Basic Emergency and Surgical Skills

This file was designed for fresh medical graduates to introduce the basic surgical skills and trauma management to them.

It was intended to be the manual of a mandatory course for the interns in Cairo University Hospitals (BESS Course).

It is suitable for all medical students and junior surgeons.

It includes the principles of:

  • WOUND MANAGEMENT
  • HANDLING INSTRUMENTS
  • SUTURING TECHNIQUES
  • SUTURES & NEEDLES
  • LOCAL ANAESTHETIC TECHNIQUES
  • PRIMARY AND SECONDARY SURVEY OF INJURED PATIENTS
  • TRANSFER
  • ABDOMINAL TRAUMA
  • HEAD TRAUMA
  • TRAUMA OF EXTREMITIES
  • UROLOGICAL TRAUMA
  • BURN

last update was in 2012.

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Advanced Update in General Surgery

I have collected these notes from different sources during my revision for the FRCS exam.

It is not a formal text book nor a systematic notes to start studying with.

It is not suitable for junior surgeons.

Some subjects are hand written.

This is a scanned version of the original notes.

It is a very good source for revision before any advanced exam in General Surgery specially the FRCS or to update your knowledge in General Surgery.

Download..

Emergency Surgery for Juniors – PDF – FREE DOWNLOAD

This PDF file is a very brief guide which was designed initially for interns in Cairo University hospitals to help them throughout the initial management of patients with surgical emergency presentation until they could seek senior advice.

Recently, I have found a lot of my junior colleagues including junior residents (SHOs) and interns (FYs) in many hospitals in Egypt using this guide in their practice. So, I decided to upload it here for you.

19-page PDF file (2 MB)

ER – Surgery Download

Again, your feedback is highly appreciated.

Urology / Clinical

TAKING HISTORY FROM A PATIENT WITH urological CONDITION

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Pain
  • Renal pain
  • Ureteric colic
  • Vesical pain
  • Prostatic pain
  • Urethral pain
  • Testicular and epididymal pain
Lower urinary tract symptoms “LUTS”
  • Irritative
    • Frequency
    • Noctorna
    • Urgency
    • Urge incontinence
    • Nocturnal enuresis
  • Obstructive (bladder outlet obstruction) “BOO”
    • Difficulty to initiate
      • Hesitancy
    • Difficulty to maintain
      • Weak stream
      • Interrupted stream
      • Forked stream
    • Difficulty to terminate
      • Dribbling
Symptoms related to change in urine
  • In Volume
    • Polyuria
    • Oliguria
    • Anuria
  • In Content
    • Heamaturia
    • Pyuria
    • Chyluria
    • Cloudy urine
    • Necroturia
    • Pneumaturia
Others
  • Incontinence
  • Discharge
  • Swelling
  • Sexual difficulties in men
  • Infertility
Occupations associated with exposure to bladder carcinogens
  • Dry cleaners
  • Leather workers
  • Painters and decorators
  • Paper and rubber manufacturers
  • Dental technicians

Bladder carcinogens

  • Aniline dyes
  • Alpha and beta naphthylamine
  • Xylenamine
  • Benzidine
Symptoms suggesting malignancy

Examination

Differential diagnosis of different urology presentation

Causes of haematuria
  • Kidney
    • Congenital
      • Polycystic kidney
    • Traumatic
      • Rupture kidney
      • Stone
    • Inflammatory
      • TB
    • Neoplastic
      • Carcinoma of the kidney
      • Carcinoma of the renal pelvis
    • Blood disorder
      • Anti-coagulant drugs
      • Purpura
      • Sickle-cell disease
      • Haemophilia
      • Scurvy
      • Malaria
    • Congestion
      • Right heart failure
      • Renal vein thrombosis
    • Infarction, Arterial emboli from:
      • Myocardial infarction
      • Sub acute bacterial endocarditis
  • Ureter
    • Stone
    • Neoplasm
  • Bladder
    • Traumatic
      • Stone
    • Inflammatory
      • Non-specific cystitis or ulceration
      • TB
      • Bilharzia
    • Neoplastic
      • Carcinoma
  • Prostate
    • Benign and malignant enlargement
  • Urethra
    • Traumatic
    • Rupture
    • Stone
    • Inflammatory
    • Acute urethritis
    • Neoplastic
    • Transitional cell carcinoma
Types of haematuria
Frank
Microscopic > 3-4/HPF
Painful Usually benign condition
Painless Must regarded as a symptom of tumor until proved otherwise
Total Origin from kidney Cylindrical clots
Origin from massive vesical bleeding Discoid clots
Senile prostatic enlargement
Tumors
Terminal Origin from bladder Trigone

