the times you can see EDH in the temporal parietal area itself then there is a very characteristic feature not only seen in EDS it can be seen in other cases of head trauma also but very commonly associated with EDH that means after a patient had a significant trauma so please remember in ADH the patient has a significant trauma that means like a bike accident or usually a road traffic accident after trauma the patient was unconscious for some time then after some time he gained his Consciousness and then again he went into unconsciousness and mostly he dies okay so this is a characteristic picture seen in case of EDH that is called as Lucid interval and that has been asked in your exam Lucid interval is a feature of so you know now Lucid interval is a feature of EDH or extra durious Hemorrhage that is nothing else but a period of Consciousness in between two periods of unconsciousness a period of Consciousness in between two periods of unconsciousness that is what is called as Lucid interval usually as compared to other cases here there is a lot of bleeding therefore we need to go for a surgical management most of the times and that is what is called as borehole surgery if it is very small breed we can only go for a burrow surgery we can make a hole over where over the surgical Landmark known as sterion okay or at the site if you don't have CD available then definitely you can make a borehole at the site itself that is the theory on itself if it is a very huge bleed then definitely a burn hole cannot suffice if it is a very huge or massive bleed then definitely you need to go for craniotomy in the patient okay opening up the cell bone and then removing the blood clot next is this one what is this you can see over here here there is a hyper density which is seen or whitish appearance which is seen in which shape banana shaped usually okay or it is called as a half moon shape and wherever there is Half Moon we call it Crescent okay so here also the opacity is what is called as concave or convex why on one side it is concave the other side it is convex okay so it is known as concave convex opacity also known as concave convex opacity also known as please remember pre-centric opacity I've told you half moon shapes are called as Christians so crescentric opacity okay so that is what is seen and if this kind of opacity is what is seen on the CT scan then we suspect which kind of image we suspect sdh that is subdural Hemorrhage that means here there is a bleeding but where beneath the dura material nature bleeding that is what is the case of subdural Hemorrhage no it shows with this usually subdural Hemorrhage occurs after a trivial trauma what do I mean by trivial minimal trauma like a patient fell in a bathroom okay that is a characteristic history What is the characteristic history in a case of sdh the patient is usually a elderly patient it can be a child but usually elderly patient who fell in a bathroom and who does not come to you urgently or in the emergency the patient might present to you after eight days of trauma okay and then the patient can complain of headache okay so that is what is the usual case of sdh that comes to you in the examination okay so that is what is seen in case of sdh please remember sdh can be of three types if the patient presents you within three days it is acute sdh if the patient presents you within 3 to 21 days that is sub-acute sdh and if the patient presents you after 21 days that is chronic acids so usually if I talk about sdh please remember what should be the treatment in this patient okay what should be the treatment over here the treatment that you need to remember okay is usually either a burn hole surgery again if the patient is symptomatic only if the patient is not symptomatic don't go for a surgery just go for observation in the patient okay the burrow surgery or you can go for a craniotomy here as well if it is very huge but important is if the patient is not having severe symptoms only the patient is having headache and headache after trauma is usually due to increased intracranial pressure If there is increased intracranial pressure because this Hemorrhage or bleed the clot which is formed it is trying to increase the intracranial pressure so if there is only intracranial pressure which is causing headache in the patient then only manage the patient by giving IV Mannitol okay that is called as osmo therapy it will help in decreasing the intracranial pressure but important contraindication you might have studied in Pharmacology is IV Mannitol should be not given it is contraindicated in cases of active cerebral hemorrhage why because it causes sudden decrease in intracranial pressure as it causes sudden decrease in intracranial pressure there will be herniation of the brain okay so therefore if there is active bleeding which is going on active cerebral hemorrhage please remember magnitol is contraindicated it can be given in Subacute or chronic cases usually no issues with this anybody that's important and which is the most common vessel which bleeds over here in cases of subdural Hemorrhage I hope all of you are quite aware the most common vessels which bleed I write the full name usually I prefer writing the full name it is the cortical bridging Emissary veins some exams they have only written a missionary vein some exams they have only written bridging winds so it's always better to remember the full name that is cortical bridging Emissary veins no issues with this anybody so those are the vessels which commonly bleed in cases of subdue and Hemorrhage another question which has been asked only venous intracranial humoration that means only intracranial hemorrhage where the bleeding is from the veins now you know the answer it is sdh because in all other types of intracranial humor age the breeding usually occurs from arteries next is this one what is this you can see the opacity usually within the Sylvian fissure and within the ventricles so if the opacity okay whitish appearance is seen okay if the opacity is within the ventricles or in the salvian fascia the opacity is within the ventricles or in the salvian facial then it is suggest you of which type of hemorrhage then definitely it is suggestion of sah what do I mean by CH it is nothing else but sub arachnoid Hemorrhage and I hope all of you are quite aware subarachnoid hemorrhage okay so subarachnoid space okay that means the space below the adenoid between arachnoid matter between parameter the space is what is called a subarachnoid space a space may we normally have a fluid in the brain and what is that fluid called as CSF cerebral spinal fluid now you will see that the bleeding is occurring in the subarachnoid space okay so therefore the CSF Now does not look black it appears white because it is not only the CSF it is a blood mix CSF which is seen over here ticket so that's important over here you need to remember that okay so here it is usually breeding in the subarachnoid space in a case of subarachnoid hemorrhage which is the most common cause of subarachnoid hemorrhage the most common cause of subarachnoid hemorrhage is usually trauma the most common cause of subarachnoid hemorrhage is usually trauma followed by that definitely it can be spontaneous rupture okay followed by that it can be done other cause can be spontaneous rupture of Barry aneurysm what is aneurysm in short aneurysm is nothing but dilatation of a vessel for example this is a vessel this dilatation is what is called as aneurysm and when that aneurysm is very small like a berry it is called as a berry aneurysm so spontaneous rupture of berianism is the second most common cause of subarachnoid hemorage and where are these perianisms more common very good question is more common in The Circle of Willis but in circle of villus also if they ask you one artery then your answer should be anterior communicating artery then your answer should be anterior communicating artery Okay then if I talk about what should be the treatment in this patient so please remember usually in this patient the treatment is generally okay the treatment is usually not surgical it is conservative and that is what is IV pneumodipine so the topic is intracranial hemorrhage body and that is managed by a surgeon you might have seen that a lot of times it is taught by a physician but usually if I talk about emergencies it is managed by surgery people please remember that okay so head traumas are managed by surgeons and that's the reason why I am covering it over here so important is please remember this IV nemodipine is a drug of choice for subarachnoid hemorrhage you will say Sir is there any important uh keyword that with the help of which we can pick up a subarachnoid hemorrhage yes we can and that case or that complaint of the patient is the patient will say Dr Saab I am having worst headache of my life okay that is what is the complaint the patient says the patient is having the worst headache of her life or the second thing that they can mention the patient is having a such a severe headache it is known as a Thunderclap headache so either worst headache of my life or Thunderclap headache please remember that and important is please remember worst headache of life or Thunderclap headache along with that the patient will also have nuclear rigidity and what do I mean by nuclear rigidity that is neck stiffness and a lot of people in the recent recent FMJ examination has marked it wrong if they only mention about headache and nuclearidity you need to mark it as subarachnoid hemorrhage if they mention the third part of the Triad that is what is fever then that is suggestion of infection and then you need to mark it as meningitis but in the case of subarachnoid humerage please remember okay so please remember usually the patient will not have any kind of fever if fever is present the diagnosis becomes meningitis so that's is very that is very clear okay next the last type of intracranial hemorrhage so please remember here you need to remember this one is what is called as intra cerebral hemorrhage okay so this is what is called as intra cerebral hemorrhage you can see the whitish opacity or the hyper density is seen within the brain tissue or within the brain parenchyma this is what is the case of intracerebral hemorrhage that means the bleeding is within the cerebrum or within the brain parenchyma therefore it can also be called as intra parenchymal Hemorrhage and please remember this you might have studied in medicine if there is bleeding within the brain tissue it is also called as hemorrhagic stroke so intracerebral Hemorrhage is nothing else but hemorrhagic stroke itself okay and now you can tell me which is the most common vessel which bleeds over your the most common vessel that bleeds please remember the most common vessel that bleeds in cases of intracerebral hemorrhage is usually the lenticulosterite artery lentically the lenticle is another name for basal ganglia so the artery which supplies the basal ganglia is known as the lenticulostoid artery also known as the charcots artery so if the shortcuts artery undergoes a rupture okay that causes intracerebral Hemorrhage or hemorrhagic stroke in the patient and what will be the most common site of breed and that is the sarkar equation of your exam the most common sight of breed we know it is the which part of basal ganglion that has been asked it is the most common site of breed is usually the puta men please remember this so it is not the uniform nucleus which commonly bleeds it is a puta mean where the breed is very common no issues with this what is done for treatment here we generally go for a drug again not surgery usually we go for drug because most of the cases can be managed with the help of a drug and that drug which we need to remember is the drug of choice is usually IV nicodipine so don't get confused Nemo Depends for scad sh and nicar crina so intracerebral that's how you need to remember intracerebral it is nicar depend in cases of intracerebral hemorrhage or Hemorrhage extra it is the drug of choice a calcium channel blocker no issues with this anybody okay so hopefully there is no issue in understanding these things moving further now talking about in a case of head trauma definitely every patient who comes with head trauma we need to assess the severity of injury in this patient and how we are assessing the severity of injury in the patient of head trauma with the help of a score or a scale that is called as GCS Glasgow Coma score or a Glasgow comma scale so with the help of a GCS we are trying to assess whether the patient is having mild moderate or a severe head injury in every case of head trauma okay so if we are trying to assess head trauma in the patient with the help of a Glasgow comma score we have three important parameters to check for okay they are remembered by the mnemonic evm that is eye-opening response second is verbal response and third is motor response okay and the mnemonic is E4 V5 M6 okay so maximum eye opening score is for