Shock ‘Shocks a systemic state of low teow perfusion (that i inadequate fr normal collar regiaton! wih impaired collar metabolism and dysfunction of vit organe Classification © Mpovolemic - Hemorrhage Incolore 4 monitor Shack: - burma, © Shock indox- HR > 0.9 sungeete devorrpenscted = Severe cleby dation ( diarrhoea, vorniting) Syeblic 8° Shock ese © Modited heck imiox “YR (Heart fate) (rs) @ Nisinibutive - Septic thock ‘mean arya pressure - Andphylactic Shock © Wore (Bde over press) — Neutrogenie. shock ee ale adrenal ineufFicienay ed 3 > dewomperatied © Obstructive shock- Cardiac tamponade = Tepwoon pneu thorax © Endocrine shock Hypovolemic shock ee as oe Pathophysiology Lie Faty changes win ponent coral nce ee Keys Extn arti ay oe Modano 4% prdond Lungs Pulmonary congestion with difuse alveolar damage J ‘Adrenal Cortical cell lipid depletion eee bran creme encephalnsthy eee Heart Coagulation neces or contraction band necrosis or Homomage etopaty Pores Don progress |@orroaroated plane @ Progressive |devompertated pate © trraverible Irmult organ fiture mx © flssess arc! maintain airway ond breathing @ Resusciterhon wrth Aud therary ~ Shoult hot te delayed to diagnose Source of shack cle — In patente with active bleeding, i i¢ Counter prcductie t inchtute nee high vole Aud torupy without controlling Cte oF haemorrhage arly ~ Tachyeardia © Pluid thoraey: = Sweoting = Gxysiallbide (Ringor Jackale Hartrnan's sol") preferred over calloih ~ Hypotension during initial recitation ~ 00d priory = Hypotonic co 4 poor volume exoandere should not be used = Tadrypnea @ Monitor using CCG, puso oximehy, blood pressure , urine output ae fatanal rrodaoncv>, Coto auto sean lace Ole ©oowect cides - Sabivm picabonate ~ Cyanosig i = Soria @©Crabate pation? for cause ard seventy and speuitic Re = Drowtings? © Blood frarsfusian , if needed = Respiratory Adithrese Vasopreseoe are indiated in Dietributve chock Ord Tonotropic Support for Careliogenic shockPathophysiology Uaemorrhage I volume loss Shock Hypothermia, faidosis foute Trumatic Coaqulopathy Fibrinolysis Wourta —————> Tiautiva induced Cooguppathy —— Inflammation = Medical tharmpy fas 0 tendency to worsen this offect: “te fe q at 004-> more hypothermia Teak trent Gor fereelas tie) = Elfrt should 66 ryote i> rapidly identity and chp bactrorrhoge and avoid physalogesl extavsan fom congulo patty, acidosit and hypothermia * classifcation: ed cp ee ed pee Noma oma mad aiedunt i > > sultan Fenny a se20 2% so Lear ~ 20% os © Tes: © fevedied - visible external haemorrhage @ concealed = inerral [Ser /Spicen injury certhral haemorrhage CE ~ Faker of Hypaclomic sk Decreases ~5é © identify haemorrhage ~ Exoral hatmarrhage is obviou ~ bx of concealed haemorrhage is aefcult Any chock shoul be osumed fo be hypovolernie unt proved otherwise and ary hypovelemia should be assumed fo bo due to haemorrhage uni! proved otheruite ® Immediate resuscitative manoeuvres’ ~ Direct pressure over Gite of extemal haemomhage - Airway # brasthing assessed and controlled: large” bore ZV acces = Blood drawn for croee Watching @ donhfiy gite of haemorrhage = Find cles in hietory (eq previous epicades, known aneurysm , NSAID induced GI bleed ofc) and examination: = Investigations “rust be anynate part physical ndon te ~ firme should not be wasted in unnecessary = Rapid bedside tests CX - ray, USG, PAST (for trawna)] rrore Appropriate than time Consuming texts like CT- © Yaerorrhaye contre) = mint bo achered apally 1 prevent patient from orfering iad oF Coagulogntny aatiosre~ hypothermia and Physiological exhavaton ~ Guraica!inferenion ( encloseapc corr! , empolisskan) ~ Limited fo minimum neceseary to op bleeding ord Sepsi¢ = Define repairs can be dlolayedl till patient i¢ haerodynamically f Damdge control Resuscitation: Damage Control Sx: lopaihy a Arrest haerrorrhage © Antiopate and ‘reat Troumatt Congulopathe @ Parmissive hypotension fill haemorrhage conrra! © Control sepsic @ Limit crystalloid 4 collod infusion to avoid dltional coogubpaty @ Protect Fram Further inuury @ Damage contra! surgery ® bo nothing elso © Once hawrerrage ic controlled, ggressive Resuscitation with orystalioide sheuld be warmed, ard coagulomthy should be Corrected © Monitor patent os in Hypoolemic shack @® fasess Fluid responsiveness © Blood Transfusion , if neededBlood transfusion 1 Indicationg « Acute blood les, to replace circulating volume and maintain axygen delivery; + Perioperative anaemia, to ensure adequate oxygen delivery during the perioperative phase; ‘¢ Symptomatic chronie anaemia, without haemorrhage or impending eurgery, ¢ Blood and blood products | Whole blood - whole blood tranefusion hae significant advantages over packed celle as it ig coagulation factor rich and, if fech, more metabolically active than stored blood 2. Packed red celle ‘ecpundown and concentrated packs of red blood col + Each nit ie appraximately 330 mL and hae a haematocrit of 50-70%, + Packed calls are stored in a $ eoltion (calne-adonine-glucose-mannitl) to inereage chet fe to 5 weeke at 26°C 3. Fresh-frozen plagma « rich in coagulation factors and is remoued fom fresh blood and ctored at ~40 to 50°C with a 2year shel ife « rating therapy in the treaiment of eoagulopathic haemorrhage 4. Cryoprecipitate ‘¢ cupernatant precipitate of FFD ‘¢ [o rich in factor VIll and fibrinogen. © stored at ~30°C with a 2year shelf if. 5. Platelets. ‘¢ Platelets are stored on a special agitator at 20-2.4°C. and have a shelf life of only 5 days + gjven fo patient with trombocutopenia or with platelet dyefuncton uho are bleeding or undergcing surgery, 6. Prothrombin complex concentrates « Prothrombin complex concentrates (OCC) are highly purified concentrate prepared from pole plasma «© Thoy contain factor I, IX and X « indicated for the emergency revereal of a coagulant (warfarin) therapy in uncontrolled haemorrhage. 7. Autologous blood = [tc poosble for patonte undergoing elective eurgory to redone their oun blood up to 3 weeks before surgery fr riranfion during the operationBlood substitutes 1) Biomimetic: Haemoglobin based = mimic Standard oxygen Carying capactty a blood 9) Abiotic = Contain synthetic oxygon carriers ( porfuorecarbon based) # xomples: - {st gon: PerPlurocarbon = and gen: Stroma free Ho = Noxt gen = Polyethylone glycol Hb (PEG) — Hemogpan (mp4ox) — Pyridoxilated Hb polyoxyethylene conjugate Complications © incompatibility haemolytic tranefusion reaction © coagulopathy «febrile tranefusion reaction © hypocaleaemia = — hyperkalaemia bacterial infection (usually due to faulty storage) 2 hypokelaemia een « hypothermia e HIV © malaria « air emboliom « thrombophlebitis ¢ tranefusionrelated acute lung injury (usually from FFP). Tranefusion Reactions: AnapryacterastonSepiic sao Pathophysiology of septic shock ‘Toxins/endotoxins from organisms like E. Coli, Klebsiella, Pseudomonas, and Proteus L Inflammation, cellular activation of macrophages, neutro- Phils, monocytes L Release of cytokines, free radicals L Chemotaxis of cells, endothelial injury, altered coagulation caseade—SIRS L Reversible hyperdynamic warm stage of septic shock with fever, tachycardia, tachypnoca L