Bladder neck

Origin  from posterior urethra
Senile prostatic enlargement
Initial Origin from urethra
Differential diagnosis of a renal mass
  • Hydronephrosis
  • Pyonephrosis
  • Polycystic kidney
  • Renal tumors
    • Hypernephroma
    • Wilm’s tumor
  • Big renal cyst
Causes of hydronephrosis
  • Unilateral hydronephrosis
    • Pelvi-ureteric obstruction
      • Congenital pelvi-ureteric junction stenosis
      • Pressure from aberrant arteries
      • Stones and tumors in renal pelvis occluding the opening of the ureter
    • Ureteric obstruction
      • Stones
      • Tumor infiltrating the ureter from: Cervix, Rectum, Colon or Prostate
      • Uretrocele
      • Schistosomiasis
      • Bladder tumor
  • Bilateral hydronephrosis
    • Retroperitoneal fibrosis
    • Prostatic enlargement
      • Benign
      • Malignant
    • Carcinoma of the bladder
    • Schistosomiasis
    • Urethral strictures and valves
    • Phimosis
Differential diagnosis of a suprabupic swelling
  • Full bladder
  • Pregnancy
  • Bladder tumour
  • Uterine or ovarian mass
The causes of retention of urine
  • Mechanical
    • In the lumen of urethra, or overlying the internal urethral orifice
      • Congenital valves
      • Foreign bodies
      • Tumors
      • Blood clots
      • Stones
    • In the wall of the bladder or the urethra
      • Phimosis
      • Trauma (rupture of urethra)
      • Urethral stricture
      • Urithritis
      • Meatal ulcer
      • Tumor
      • Prostatic enlargement; Benign or Malignant
    • Outside the wall
      • Pregnancy (retroverted gravid uterus)
      • Fibroids
      • Ovarian cyst
      • Faecal impaction
      • Paraphimosis
  • Neurogenic
    • Post-operative retention
    • Spinal cord injuries
    • Spinal cord disease
      • Disseminated sclerosis
      • Tabes dorsalis
    • Hysteria
    • Drugs
      • Anti-cholinergic
      • Anti-histaminic
      • Smooth muscle relaxants
      • Some tranquilizers

According the sex

Females

Males

Retro-gravid uterus Infants Posterior urethral valve
Pelvic tumor Meatal ulcer crust
Multiple sclerosis Child Congenital bladder neck obstruction
Hysterical Teens Urithritis
Adult Stricture
Bilharzial
Old age BPH
Carcinoma of prostate
Causes of a urethral discharge
  • Infection (urithritis) by
    • Gonococcus
    • Chlamydia
    • Coliforms
    • Trichomonas
    • Candida
  • Lesions in the urethra
    • Warts
    • Herpes
  • Foreign bodies
The causes of urethral strictures
  • Congenital
    • Pinhole meatus
    • Urethral valve (not a true stricture)
  • Traumatic
    • Instrumentation (catheterization)
    • Foreign bodies
    • Prostatectomy
    • Amputation of the penis
    • Direct injuries
  • Inflammatory
    • Gonorrhea
    • Meatal ulceration
  • Neoplastic
    • Primary and secondary neoplasms
Differences between different types of trauma to the urinary bladder and the urethra

Extraperitoneal urinary blabber rupture

Intraperitoneal urinary bladder rupture

Injury of posterior urethra (intrapelvic)

Injury of  anterior urethra (extrapelvic)

History of trauma

  • Sever trauma
  • Shock
  • Pelvic fracture
  • A blow or kick to lower abdomen in presence of a full bladder
  • Sever trauma
  • Shock
  • Pelvic fracture
  • Falling Astride hard object
  • Kick to perineum
  • Perineal haematoma

Urine retention

  • Desire
  • Full bladder
  • No desire
  • No full bladder
  • Desire
  • Full bladder
  • Desire
  • Full bladder

Urine extravasation

Boggy swelling in suprapubic area Free fluid in peritoneal cavity with peritonism deep in extra-peritoneal space like extraperitoneal rupture of bladder If patient tries to void To superficial peritoneal poch