maximum verbal score is 5 and maximum motor score is six okay so that's important please remember this now important is first of all if I talk about the eye opening response of a patient okay if the patient is opening the eyes spontaneously he is given a score of E4 if the patient is non-opening eyes on his own but when you call him okay when you ask him to Open the Eyes he opens eyes so on voice command it is E3 when the patient opens the eyes on pain okay so when the patient is not opening the eyes definitely you will apply pressure or you will try to give painful stimulus if the patient opens eyes on painful stiffness it is E2 and if the patient does not Open the Eyes it is a score of e one next is if I talk about the verbal response you will check whether the patient is able to speak or not okay if the patient is oriented to time place and person what do I mean by this the patient if you ask the name the patient tells his name okay if you ask where are you the patient tells I'm in hospital okay that means the patient is oriented to time place and person if he's answering everything properly that means a score of V5 is to be given next if the patient appears to be confused okay that means if you ask the patient where are you okay so who are you the patient does not know his name okay if the if you ask the patient where are you the patient says I am in the crematorium and what is going to be done the patient says you're burning me okay so that kind of a confused patient he should be given a score of V4 next if the patient starts abusing you with words okay inappropriate words if the patient starts abusing you patient that is the score of B3 yes a lot of head trauma patients starts abusing next if the patient is not even able to speak words he's only making incomprehensible sounds like ah ooh okay all of these incomprehensible sounds are given a score of V2 and if the patient is not making any sound that is a score of V1 next is if I talk about the motor response of the patient maximum water response I've told you it is m6 so if the patient is opening commands if you ask the patient he's raising his hand if a patient obeys commands it is given a score of M6 next if the patient is not able to obey the command but if you ask Baba where is your pain power tries to locate the pain okay Baba says over here okay that means if the patient is able to localize pain he is given a score of M5 if the patient withdraws on pain that means he is not even able to localize pain but if you tried that means if the patient withdraws on pain then definitely it is given a score of M4 okay so if the patient withdraws on pain it is a score of M4 okay so normal selection or you can say withdraws on pain that is the score of M4 next if they ask you if there is abnormal selection there is not normal selection there is abnormal flexion in the patient okay if there is abnormal selection it is given a score of M3 and of that abnormal selection is what is called as the corticate position so decorticate position is the score of M3 if there is an abnormal extension in the patient that has given a score of M2 and that abnormal extension is what is called as D celebrate position so D celebrate is given a score of M2 and if the patient is showing no motor response that is called as that is given a score of M1 now if I combine all of these scores E4 V5 M6 what is the maximum GCS in a patient the maximum GCS of a patient can be 15 okay the maximum GCS score of a patient can be 15. whereas if I talk about the minimum GCS score of a patient what is the minimum CCA score of a patient everywhere it was one one so if I combine all of them the minimum GCS score of a patient can be three minimum GCS score of a patient can be three and a lot of times they give you a lot of parameters and depending on that you need to assess the GCS score of a patient and then they ask you usually which grade of head injury it is so if the patient GCS is between 13 to 15 if the patient's GCS is between 13 to 15 it is a gesture of mild head injury 13 15 might energy 13 to 15 mild head injury okay if the score is between 9 to 12 it is suggestive of moderate energy 9 to 12 moderate head injury 9 to 12 moderate head injury and if the score is between three to eight okay if the score is between three to eight it is suggestive of severe head injury why do not why 328 did a severe head injury please remember why don't write it as less than and more than because that causes a lot of confusion okay that causes a lot of confusion so that's important okay and if a patient is having the minimum GCS score okay that is what is suggestive of a brain dead patient thank you so much all of you so that is what is suggestion of brain dead patient okay that's important once you have done with the GCS score understood properly great no one should make a mistake in the GCS code now so these are the important points to be remembered moving further now talking about next type of head injury and that is what the most severe type of head injury rather it is I'm talking about a brain injury when there is injury to the brain now there can be various types of injury to the brain please remember okay one of the brain injury can be contusion okay or another brain injury can be concussion concussion is the mildest form of brain injury one important one liner that you need to remember concussion is nothing else but it is the mildest form of head injury but here I'm not going to discuss about the mildest form of end injury because here we do not go for any surgical management only observation is done and the ncct also appears normal in this patient okay so I'm talking about this question which has appeared in your examination multiple number of times neat PG as well as FMJ exam and what was that question a 22 year old male following a road traffic accident was referred to you two days later on examination his GCS Glasgow Coma score was E2 B3 M2 combine all of them what is the final GCS of the patient it is seven so we know if the score GCS score is 7 less than eight definitely it is suggestive of a severe head injury in the patient so this patient has sustained a severe head injury and he had no fractures or any visible bleeding or any lacerations were not present blood pressure of this patient is around 180 by 90 millimeters of mercury that means the blood pressure of this patient is very high heart rate is 52 beats per minute that means the heart rate is less than 60 that means it is suggestive GCS of the patient is not improving your keyword GCS of the patient is not improving and the ncct head was performed which has been given below and the ncct had fvc can you see any whitish or blackish appearance in the city no it seems to be Krishna and Gray's normal brain burning therefore this is what is a normal NCD of the patient okay the ncct head of the patient appears to be absolutely normal but even if the ncct head of the patient is normal the GCS of the patient is very low and the GCS of the patient is not improving so what it is suggest you are the likely diagnosis in this patient please remember the likely diagnosis in this patient is the most severe form of head injury or brain injury and that is what is called as diffuse accidental injury I hope all of you are quite aware of the Formula One racer the top most he was known as Michael Schumacher he sustained diffuse external injury okay so please remember diffuse axonal injury or Dai okay it is the small severe form of head injury it is the most severe form of head injury that you need to remember and diffuse accidental injury what is the cause now okay what is the cause please remember there is a stretching force or a shearing force between the gray matter and the white matter Junction okay there are two matters in the brain now gray matter and white matter at that Junction there is a stretching force or a shearing force due to which what happens see this is the gray matter white matter Junction and here we are having some neurons this part of neuron is cell body this part of neuron is like zones so now what has happened at the gray matter white miter Junction due to a shearing Force there was injury to all these neurons mainly to which part of the neurons axons of the neurons okay and that is what is called as diffuse accidental injury okay so that's important please remember diffuse accidental injury is nothing but due to a shearing Force at the gray matter of white miter Junction there is injury to the axons okay where at the gray matter and the white matter Junction no issues with this anybody important is what are the keywords to pick up in this question the keywords to pick up in this question are the patient has sustained a road traffic accident and important is the GCS of the patient the GCS of the patient is very low it is not improving okay the GCS of the patient is very low it is not improving or it is falling down or the gcss decreasing it is falling these are the keywords to be picked up okay and the ncct head even after such a severe head injury the ncct head appears to be normal why because these neurons could not be picked up properly on a CT head therefore in most of the patients the CT head is normal some patients can show us change but then therefore if CT head appears to be normal what is the investigation of choice for diffuse accidental injury and that has been a question again so the investigation of choice of the MRI okay the investigation of choice is MRI but usually it is a T2 weighted MRI why T2 weighted MRI because water appears white on a T2 weighted Amara any type of water fluid or blood appears white on a T2 weighted MRI and on the t2 weighted MRI you can see this Blood over here okay and these type of small small hemorrhages are the gray matter white matter Junction or known as puncted hemorrhages these are known as punctate hemorrhages no issues with this these are known as puncted hemorrhages child next if I talk about that was about your diffuse accidental injury treatment is usually the patient does not have a proper outcome okay so therefore we do not go for any surgical management in this patient only palliative care is given to the patient to improve his survival next is this one Tau talking about the facial structures and there can be upper facial structures or there can be lower facial fracture upper facial fracture the upper part of the face is formed by which bone maxilla so therefore these upper facial fractures are nothing else but the maxillary fractures and I hope all of you are quite aware maxillary fractures are also known as La Fortis fractures okay maxillary fractures also known as laffote structures there are three types of magazote fractures type 1 you can see in type 1 La Forte from where is the fracture line passing in type 1 law 14 the fracture line is passing via the palate so if fracture line passes by the palette okay this is called as type 1 La Forte and this is what is called as a transverse or a horizontal fracture this is called as a transverse or horizontal you can see the fracture line is horizontal next one you can see in type 2 La Forte the fracture line is passing via the root of the nose and which kind of fracture it is seen here the fracture line passes by the root of nodes and the fracture is known as a pyramidal structure it looks like a triangle of pyramidroid so it is known as a pyramidal structure and type 2 love and type 3 law 4A if they ask you type 3 La Forte here you can see the fracture line is passing via the orbit and also via the bridge of the nose okay or the root of the nodes so here the fracture line passes by the root of nose and this type of fracture if there is a fracture in via the orbit the cranial cavity and the face both will not have any connection this is what is called as craniofacial disjunction this is what is called as craniofacial disjunction okay now can anybody tell me okay I'll move further please tell me okay please remember no it is not for neat PG but please remember important as fmg has become almost to the level or Beyond knee PC as well if you feel that fmg is easy it's not okay so that's the important thing please remember that okay now please let me know in which types of La Forte will you have CSF Rhino what was CSF rhinuria when the CSF leaks out of the nose okay and why CSF leaks out of the notes because the crib from plate is fractured whereas the Crypt from privilege from plate the crib from plate is in the ethnoid one and where is that white bone in between the orbits at the root of the nose now please tell me in which type of Law photo you will have CSF Primary in the patient because that has been a previous year question I'll talk about till then I'll talk about the lower facial fractures please remember okay so if I talk about the lower facial fractures usually okay so in the lower fracture fracture which is the fracture over here the mandible okay so if I talk about the lower facial structures that is nothing else but your mandibular fractures that is nothing else but your mandibular fracture what is the most common site of a mandible to be fractured the most common side of a mandibility to be fractured is this one that is the neck of the mandible which forms a temporal mandibular joint right so it is usually the most common site of fracture is definitely the condyle it is the condyle followed by the angle of mandible the most common site of fracture will be the condyle followed by the angle of mandible no shoes with this but this structure which is seen over here it is over here at the momentum or at the genial tubercle it is at the momentum of the genial tubercle this is considered as a dangerous mandibular fracture this is considered as a dangerous fracture of the mandible and why it is considered as the dangerous structure of mandible it is also known as a butterfly fracture white is considered dangerous because I hope all of you are quite aware at this part of the mandible at the genial tubercle of the mandible we have a muscle known as safety muscle of tongue known as genioglossus muscle which is attached it keeps the tongue okay it keeps the tongue pulled downwards if there is a fracture at the mandible over here what will happen the genioglossus muscle is released as the genioglossus muscle is released it will fall back and it will close the airway of the patient and the patient can die of respiratory arrest okay so therefore it is considered a dangerous fracture because there is release of the safety muscle of tongue treatment for this type of a fracture is usually or that is open reduction or internal fixation or we can go for interdental wiring next is this important fracture what is seen over here you can see there is some fracture in the orbit of the patient okay so you can see there is fracture in the orbit of this patient over here okay and this is what is called as the blowout orbital fracture this is known as a orbit normal again this orbit is having a fracture in which part of the orbit there is a fracture I hope all of you are quite aware of the walls of orbit there is a floor of the orbit there is the superior wall or roof of the orbit there is lateral one and there is a medial wall of orbit so here the inferior wall or the floor of the orbit has been fractured and this is what is called as the blowout orbital structure if I talk about the blowout orbital fracture please remember it is usually due to which kind of a trauma yes recently it was appeared and it has appeared many times in exam it is usually due to a blunt trauma to the orbit okay blunt trauma to the orbit and usually they will mention a tennis ball injury they will mainly mention a tennis ball injury to the patient okay that's important which is the most common wall of orbit to be fractured the most common wall of orbit to be fractured as seen in the image it is the floor the most common wall of orbit to be fractured is the floor followed by the medial wall followed by the medial wall no shows with this anybody that's important important is here on a CT okay investigation of choice is the ncct scan as given in the image and which is the sign C you can see as the floor of the orbit is fractured the soft tissues of the orbit they are going into the maxillary sinus the soft tissues of the orbit they are protruding into the maxillary sinus and this looks like a tierna teardrop okay therefore this is what is known as the teardrop sign that is characteristically known as a teardrop sign and management of blowout orbital fracture is done by conservative management surgical management is rarely required okay if they ask you which is the muscle entrapped over here so usually the most common muscle which can be entrapped because it is slower now it is usually the inferior rectus muscle okay it is the inferior rectus muscle after also power moving further again and important is I have asked you okay in which types of la photo you will get CSF rhinoria so please remember CSF primary all of you have answered as type 3. in type 3 is very good there is definitely damage to the crib from plate in type 2 also we are having damage to the credit form date right so please remember that's the reason why CSF rhinoria is seen in type 2 as well as type 3 la 40. it is usually seen in type 2 as well as type 3 law 40. okay that's important next talking about thoracic trauma in a patient okay if I talk about thoracic trauma in a patient or just trauma in a patient if I talk about thoracic trauma or chest trauma important is usually what is the first line investigation in a case of thoracic trauma in the patient if a patient comes to you with thoracic trauma definitely the first sign investigation is a chest x-ray the first line investigation is a chest x-ray what is the emergency investigation that we perform the emergency investigation that we perform to see any bleeding okay in the thorax blood is fluid and for fluid the better investigation is always the ultrasound so here also we perform a very rapid ultrasound and that rapid ultrasound which is done in cases of emergency is called as a e fast or an extended fast I am going to talk about it in abdominal trauma don't about don't worry about that okay so emergency investigation is extended fast it is nothing but a rapid ultrasound okay which is done of the abdomen and the thoracic cavity if I talk about the most common causes of death or mortality okay death is nothing but mortality the most common causes of death in a case of thoracic trauma or chest trauma please remember in a blood thoracic trauma in the case of blend thoracic trauma the most common cause of death is a tracheobronchial injury if there is injury to the trachea or the bronchus or rupture of the trachea and the bronchus the most common cause of death in a blunt abdominal blunt thoracic traumas tracheal bronchial injury but in the case of penetrating thoracic trauma it is usually a massive hemothorax what is hemothorax as I have told you hemogram blood thorax that means in the pleural cavity there's a lot of blood collection in the pleural cavity that is what is called as massive hemothorax most common cause of death in a penetrating thoracic trauma penetrating Matlab there is some okay sword or there is some knife usually in the thorax that is what is the penetrating thoracic trauma important is what is this condition over here in this chest x-ray what you can see over here in this chest x-ray there is structure of this rib there is fracture of this rib here also these two ribs have been fractured again the structure of this ribs so again these are fractured over here as well okay so this is a case of loyal chest this is what is the case of flyal chest so what is the Flies the definition of flail chest you need to remember guys the oil chest is nothing but fracture of two consecutive reps what do I mean by consecutive one after the another that means third or fourth fourth or fifth fifth or sixth always the ribs should be conjugated okay so it is nothing but fracture of two consecutive reps or more structure of two consecutive reps of more at more than equal to two sides okay so fracture of two or more consecutive reps at more than equal to two sides so you can see two reps have been fractured yes are they consecutive yes how many sides they have been fractured at they are fractured at two sides so is it a case of trial chest yes it is the case of flatter chest okay so that's means very good more than equal to two ribs structured consecutively and more than equal to two side square that is the case of branches now usually the patient will have a lot of pain we don't go for any type of refractures we don't go for a surgical management okay so usually we will go for a conservative Management in the patient and what should be the treatment okay so in a case of flyal Chess definitely what is the complaint the patient is either having respiratory distress okay because the lung is not able to expand properly or the patient will have a paradoxical breathing you can see that the flail part or the fractured partner it is moving opposite to as compared to the rest of the chest if rest of the chest is rising this part is falling if this part is rising rest of the chest is falling this is what is called as classically the power paradoxical breathing that is what is known as the paradoxical breathing the paradoxical chest movements or paradoxical breathing is a feature of Royal chest that is a keyword in the equation treatment is give enough analgesia and what is analgesics painkillers give enough amount of pain killers to the patient because there will be a lot of pain in this patient and if required definitely give oxygen support as well if required give oxygen support to the patient either with the help of a mask or if the patient is not able to definitely even breathe with the help of a mass also then intubate the patient okay so that should be done properly ippv should be given that is intermittent positive pressure ventilation okay next is this condition what is this condition over here this is the recent image which came in the December examination okay this image that you can see usually important okay not in 2023 it was usually the 2022 December okay this image you can see it is not fat necrosis a lot of people marked it as fat necrosis it is autopsy picture or a post-mortem picture on which you can see the body of the patient is open and you can see the heart is appearing completely black why because there is a lot of collection around the heart and what is that collection that collection is nothing but the blood okay so if I talk about C I explain about this condition I'll explain so I hope all of you are quite aware this is the heart for example and this is what is your pericardium the outer covering of heart is what is called as pericardium now around the heart if there was some injury to the pericardium okay there were some penetrating injury to the pericardium due to which there is a lot of blood which is collected in the pericardium an excess of blood if it collects in the pericardium okay what will happen that will start exerting a lot of pressure due to this excess of blood which is collected there will be a lot of pressure on the heart will the heart be able to relax properly relax if the heart is not able to relax properly what will happen the incoming blood will it be able to come into the heart no if the blood is not able to come into the heart okay so what will happen the incoming blood is less so outgoing blood will also be low so outgoing blood is also low okay so if outgoing blood is low what is outgoing blood cardiac output so if outgoing blood is low as I've told you cardiac output decides what blood pressure of the patient such cardiac output is low the blood pressure of the patient is also that is what is hypotension that is the first part of your classical Droid second part of stride now as this blood is not able to come into the heart what will happen this blood will keep on collecting in the veins above this blood will keep on collecting in the vein and which is the main vein which drains into the heart from above superior vena cava so all of this Blood keeps on collecting in superior vena cava and superior vena cava say where in the igb in will be elevated so you can see that the neck veins are congested or they are dilated okay so that is what is seen second part of that right and third part if you try to auscultate this patient from outside if you try to auscultate will you be able to auscultate no reason yes please please remember as there is a lot of blood around the heart you will not be able to hear the heart sounds properly and clearly that is what is called as muffled heart sounds the S1 and S2 will not be heard clearly that is what is known as and this is what is the case of cardiac tamponade this is what is the case of cardiac tamponade no issues with this anybody cardiac tamponade can also occur after a massive pericardial effusion that you are study in medicine but it can also occur after trauma as well thoracic trauma okay so we need to discuss it over here as well it is a case of cardiac tamponade okay and important is in cases of cardiac tamponade which type of trauma is commonly responsible Billy clearly writes it is penetrating trauma more than blunt trauma which is responsible blend trauma also causes but more common is the penetrating trauma next important is what is the classical trial seen over here the classical clinical features which are seen they are remembered as a backstride and what is the three features of bextroid in this patient so the three features of backstrid as we have discussed as incoming blood is low outgoing blood is also low that is hypotension second the patient has raised jvp non-pulsatile raised tubular venous pressure is seen because the SVC is not able to drain the blood into the heart and third important feature the patient has muffled S1 and S2 because of the blood we are not able to hear the sounds clearly that is what is muffled hard sounds muffled S1 and S2 these are the three features