Bleeding per-urethra

No

Drops of blood at external meatus

DRE

Prostate in normal position

Prostate in higher position

Passage of catheter

Urine or not

blood

Contraindicated

Ascending Urethrography

Normal

Show the site of extravasation

Ascending cystography

Leakage of contrast outside the bladder

Differences between congenital and acquired bladder diverticulae

Congenital bladder diverticula

Acquired bladder diverticula

Rare Common
No obstruction Distal obstruction
Usually solitary Usually multiple
No bladder saccules Associated with bladder saccules
Medial to and above uriteric orifice Posterior wall
  • Full thickness pouch
  • Contains muscles
  • Mucosal pouch
  • No muscle
Wide neck Narrow neck
No stasis
  • Stasis
  • Infection
  • Stone formation can happen
Usually requires no treatment Treatment of obstruction and need excision

Anal canal / Clinical

TAKING HISTORY FROM A PATIENT WITH Anal condition

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Swelling
  • Pain
  • Discharge
  • Bleeding
  • Pruritus
  • Change bowel habits
  • Incontinence

Examination

Position
  • Left lateral position
  • Chin rest on the chest
  • Hip flexed 90o or more 
  • Knee flexed less than 90o
Inspection
  • Skin rash and excoriation
  • Faecal soiling, blood or mucus
  • Scaring, or opening of a fistula
  • Lumps and bumps
  • Ulcers, especially fissures
Palpation (digital rectal examination “DRE”)
  • Inspect your finger, when you remove it
  • The Anal canal
    • Tone of the sphincter
    • Pain or tenderness
    • Thickening or masses
  • The rectum
    • Texture of the wall of the rectum
    • Masses
      • Mobility of the mucosa over the mass to decide if it is within or outside the wall
    • Ulcers
    • Content of the rectum
      • Hard or soft
      • Faeces may feel like a tumor but are indentable
  • The recto-vesical/recto-uterine pouch
  • Bimanual examination
  • The cervix and uterus
  • The prostate and seminal vesicles
Proctoscopy
Sigmoidoscopy

Differential diagnosis of different anal disorders and approach for diagnosis

Diagnosis of conditions which present with rectal bleeding
Bleeding but no pain
Blood mixed with stool Carcinoma of colon Also proctitis caused by specific infection (e.g. schistosomiasis)
Blood streaks on stool Carcinoma of the rectum
Blood after defecation Heamorrhoids
Blood and mucus Colitis
Blood alone Diverticular disease
Melena Peptic ulceration
Bleeding + pain
  • Fissure
  • Carcinoma of anal canal
Diagnosis of conditions which present with pain
Pain
  • Fissure (pain after defecation)
  • Proctalgia fugax (pain spontaneously at night)
  • Anorectal abscess
Pain and bleeding
  • Fissure
Pain and lump
  • Perianal haematoma
  • Anorectal abscess
Pain, lump and bleeding
  • Prolapsed haemorrhoids
  • Carcinoma of the anal canal
  • Prolapsed rectal polyp or carcinoma
  • Prolapsed rectum
Diagnosis of conditions which present with lump
Lump and no other symptoms
  • Anal warts
  • Skin tags
Lump and pain
  • Peri-anal haematoma
Lump, pain and bleeding
  • Prolapsed haemorrhoids
  • Carcinoma of the anal canal
  • Prolapsed rectal polyp or carcinoma
  • Prolapsed rectum
Common causes of acute anal pain
  • Fissure in ano
  • Anal abscess
  • Strangulated pile
  • Perianal heamatoma
  • Proptalgia fugax
The causes of Pruritus ani
Mucus discharge from the anus
  • Haemorrhoids
  • Polyps
  • Skin tages
  • Condylomata
  • Fissure
  • Fistula
  • Carcinoma of the anus
Vaginal discharge
  • Tricomonas vaginitis
  • Monilia vaginitis
  • Cervicitis
  • Gonorrhea
Skin disease
  • Tinea cruris
  • Fugal infections, especially monilial
  • Infection in diabetics
Parasites
  • Threadworm
Faecal soiling
  • Poor hygiene
  • Incontinence
  • Diarrhea
Psychoneurosis
Differences between acute anal fissure and chronic anal fissure

Acute anal fissure

Chronic anal fissure

Soft Indurated
Spastic muscle Fibrotic muscle
Conservative treatment Operative treatment

Cardinal symptoms of common anal disorders

Anal disorders usually share the same symptoms but every disorder has its own cardinal symptom

Disease

Cardinal symptom

Other symptoms

Fissure Pain Sentinel pile (swelling)
Abscess Swelling Continuous throbbing painful swelling
Fistula Discharge Pruritus
Haemorrhoids Bleeding Pruritus