of backstride now what is the investigation of choice over here investigation of choice if they ask you answer is a echocardiography okay answer is echocardiography because that can tell you about the blood collected around the heart okay but if they ask you what is the emergency investigation of choice emergency May which will be the investigation that you will do then I will answer it as fast or refast okay I will answer it as fast story first what did I tell you fast is also an ultrasound but a very rapid ultrasound done in cases of emergency okay so fast only I will keep the ultrasound probe over here and I will see if there is any collection around heart to rule out cardiac tamponade in the patient investigation of choices ecocardiography then if I talk about management of cardiac tamponade so management of cardiac tamponade in emergency to give immediate relief to the patient what should be done to an emergency see I am in this patient along with that I am taking a needle and I am inserting that needle in the sub xiphoid space what is the sub-zipoid space the space below the city sternum okay so in the sub zippoid space I'm inserting a needle and this needle should be facing my shoulder the left shoulder at how many degrees angle to the skin at 45 degrees angle to the skin okay and I'm inserting that this needle in the pericardium once I insert this needle in the pericardium okay I will try to aspirate all this Blood it will try to aspirate all the blood and once I've aspirated the blood even 5 to 10 MLS if I aspirate then definitely a patient will have immediate Improvement in the blood pressure because the heart will at least be able to relax incoming blood will increase outgoing blood will increase okay so Emergency Management which is done with the help of a needle this is what is called as needle pericardiocentesis this is what is called as needle pericardiocentesis that is what is remember definitive management if I talk about what is the definitive management I need to open up the thorax of this patient and if I need to open up the thorax opening up of thorax is called as emergency opening up of thorax is what is called as emergency thoracotomy should be done that's important next talking about another condition and what is this condition guys the over here this is the normal lung okay hopefully you are able to identify and this is what is the affected lung over here okay this side is the affected line so right side of the patient is affected okay how to identify a right and the left side I hope all of you are taught by radiologist over here if you see the heart shadow that means it is the left lung okay so it's important okay so if you can see the left side of the heart left side of the lung is normal the right side is affected and what is seen on the left left side you can see there is more blackening on the left side right the left side sorry the right side the right sided lung appears more black the right sided lung appears more black why it appears more black what appears black on x-ray except so here you can see on the right side of the lung there is excess amount of air so thus air is not within the lung so where is this air for example this is your lung and this is the outer covering what is the outer covering of long called us very good outer covering of lung called as pleural cavity the outer covering of the lung is called as plural cavity now what has happened there was some injury to the pleural cavity due to which a lot of air has come inside a lot of air has collected inside the pleural cavity now if there is lot of air inside the pleural cavity it will again cause just like cardiac tamponade here also there will be a lot of pressure on the lungs okay here there will be a lot of pressure on the lungs will the lungs be able to expand properly if the lungs fail to expand the patient will suffer from respiratory distress and this condition when there is a lot of air in the pleural cavity air is called as Nemo and whereas the air in the thorax therefore this condition is what is called as pneumothorax okay so here we are going to discuss about pneumothorax now important is pneumothorax can be spontaneous also but spontaneous pneumothorax is usually not so severe it does not cause decreased blood pressure in the patient and it is usually seen in a case of emphysema when the blabber usually ruptures but tension pneumothorax is the important one which is seen in a case of trauma in a case of thoracic trauma what is seen in tension pneumothorax now see on one of the sides there's a lot of air what will happen this side will compress the superior vena cava and it will also compress the heart if the heart is compressed definitely if the heart is compressed what will happen will the heart be able to receive a lot of blood no not the hardest compressed it is not able to relax it is not able to receive a lot of blood the heart is not able to receive a lot of blood incoming blood is low outgoing blood is low outgoing blood is what is cardiac output so if cardiac output is low blood pressure of the patient falls and that is what is called as hypotension so tension pneumothorax you need to remember why we call it as tension because the blood pressure okay of the patient will fall okay the blood pressure of the patient falls that is the reason we call it as tension pneumothorax there is so much of air that the heart is even compressed due to that okay and it is following a trauma usually how to pick up the X-ray please remember as I've told you there's a lot of air surrounding the lung therefore the lung of the patient will be collapsed so you can see this is what is the collapse trunk on the affected side you can see there is a collapsed lung and this excess air this black colored air which is seen now it is surrounding the lung and this is what is called as hyperlucency okay hyperlucency that is nothing but increased blackening so you can see on the affected side there is hyper lucency opacity on x-ray is white you sension X-ray is black so there is hyperlucency or hype increased blackening on the affected side next you can see there is deepening of this angle what is this angle called as costophrenic angle the angle between the diaphragm and the rib costophrenic angle has deepened this is known as the Deep salsa sign there is a sign usually which is seen in this patient apart from that the diaphragm is which shape normally Dome shape but here due to excess of air an excess of compression from above the diaphragm has flattened down so that is what is flattening of diaphragm which is also seen there is flattening of diaphragm which is commonly seen in the patient next you can see over here in this patient you can see any bronchovascular markings so in a normal lung you can see there are these whitish lines these whitish lines are nothing but the bronchus and the vessel markings okay in a normal lung you can see that but in a case of tension pneumothorax are you able to see that no no whitish markings are seen that means the bronchovascular markings are absent so the bronchovascular markings are absent in a case of tension pneumothorax apart from that this is a classical feature you can see this is the trachea where you can see the trick has shifted towards the opposite side the same trigger should be Central right but here you can see the trachea shifted to the opposite side there is that contralateral tracheal shift opposite sided tracheal shift is what is seen okay so contralateral trickle shift is C how to pick up a case of tension pneumothorax okay this was about the X-ray I have told you the X-ray now how to pick up a case I have made the classical ABC of pneumothorax and what are these ABC these ABC will help you make a clinical diagnosis of tension why clinical diagnosis is required clinical diagnosis is required because most of the patients of tension pneumothorax will be having a low blood pressure and therefore we need to immediately manage the patient just say how we were doing Management in cases of foreign on the affected side next b stands for what breathlessness that is a complaint of the patient respiratory distress or breathlessness because the lung is not able to expand and C stands for what congested neck winds I have told you what happens the excess of air or the pleura which has been enlarged it compresses the superior vena cava due to which as the superior vena cava is compressed blood cannot go into the heart blood stays in superior vena cava and then it stays in ijv and that causes congested neck veins in the patient the neck vents are full that is the ABC of tension pneumothorax that will help you make a clinical diagnosis okay these are the keywords of your question also if you suspect tension pneumothorax in a patient then definitely what should be done investigations please remember investigation first line is always first line is always a chest x-ray that has to be done but if they ask you what is the better investigation definitely it can be a CT scan which can be done if the patient's blood pressure is not falling okay CD is a time taking procedure so if you have it available you don't need to send the patient for any other Center to take a CT scan no you need to manage the patient in emergency so most of the times it is a clinical diagnosis even without x-ray or CT we are able to make a diagnosis okay and I've told you what is another emergency investigation for thorax it is usually a fast so if I perform a fast I'll be able to see these signs okay on a fast I am able to see these signs no need to remember everything please remember in a normal lung we will be able to see a seashore sign why normal lung is expanding well it is usually relaxing constricting relaxing constricting so there is a lung movement which is seen therefore a normal lung shows a sea shore sign but in a case of pneumothorax is the lung able to expand no so there is no lung moment which is seen if there is no lung moment in a case of pneumothorax we can see a barcode or a Stratosphere sign we can see a barcode or a Stratosphere sign so that has to be remembered normal lung Seashore signature barcode or Stratosphere side then if I come to the management of the patient if I could talk about the management in a case of tension pneumothorax Emergency Management should be done by what so please remember Emergency Management important is here we will take a needle a wide bore needle wide diameter well a needle and we are going to insert in the intercoastal space of the patient why because if we insert in the intercostal space of a patient what will happen all that air will come out via this needle and the lung will be able to expand now the pressure decreases along with the able to expand definitely the patient will have Improvement in breathing also and the blood pressure will also improve the patient so definitely Emergency Management okay we were inserting needle in pericardium that was called as needle pericardiocentesis now we are inserting the needle in thorax so this should be called as needle thoracosynthesis this is known as needle tornado centers now important is insertion of needle according to atls protocol it has changed okay according to atls protocol previously it was second intercostal space made clavicular line now it has changed okay now in cases of adults according to the atls protocol that we follow it is usually the fifth intercoastal space it is the fifth intercostal space on the mid axillary line or just anterior to the mid axillary line to be specific okay so that is what is the site in adults but in a case of a child in a case of child it is still the same atls protocol still stays the same in a case of child it is usually the second intercostal space okay on which line Second intercostal space on the mid clavicular line in children it is still the same second intercostal space on the medical articular line I know Harrisons has not changed it but as we are following atls protocols for trauma management it is this one that you need to follow next one if I talk about definitive management definitive management please remember over here is what you need to insert a chest tube okay so if you insert a chest tube see this is what is the pneumothorax you are inserting a chest tube in the patient okay and that chest tube which is inserted now it is connected to underwater seal okay why underwater seal is required what is underwater seal that means the tube goes and it is going into the fluid because if you don't fill up the fluid in the bag if you don't fill up the fluid in the back what will happen air will come out it will go in it will come out it will go in now the air is coming out okay and it will escape by forming bubbles but will they able be entered will the air be able to enter the tube no it is not able to enter the tube and therefore this underwater seal is required okay so definitive management is ICD insertion what is ICD intercoastal drainage tube or ICT also you can call it okay so intercoastal drainage tube insertion has to be done okay so intercoastal drainage tube has to be inserted okay so intercostal drainage tube with underwater seal is inserted with the underwater seal what is the site so please remember it is the fifth intercostal space where we insert it but which line usually so we don't call it the line okay it is usually in the Triangle of safety triangle of safety once just see it the anterior border is formed by lateral border of pectoralis measure the posterior border is formed by lateral border of latissimus dorsi the base is formed by the fifth intercostal space and the Apex is formed by the base of axilla okay so that's important so usually fifth intercoastal space in the Triangle of safety we generally insert this ICD or intercoastal drainage tube with underwater seam no issues with this anybody so this is important to be remembered for the management of tension pneumothorax thoracic trauma now talking about abdominal trauma so let's try to complete abdominal trauma maybe we'll start with brush tomorrow okay or Burns will complete and then we'll start with rest tomorrow only okay if I talk about abdominal trauma now here we have a 17 year old girl here we have a 17 year old girl who presents to the emergency department with a stab wound stab is a penetrating order blunt trauma definitely it is a case of a penetrating trauma to the abdomen margin blood pressure of patient is 80 by 50 millimeters of mercury that means the patient's blood pressure is dropping down that means the patient is having hypotension next important is the pulse rate of the patient is 120 beats per minute okay so definitely the heart rate or the pulse rate of the patient is high okay that means tachycardia and we know if there is blood low blood pressure and tachycardia in a patient that is what is suggestion of shock in a patient right respiratory rate is also High 28 breaths per minute normal is 12 to 20. okay two large bowl IV lines are inserted definitely we know for circulation management we insert minimum to 18 gauge IV lines those were inserted nasogastric tube was inserted foli's catheter was inserted blood pressure after giving fluids to the patient increases to 90 by 60 millimeters of mercury what is the appropriate Management in this patient now important is how do I determine shock in a patient or how do I determine if the patient is hemodynamically stable or the patient is hemodynamically unstable that term here are going to use a lot now so important is please remember we will try to check the shock index of the patient what is the formula of shock index shock index is heart rate upon systolic blood pressure what is normal heart rate in a patient normal heart rate of a patient is 72 beats per minute what is the normal systolic blood pressure 120 mm of HG so usually in a normal patient the shock index will be more than one or less than one so in a normal patient or in a stable patient hemodynamically stable patient the shock index should be less than one okay the shock index will be less than one in a normal or a stable patient but if the patient is in shock okay if the patient is in shock that means a hemodynamically unstable patient okay hemodynamically unstable patient that means the patient was in shock is what is the heart rate of this patient 120 beats per minute okay and what is the blood pressure of this patient 80 millimeters of mercury systolic blood pressure okay now is the shock index more than one or less than one definitely the stock index is more than one so if the shock index is more than one that is suggestive of a hemodynamically unstable patient or a patient who is in shock that's important now if I talk about abdominal trauma I'll come back to this question don't worry so if I talk about abdominal trauma what is the most common organ injured these are some important one liners that you should be aware of the most common organ injured in a case of blunt abdominal trauma is definitely the stream the most common organ injured in cases of blunt abdominal trauma is the spleen followed by the second most common organ injured is the liver if they ask you which is the most common organ injured in penetrating abdominal trauma then the most common organ injured in penetrating abdominal trauma is usually the liver if liver is not an option then you'll need to mark it as stomach okay penetrating somebody stabbed you with a weapon okay so liver followed by stomach followed by small intestine okay if they ask you which is the most common organ injured in seed by trauma now when I was driving a car okay there was a I was I was wearing a seat belt and then applied a sudden break or there was a collision of my car with the next car that means and what will happen there will be a sudden hyperflexion if there is a sudden hyperflexion the thorax of mind will be saved but the abdominal organs will go ahead as the abdominal organs go ahead I hope all of you are quite aware we have the intestine and the intestine is attached with the help of a mesentry okay so now if the intestine goes ahead suddenly okay there is sudden hyperflexion of the intestine what will happen there will be stretching over the mesentry and that will cause rupture of the mesentry okay there will be rupture of the mesentry the most common organ injured in cases of seed by trauma is the mesentry and what happens to the main then read that is a means and trick rupture which occurs okay next is in cases of blast injuries if I talk about the abdominal organs overall it is the eardrum followed by trachea followed by lungs but indefinitely in the abdomen it is the small intestine or the intestines in short you can remember okay it is the intestines more commonly it is a short intestine small intestine now if I talk about the flowchart of abdominal trauma very important for all of you to no if I talk about management of in a case of abdominal trauma guys if I talk about Management in a case of abdominal trauma I need to see whether the patient is suffering from a blunt abdominal trauma or the patient is having a penetrating abdominal trauma or the patient is having a penetrating abdominal trauma okay if the patient is having a blunt abdominal trauma again I need to see if the patient is hemodynamically unstable that means the patient is in shock or the patient is hemodynamically stable that means its blood pressure and heart rate is normal same thing with penetrating also I will see if my patient is hemodynamically stable or my patient is hemodynamically unstable okay so that is how you need to remember the flowchart important is first I'll start with blunt trauma okay blunt trauma usually in this condition I'll start with all the types of drama first important line that I will need all of you to remember okay any case of abdominal trauma who comes to you whether it is a blunt trauma or it is a penetrating abdominal trauma whether the patient is hemodynamically stable or the patient is hemodynamically unstable if you are having a rapid ultrasound in the emergency itself or in the operation theater itself that rapid ultrasound has to be done in this rapid ultrasound we only check for four sites first is the we keep the ultrasound probe in the sub xiphoid space we check for the pericardium to rule out any cardiac tamponade second we keep the probe in the right hypochondrium to check for any peripatic breed third we keep the probe in the left hypochondrium to check for any perisplanic bleed and fourth we keep the probe in the suprapubic region to see any blood collection in the pelvis okay so this is what is called as a fast okay or E fast extended fast the two other sides that we add is the right and the left thoracic cavity okay so the first line investigation important is the first line investigation in any case of abdominal trauma is a fast or a fast okay it is usually a fast or a fast that we perform okay so fast e fast important that should be done definitely okay so fast story fast whatever is available that should be done no issues with this anybody that's important in every case important is now if my patient is having a blunt abdominal trauma and he is hemodynamically stable okay I have performed a fast two conditions can be there fast will tell me about what ultrasound will always tell you about any fluid collection so it will tell you key in the abdomen if there is any fluid collection and what is that fluid collection in a case of trauma nothing else but blood so if the fast comes out to be negative nothing has to be done just go for observation of the patient but if the fast shows any fluid collection if it comes out to be positive then I need to go for the best or the goal standard investigation and what is the goal standard investigation in cases of abdominal trauma it is CCT abdominal okay it is CCT abdomen that is the contrast enhanced CT scan of abdom okay that should be done in the patient okay and depending on the findings in the CCT abdomen you will manage the patient okay if conservative manager management is required go for conservative management if surgical management is required go for surgical management next if I talk about unstable patient with a blunt abdominal trauma and having a hemodynamically unstable patient with a blunt of dominant trauma now there can be two conditions either the e-fast can come out to be positive if the E fast comes out to be positive it shows blood collection and your patients BP is suddenly dropping that means there is an active Hemorrhage or active bleeding which is going on then definitely go for a surgery and what is that surgery that we perform we need to check now which side is bleeding therefore we completely open up the abdomen with the midline incision and we check for the bleeding site checking is known as exploration and we are performing opening of the abdom that is called as laparotomy so the surgery that we perform is what is called as exploratory laperotomy has to be done exploratory foreign next is if the E fast comes out to be negative then what should be done in this condition if the E fast comes out to be negative okay we will give fluids to the patient definitely okay if the patient's condition starts worsening take up the patient for surgery but if the patient is unstable definitely but his BP has not Fallen too low then take up the patient for a repeat e fast okay take up the patient for a repeat e fast or a fast whatever it is and and how much time usually within a span of 30 to 45 minutes okay after 30 to 45 minutes take the the patient for a repeating fast if the repeat if I shows positive take up the patient for surgery and that surgery is nothing else but again the exploratory laparotomy itself okay it is again the exploratory the problem next if the repeater fast comes out to be negative then there's a problem now too fast have come out to be negative then go for serial PCV then go for serial PCV and hemoglobin monitoring PCB is what part cell volume also known as hematocrit check for PCV and hemoglobin monitoring what do I mean by serial after every half an hour to one hour you take the blood sample of the patient and you send it to the lab and you check for a PCB pack cell volume hematocrit or hemoglobin okay if the serial PCB monitoring or hemoglobin monitoring is showing you a decreasing Trend that means the values of hemoglobin or PCV are decreasing that means there is a bleeding which is going on in the patient take up the patient for surgery that is the exploratory laparotomy but if the serial PCV and hemoglobin monitoring appears to be normal then definitely go forward then definitely go for observation in the patient only go for observation in the patient okay that has to be done no issues with this anybody so hopefully there is no problem as such you are able to hear me out next moving further just a minute I'll reconnect it so some problem is mirroring next is important one now I am going to talk about the penetrating trauma patient if I talk about penetrating trauma again whether the patient is hemodynamically stable or unstable the first line investigation is always a fast okay important is if the fast here also okay here we need to see if the fast is positive if the fast comes out to be positive definitely I am going to take up this patient for a CCT abdom you will say sir you are taking a stable patient for CCT abdomen why because it is the gold standard investigation it can tell you more about the breeding site it can tell you about all the injuries in the patient but why are you not taking a patient who is unstable so a patient with hemodynamically unstable the patient is in shock if I take this patient for a contrast and on CT scan which is a time taking procedure the patient will go alive inside but to come out dead outside okay so that's the important thing we do not have time to perform a CCD of dominant unstable or a shock patient okay that's important tcd abdomen usually here we need to check for what we need to check if there is any penetrating trauma now so see there is a penetrating trauma to the abdom you need to check okay if the abdominal wall is damaged no issues with that but if the peritoneum is damaged then there is a problem why because if there is peritoneal injury or there is a peritoneal breach which is seen then the patient will land up into peritonitis and peritonitis is a indication for extraordinatory laboratory because peritoneum is does not okay so peritoneum please remember sorry peritoneum will not handle any kind of nuisance it will immediately undergo inflammation and the patient can die due to that that's the reason okay so you need to check for any peritoneal breach in the patient okay check for any peritoneal breach in the patient if peritoneal breach important is if peritoneal breach is seen definitely take the patient for a surgery and that is what we know exploratories approximate but if peritoneal breach is not seen that means it is only a injury till the abdominal wall the peritoneum is not breached then only go for a local wound exploration then only go for local wound exploration and suturing only explore the local wound clean it properly and go for suturing foreign next if the patient is hemodynamically unstable in a case of penetrating abdominal trauma okay and the fast comes out to be positive in most of the conditions even if the fast is not available guys even if the fast is not available and the patient is having a penetrating abdominal trauma and the patient is hemodynamically unstable in this condition always take up the patient for surgery even if the fast is available or not available okay so there are few conditions that means any one of the following any one of the following where the patient is always taken off okay so any one of the following with penetrating abdominal trauma any one of the following condition with a penetrating abdominal trauma where the patient will always be taken up or okay where the patient is always taken off for a exploratory zaper Atomic or a surgery and what are these conditions first if there is a impiled object what is impaired object that means the knife or the sword is still intact over there itself and we know we ask all of them don't remove the knife or this word why because if you remove the knife or the sword outside in the emergency room or anywhere outside what will happen maybe this sword or the knife is having a tampon adding effect and it has stopped the bleeding if you remove it maybe there will be more bleeding and you can lose the patient therefore if there is an impaled object only remove the object in the OT and that is done by explosive proton second important thing definitely apart from this important is any patient who is having a features of peritonitis as I've told you peritonitis hair that is always an indication of surgery third important if there is EV serration what do I mean by evisceration viscera is nothing but the internal abdominal organs intestine for example intestine is coming out from the injury definitely you need to perform a proper explorative laboratory or if there is any bleeding from natural orifices okay if there is bleeding from your nose or throat so bleeding from natural orifice or anal bleeding if there is okay for rectal breeding is there so breeding from natural orifices okay so that is also an indication and the fifth indication is plus minus because baby says now depending on the severe rate of injury you will manage the patient that is a gunshot one that is a gunshot one okay so these are the five indications that was all about your abdominal term now going back to your question guys here now definitely please answer me in the chat box okay that till that time I'll cover the next topic so please answer me in the chat box just see the question once 17 year old girl which type of trauma stab one so it is a penetrating trauma blood pressure is 80 by 50 and heart rate is 120 okay so if the blood pressure is 80 and heart rate is 120 shock index is more than one patient is unstable or stable patient is unstable that means she is shocked a penetrating abdominal trauma and unstable patient if fast is not even available we can directly take up the patient for surgery so here the better answer should be explained to the problem even if fast is not done we can directly take up the patient for a surgery as well okay that's important next if I talk about few points about fast only as I've already told you cost is nothing else guys but a rapid USG or a rapid ultrasound which is done in cases of emergency there are only four passes in a case of fast we only keep the ultrasound probe at four sides one it is kept in the sub xiphoid space and it is to check for any pericardial collection of fluid that is cardiac tamponade second it is kept okay in usually with space second it is kept in the right hypochondrium to check any peripatic blood correction third it is kept in the left hypochondrium to check for any Paris planning Bullard collection both it is kept in the suprapubic region to check for any pelvic blood collection okay so that's important and if they are safe e fast so e fast as I've told you along with the four first or the four passes that we have we have two more passes as well and these two passes are for the right and the left thoracic cavity these are for the light and the left thorax to check any blood collection in the right and the left thorax fast is what fast they might ask you the full form at times they have asked earlier it is nothing but focused assessment by sonography in drama it is nothing but focused assessment by sonography sonography is nothing but ultrasound okay so focused assessment by sonography in cases of trauma is what is fast okay so that was what you need to remember no issue silly anybody that is important moving further to next question okay answer the question a 60 year old male known case of coronary artery disease was taking a lot of NSAIDs non-steroidal anti-inflammatory drugs and was brought to the emergency with acute pain abdomen on examination tenderness was present all over the abdomen so if you touch the abdomen the patient is crying out in pain that is what is tenderness guarding is there that means if you try to palpate the patient will contract his abdominal muscles therefore you are not able to con palpate that is what is called as garlic the blood pressure of patient is 90 by 60 mm of 5G that means the patient is going into hypotension and finally shock chest x-ray has been given below what is the Preferred Management so one hint if they talk about pain abdomen and they will give you a chest x-ray they are going to talk about this condition only and that is what is hollow viscous perforation that means perforation of your stomach or your intestine okay so usually here you can see what is seen on the chest x-ray you can see there is blackish appearance beneath the right Doom of the diaphragm we need the light lung or beneath the right dome of diaphragm you can see a blackish appearance and what appears black on x-ray we know air appears black on x-ray so you can see this gas or this air which is collected beneath the right dome of diaphragm this is what is called as gas under diaphragm this is what is known as the gas under diaphragm and gas under diaphragm is also known as with sign it is also known as the cupola sign and if it is on both sides it looks like mustache right if it is also known as the moon start sign SO gas under diaphragm also known as copula or mustard sign okay important it is suggestive of what it is suggestive of Nemo peritoneum in the patient what is Nemo peritoneum air so if there is air or gas inside the peritoneal cavity and when there will be gas in the peritoneal cavity do we have normally gas in the peritoneal cavity no so if the intestines will undergo perforation okay the gas or the air from the intestine will go into the peritoneal cavity and that will cause a Nemo peritoneum that means here the intestines have perforated or the hollow viscous have perforated because it is not only the intestines now it can be the stomach also so it is called as Hollow viscous perforation that has been a sarkari question of your exam pure my diagnosis is definitely Hollow viscous perforation and if I talk about Hollow viscous perforation guys if I talk about Hollow vessels perforation important it can be either a stomach or intestinal perforation why do I suspect holoviscus perforation in this patient because this patient is taking NSA it's non-steroidal anti-inflammatory drugs for a longer duration of time that are known to cause ulcers in the stomach as well as the duodenum and these ulcers can finally perforate as well okay and that is important and what are all these signs shown in the question acute pain abdomen diffuse tenderness guarding all of these signs are suggest you of if the intestine perforates will it be only the gas which goes into the peritoneum no it will also be the intestinal contents and all these intestinal contents fluids food all of this will go into the peritoneum as I've told you peritoneum does not handle any nuisance it is a sterile cavity it needs Everything clean if all this dirty dirt comes into the peritoneum what will happen there will be inflammation of the peritoneum that is what is called as peritonitis so all the viscous perforations can land up the patient into peritonitis what are the signs of peritonitis we know there will be diffuse tenderness over the abdomen of this patient okay the patient will have severe abdominal pain as well along with that what will be the other complaints the patient will have guarding as well the patient will not let you palpate that is guarding then the patient will have cardboard like rigidity yes the abdomen will become hard like a cardboard it will be cardboard like rigidity in the abdominal of this patient okay so that's important and if there is peritonitis the patient can also have shock as well okay so all of these features will be present so the X-ray features that I've already told you it is gas under diaphragm cupola or Musta sign which will be seen due to collection of gas below the right dome of diaphragm okay so that is what is important now what should be the treatment definitely if it is a case of hollow viscous perforation you need to open up the abdomen as it is a case of peritonitis and as we are opening up the abdomen that is what is called as exploratory laparotomy laproscopy is not done in cases of shock patients any surgery is not done via laparoscopy if the patient is in shock okay so it is always expect it is approxima that we give and definitely as a patient is in shock we will net IV fluids in the patient as well okay so that's important okay no issues with this anybody that is very important to be remembered guys okay and we will also do a peritoneal lavage in this patient as the peritoneum has been infected it is inflamed we need to clean the peritoneum that is what is called as a peritoneal watch next if I talk about this condition what is this this is what is telling you about the retroperative trauma if there is any trauma in the retroperitoneal region that means behind the peritoneum now the retroperitoneal region is divided into three zones The Zone one which is there you can see it is the central zone and what lies in the central zone the inferior vena cava and the aorta so the major vessels are lying in the central zone if there is damage to the central zone of the retroperitoneum what should be that so if there is damage to the Zone one there will be very high chances of bleeding now because major vessels lie over there and if there will be excessive bleeding in the patient what will happen if there is excessive bleeding in the patient definitely the patient will go into shock and therefore Zone 1 always requires a Zone 1 trauma always requires a surgical exploration Zone 1 always requires a surgical exploration next is zone two Zone 2 is which zone Zone 2 is a lateral Zone what lies in the lateral Zone you can see it is the kidneys and it is the renal vessels now definitely there is a risk of bleeding but not so much okay which was seen in zone one and zone three is which one zone three is not nothing but the pelvic Zone okay and in pelvic Zone which should blood vessels lie it is the iliac vessels which will lie over you direct branches of aota okay now usually in zone two okay in zone two or zone three retro peritoneal trauma in zone two or zone three retro peritoneal trauma what should be the treatment in the patient the treatment and the patient please remember and this condition is usually we try initially for angio embolization okay we try to stop the bleeding with the help of angioembolization by embolizing the arteries which are bleeding but if that fails but if that fails definitely we need to take up the patient for a surgery that is surgical exploration okay that's important in the August examination August 2020 fmg examination they asked that which zones require surgical exploration always now if they ask you single best answer we know the answer is Zone one but in those options it was Zone 1 and zone two Zone 1 and zone three Zone 2 and zone three so these were the options and all of the above so please remember if you need to mark it as two zones then it should be Zone one because it contains the major vessels like IBC and Iota and if you need to Mark another Zone it should be zone three because it contains direct branches of the outer that is iliac vessels which are major vessels again okay zone two usually it contains renal vessels one of the smaller branches okay so that's the important thing talking about Burns then I will complete and just to answer your previous question I hope all of you are quite aware okay I have answered that question anyway talking about the last part for today we will continue with endocrine surgery tomorrow breast and thyroid because all of you will be exhausted as well talking about last part of general surgery and that is what is Burns if I talk about Burns guys definitely Burns can be of two types either it can be hot Burns that is heat Burns as well or it can be cold ones as well okay if they ask you which are the most common Burns overall I hope all of you are quite aware every day we have some hot liquid or hot milk falling on our surface okay on the skin surface that is what is the most common type of Bones overall are the scouts and the scouts are a type of burns which usually occur due to hot liquids so Square Scouts usually occur due to hot liquids next important is the most common hospital Burns if they ask you the most common hospital burns are definitely the thermal buns okay the most common hospital bones are the thermal bones mainly the burns which occur due to Flame okay if they ask you most common cold buns which occur at freezing temperatures the most common cold Burns which occur at freezing temperature are known as frostbite okay which usually occurs in the fingers or the Toads that is Prosper no issues with this if they ask you these are one liners that I am covering first now in a case of burns what can be the problems please remember see a case of burns can die usually due to three reasons first of all the patient will have Suffocation and the patient will have decreased oxygen and the patient can die of hypoxia okay so the patient will have hypoxia why there will be hypoxia so please remember hypoxia can be due to edema of the airway okay so there can be edema of the airway Airway edema so therefore the patient is not able to breathe second the patient has in irrational bones due to inherational Bones again there was a lot of Edema and damage to the airway the patient could not breathe and third important the patient was having a escar what is the escar a tight thick leathery skin which is formed around the chest and it acts like a compression band around the chest therefore the chest could not expand the lung could not expand the patient is not able to breathe freely and that can also lead to hypoxia next is the patient can die due to hypovolemia what is hypovolemia decreased amount of blood in the body and why there will be hypovolemia we know if there is excessive Burns there will be evaporation of fluid from the body right and the blood vessels will also be damaged that will cause blood loss and the patient will land up in hypovolemia okay and next important is the patient can die due to infections and what are these infections the patient will have sepsis okay so usually the patient can diet due to sepsis these are the three main important reasons where due to which the patient of burns can die or which we need to manage properly if I talk about the most common cause of burns okay a patient of burns can die immediate on the spot itself so what is the most common cause of immediate death in case of burns so the most common cause of immediate death in a case of burns is definitely asphyxia what is a spike their Suffocation so due to Suffocation the patient was not able to breathe and the patient died on the spot okay why because the patient was having either some face Burns or the patient was having some neck burns due to which there was a lot of edema in their way the patient had hypoxia and the patient died that is a size F or the patient was trapped in a closed room or a closed cabin which was burning now definitely if there was a closed room what will happen there will be a lot of suit particles which will be released these food particles which are released now the carbon particles they contain a toxin and that toxin is carbon monoxide that carbon monoxide toxin is definitely known to cause damage to the Airways that will land up the patient into Suffocation and the patient can die next is if that is not an option go for neurogenic shock due to excessive pain in case of burns the patient can die as well but that is the second most common cause of immediate death in Burns if they ask you early death in cases of Burns early death that means usually within a span of 24 to 48 hours the patient dies so in a case of give me earlier what is the most common cause of early death in Burns within 48 to 70 72 hours maximum 72 okay so usually it is hypovolemic shock okay that we studied the second cause that is hypovolemic shock next what is the cause of late death in cases of burns the most common cause of late death usually rate death means more than three to five days later so after three to five days in a case of burns if the patient dies the most common cause is usually sepsis okay and important to be remembered is sepsis is also the most common cause of death in Burns overall Pepsis is also the most common cause of death in Burns overall if they do not mention immediate earlier late then the overall most common cause of death in cases of burns is sepsis and sepsis is nothing but infection what is the most common organism or the most common cause which causes sepsis or infection in a case of burns that organism is known as pseudomonas second most common is staph aureus but this is a previous year question and it is pseudomonas why I have highlighted it with green because we know pseudomonal infection will cause a green pus discharge okay important and they will also have green colored colonies micro okay and what is the source most common source of sepsis in the patient that has been asked once so from where the infection starts so the infection starts from the Burns wound itself so the infection starts from the bones wound itself together the source of infection as the burns wound itself now moving further talking about this question a 30 year old male was caught in fire was brought to the emergency room doctor for assessment of total body surface area of Bones tvsa is nothing else but total body surface area of burns we need to check now how many percentage of the body is burnt so to assess the total body surface area of burns they use the Wallace's rule okay so Wallace's rule is used to calculate the total body surface area of burns okay or the percentage of Burns in a patient his both upper limbs were charred and the thorax was also charred anteriorly as well as posterior total body surface area of bones in this patient is now we know to calculate the percentage of burns to calculate the percentage of burns or to assess how much total body surface area in a patient has been involved with Burns we use this policies rule of nine which was given by Alexander Wallace this just a minute this Wallace's rule of nine which is there guys here everything is nine percent except one part of the body and that has been asked commonly okay so you need to remember the head and neck is taken as nine percent okay the trunk that means the chest and the upper back chest is not the whole part please remember the chest and the upper back is taken as nine percentage so total eighteen percent then the posterior trunk okay so please remember the abdomen and the lower back okay so chest is nine percent upper back is nine percent abdomen is nine percent lower back is nine percent so again it becomes eighteen percent each arm each Upper Limb will be nine percent each Upper Limb is nine percent please remember anterior plus posterior so four point five four point five again next is the leg each leg each lower limb is 18 yes anterior overlay nine percent posterior lower limb nine percent anterior lower M9 and posterior roll them nine percent okay only part which is one percent okay only part which is one percent is the genitalia and the perineum and that has been asked as a previous year question okay so please remember according to the Wallace's rule of nine which part of the body constitutes or which part of the body is only one percent of the total body surface area an answer you know now it is the genitalia and the perineum okay so that makes a total of hundred percent of the total body surface area okay so in this coming back to the this case how much percent of burns are seen in this patient you can see both the upper limbs are involved one Upper Limb is how much percent nine percent so both the upper limbs are involved it is 36 per sorry it is 18 next they are saying that the thorax is charred okay thorax is charred anteriorly as well as posteriorly so thorax anterior is the chest nine percent thorax posterior is the upper back nine percent so nine plus nine again eighteen so it will be total how much percent totally 18 plus 18 will be 36 percent the total body surface area involved in this patient with Burns is 36 percent important is if there are catchy Burns in a patient if there are patchy Burns in patient so in a case of patchy worms please remember definitely we need to use the rule known as the Palm rule okay we take the palm of the patient we cut a paper according to the size of the palm of the patient and we keep this paper on the burnt part of the body and we will try to calculate key okay how much area of the body has been burnt because it is patchy once now one Palm will constitute how much percent one Palm constitutes one percent of the total body surface area one palm of the patient constitutes one percent of the total body surface area of Bones no issues with this but if they ask you which are the best method to assess the total body surface area of burns okay so it is the Lund and the Browder charts mainly used for Pediatric population but for Pediatrics also we have the Alexander Wallace's rule of nine but if they ask you overall best method is Lund and Browder shots moving further guys next is question a person was stuck in a cabin when it caught fire he was rescued by the firefighters but was brought in unconscious state to the emergency room what is the most important step in this management now important step in the management of this patient is not fluid why because over here the patient was stuck in a cabin and I've told you if a patient is stuck in a cabin which was burning what will happen there will be a release of lot of suit particles and if there is a release of lot of suit particles what will happen definitely the patient will have inhalational Burns and if the patient is having inhalational burns what will happen there will be edema of the airway and if we wait for some time now definitely now the patient is not having respiratory distress but the edema will keep on progressing progressing and the Lumen Airway Lumen will keep on narrowing narrowing narrowing and finally we will not be able to even see the vocal cords of the patient the airway will be completely blocked we will not be able to intubate the patient so if we are suspecting inhalational bones in a patient if we are suspecting inhalational bonds how to suspect in additional Burns so we suspect inhalational Burns if there is any Burns to the face to the neck of the patient okay to the face or to the neck of the patient we suspect generation burn second if there is signing or burning of the nasal hairs that is the important sign again signing or burning of nasal heads third if the patient was trapped in a burning closed room if the patient was trapped in a closed burning room okay so that's important if the patient is having hoarseness of voice if there's hoarseness of Voice or fifth if the patient is having black carbon deposits in this sputum okay if there is black carbonaceous deposits in its sputum all of these are signs that the patient has sustained an irrational bone and if a patient comes to you with an irrational bone the most important and the first step in management is a prophylactic intubation yes even if the patient is not having a lot of respiratory distress now it will further progress so it's always better to go for a early elective intubation known as prophylactic intubation that what the etls also suggests and the baby also suggests okay no issues with this that was a previous year question whatever questions I've taken all of these are your py cues itself now if I talk about the degrees of Bones if I talk about the degrees of bones or grades of Bones there are four degrees of four grades of burns okay if only the epidermis has been burnt okay if only the epidermis has been burnt it is a first degree burn what will be seen over here only there will be redness of the skin there will be swelling or edema of the skin and the patient will have a lot of pain okay so that is what is seen usually use carrots now due to hot liquids or hot milk okay or your sunburn okay that is what is the first degree burn then second degree are two types okay we have second degree superficial Burns okay second degree a or second degree superficial Burns and we have second degree deep that is second degree B Burns importance is second degree though types second degree superficial Burns that is not only damage to the epidermis but there is also damage to the superficial dermis okay there is also damage to the superficial dullness here there will be redness of the skin there will be pain in the patient but important is the patient will also have a blister and what is a blister I hope all of you are quite aware blister is nothing but a balloon you can understand which contains fluid that is a blister you might have seen when you get Burns definitely you get this kind of a blister now so it is a feature of second degree burns and in second degree also you need to mark one second degree superficial or second degree deep so blisters is a classical feature of second degree superficial Burns Okay then if I talk about second degree deep burns here the patient will not have redness rather there will be parallel the patient will still have pain and the patient sometimes can have blister not always you can see over here the patient is not having a blister so blister answer should be second degree superficial and if you need to answer it as second degree so that's the best one here definitely there is damage not to the epidermis but also to the complete determinants there is damage to epidermis as well as the completed dermis okay next is third degree burns or grade four bones third degree burns man the patient has grayish or a grayish white or a blackish necrosis and this blackish necrosis gives a thick leathery appearance to the skin and this thick leathery appearance of skin is what is called as a scarf so escarp and jata in the patient the patient will have analgesia what is analgesia no pain sensation yes third and fourth degree burns are painless bones you will see how so how third and four degree burns are painless Burns please remember third and fourth degree burns May the nerves are damaged and you know if the nerves are damaged the patient will not be able to feel any pain so the important thing is third and fourth degree burns both are painless bones okay both are painless bones so usually here the patient will have analgesia that is painless Burns will be there there is damage to the epidermis plus there is damage to the complete dermis even there is damage to the subcutaneous tissue and we know usually if there is damage to the subcutaneous tissue the bones are deeper okay and this escar I have told you it can form around the chest and it can compress the chest and therefore the patient will not be able to breathe freely and therefore to release the escar what we will do we will give multiple incisions over the saskar we will give multiple Cuts over this ascar so that the patient can breathe feeling and that treatment is what is called as escarotomia that has been asked in your pre-wide queue escarotomy is done if the patient is not able to breathe due to an escar formation as this grade four Burns usually here there is damage to the epidermis plus the dermis plus the subcutaneous tissue plus the muscle layer as well so it is so deep burns that the muscle layer has also been damaged painless or painful definitely painless Burns because the nerves have been damaged completely you can see all the people layers have been damaged okay you can directly see the bone of the tendons of the patient okay so these are grade four ones if I talk about management definitive management of great according to grading yeah right now what is initial management initial Management in a case of inhalational burns is always prophylactic intubation but in all other cases the initial management will be what because I told you hypovolemia is a very important risk because the patient can die due to hypovolemic shock so initial management we need to do basic resuscitation of the patient what do I mean by basic resuscitation that is the same thing that we followed in from a b c d e Airway breathing circulation disability and exposure we need to take we need to insert a peripheral IV line and we need to start fluids in this patient to prevent any hypovolemic shock now coming to definitive Management in first degree burns they were very superficial Burns do we need any treatment no the first degree burns only we treat them by exposure just expose them don't even do a dressing the treatment is dressing which is the most common ointment used over here the most common ointment of the cream which is used for dressing in a case of burns is usually one percent silver sulfur diazine and that was the question the most common ointment that is used is known as one person silver sulfur diazine in a case of burns formation that isn't usually in some second degree or most of the third degree burns we need to use another cream and that cream or ointment is known as mafenide acetate problem with this mafenide acetate cream is it will penetrate the scar it will go deeper but it will cause a lot of pain on application once you apply patients so that will be the problem and it will also cause metabolic acidosis in the patient for third and four degree burns as majority of the tissues have been damaged we need to go for a skin grafting in the patient a third and four degree burns we need to remove the necrotic tissue and removal of necrotic tissue is what it does nothing else but debridement and debridement along with skin grafting has to be done okay so that's important now here we have a child okay a child who has 20 kgs in weight was brought to you with bones and fluid resuscitation was to be started the total body surface area of burns involved was 30 percent calculate the fluid requirement in the patient according to the Parklands formula now there is an update in the Parklands formula now in a case of burns we calculate the amount of fluid or the requirement of fluid to a case of burns according to Parklands or according to the etls formula alkaline's formula formula had the updated version is 2 into body weight of the patient in kilograms body weight of the patient in kilograms into total body surface area of Burns in percentage total body surface area of Burns in percentage that is the Parklands formula which is updated and it is the same atls formula for adults also it is the same formula of atls for adults as well for adults also we use this same atrs formula if I talk about children guys if I talk about children important is what is the formula for children children need more amount of fluid okay therefore it is three into body weight in kgs in kilograms into total body surface area of Burns in percentage that is the formula used for children and if I talk about this is only okay atls formula for children is separate but for Parklands for children also we use the same formula for Parklands we use the same formula for children's also in only atrs we have a separate formula for children where the multiplier is three in Parklands we do not have a separate formula for uh adults and children and the third formula which is given in atls protocol is for the electrical bones in cases of electrical Burns there is excessive volume loss or excessive blood loss from the body therefore more fluid requirement is there and therefore the multiplier is 4 over there okay and that was the previous Parklands formula now the Parklands formula is two as I've told you we do not use a lot of fluids now that's the reason okay so in cases of electrical bones only the ital is formulas four into body weight in kilograms into total body surface area of buns important is please remember they have asked you to calculate the fluid requirement to the child according to the Parklands formula so Parklands formula is two into body weight into total body surface area of burns so what is the body weight of the child 20 kg what is the total body surface area of burns 30 so two three the five so truth is the six and six to the 12th so the total amount which is required is to 1200 ml so the total amount of fluid which will be required by this patient will be 1200 ml important is out of this 1200 ml the amount that we get this is the amount which should be given to the patient over a span of 24 hours this is the amount of fluid which should be given to the patient over a span of 24 hours first half of this fluid that means 600 mL should be given in a span of 8 hours okay so first half should be given in a span of first 8 hours whereas the next half okay the next half should be given over the next 16 hours it should be given over the next 16 hours those who are having confusion 0 to 8 hours give half amount of fluid that is 600 mL and 8 to 24 hours in these 16 hours give the remaining half amount of fluid that is 600 mL again okay that's important next if I talk about the last two topics and one is what is this this is what is your frost bite okay so as I've told you most common cold ones that is frostbite usually it only occurs at freezing temperatures when there is ice freezing temperatures usually right like in a siachen glacier our soldier who is in Glacier is exposed to temperatures as low as minus 50 to minus 60 degree Centigrades over there definitely the patient will have ice crystals formation in the tissues due to that the blood supply to the fingers and the toes will be decreased and if the blood supply is decrease the patient will have gangrene as well okay further next this is the case of trench foot it is not seen at freezing temperatures but it has seen at some freezing temperatures that means temperature around -10 or 0 degree Centigrades of 4 degree Centigrades plus four plus five okay at such sub freezing temperatures and usually moisture is there that means of soldier who is standing in a trench okay trench Is Nothing But A Gadda which contains some fluid okay water usually and a soldier is standing in that trench for a longer duration of time that person is definitely in both these conditions both are examples of cold ones in both these conditions what is the treatment so treatment is Rapid rewarming or gradual rewarming usually please remember it is a gradual reforming rapid rewarming should be avoided because it can cause reperfusion injury that is the risk factor so gradual reforming has to be done and gradual rewarming is done with usually immersing the hands or immersing the foot in a warm water bath what is the temperature of that water that has been asked the temperature of the water is maximum 40 degree Centigrade it can be below 40 degree but not above 40 degree okay it is usually 40 degree Centigrades the temperature it is and if there is gangrene we will go for a early amputation or a delayed amputation we will generally go for a please remember we will go for a delayed amputation why delayed amputation is done we wait so that a clear line of demarcation appears okay a clear line of demarcation appears between the viable parts and between the non-viable parts okay so you are able to see which parts okay you wait for some time you let that line of demarcation appear okay if you do it early what will happen you are not aware if this part is also having necrosis okay if you have cut this part amputated this part then a crosses are still going on that's the important thing you wait for some time and then you go for amputation period amputation thank you so much so I hope you enjoyed the class and please let me know in the chat box so I can end the session okay if you have having any doubts you can message me definitely in any platform possible okay my every platform is with the same name that does Dr um you can find me on Facebook Instagram telegram everywhere okay so that's important I hope you have enjoyed the lecture of surgery we have completed general surgery today I know endocrine surgery is left but any which ways I'll try to complete it tomorrow definitely okay so all of you I had a great time hope you all you had a great time Okay so like the video if you have liked the session as well recommend it to your friends okay because fmg is the exam please remember where you need to take other people along with you it is a qualifying exam not a competitive exam yes that's the reason why please take your friends along with you let them get benefits of this session as well and I'll be more than happy to help you with any problem that you face hello done with this let me in the let me know in the chat box a thumbs up thank you so much so tomorrow's topic I will be covering endocrine surgery and then I'll be starting with definitely vascular surgery and then we'll proceed with Git don't worry about that okay