Severe circulatory failure with MODS (failure of lungs, kidneys, liver, heart) with DIC + Hypodynamic, irreversible cold stage of septic shock. Gages ¢_cle © Hypardynamic (watw) chock ~ Reversible ¢tage - far ~ Tachycardia = Tachypnea @® Hypotyrarnic Uypovolornic (Geld soptte shock) — Pyogenic: Rospanse 18 lost = Stage oF Jowmpersated shock = Irreversible gage with fons ~ (yanosis (Respiratory failure) = Anuria (eral Faliure) ~ Drowsiness - Coma - Death Sinn + Common causesare ilar, urinary, GIT sepsis (peritonitis stran- ‘ulation, respiratory (pneumonia) ‘Common bacteria ae col Klebsiella Pseudomonas Common pathophysiologies ae release of toxins, neutrophil activation, cytokine release and sik el syndrome IRS, MODS ‘linical stages are hyperdynamic ama hypodynamic Find out the source of the infection by US, CT scan Do pusfblood/urine culture Start antibiotics of high generations like ceftazidime, amikacin, ‘cefoperazone Dopamine/dobutamine infusion (stow) Monitoring by pulse, BP, respiration, urine output, level of consciousness + Ventilator suppor, ICU management Treatthe causestike peritonitis abscess eeee oe oe ‘Treatment of septic shock. ¢ Correction of fluid and electrolyte by erystalloids, blood transfusion. Perfusion is very/most important. ¢ Appropriate antibiotie—third generation cephalosporins! aminoglycosides. Treat the cause or focus—drainage of an abscess; lapa- rotomy for peritonitis; resection of gangrenous bowel; ‘wound excision, ¢ Pus/urine/discharge/bile*blood culture and sensitivity For antibiotics. ¢ Critical care, oxygen, ventilator support, dobutamine/ dopamine/noradrenaline to maintain blood pressure and urine output Activated € protein prevents the release of inflammatory mediators and blocks the effects of these mediators on cellular function ‘¢ Monitoring the patient by pulse oximetry, cardiac status, urine output, arterial blood gas analysis. ¢ Short-term (one or two doses) high dose steroid therapy to control and protect cells from effects of endotoxaernia. It ‘improves cardiac, renal and lung functions. Single dose of | _methylprednisolone or dexamethasone which often may be repeated again after 4 hours is said to be effective in endo- toxie shock. ‘Septe Shocks also krown as Vasodletry Sheck Su remember Vasopressor ae nt the tt ne) ‘Management Protocol for Septic Shock ‘Stop 1: Immedateerahaton - Seong the away It indested and carecting hypoxemia and eetabting venous acoaes or arinsvaten of us and artbotes ae pits nthe manapemet of pats wih sepls and opte sack ‘Stop 2 INITIAL RESUSCITATVE THERAPY. apgrsave amination of ntaveno us (WF, sual estates gen at 99 mL/kg acs Boa) eight wit the tat hee nurs follwing presentaten mpc ntti therapy started win fret hour ‘Stop 3 navenovsvasopressrs are sett pars who rman hypotensive deste adequate ld resuscitation er who devcpcariogenic pulmonary edema. (ource: rtnationa ulin fr the management epi shack) \Vosoprescor agents ouch oe Phenylephrine, Noradranline ao ndcatedin detibutve shock stats which inca sept shock, newogene shock ete where her i peripheral vasodiataton and alow system asclreistance dng nypotengien Bu hey ae nat te Frat neDaediatric SurgeryTracheo-Ocsophageal Figtula/Oesophagial Atresia - Associated with NeMmyc mutation: VTupe &| “desophagus. tind endirg atrette J *No communication with taghea Uh *Type 8 |+Provimal end - cormmuniades with trachea, C * Distal end- blind ending a *Typec |+Proximmal end = blind ending i + Dictal eng - Communicates with trachea, DS Type D * Type E} «0esophagus is rule, + Most cormmman type Both ends comnmnnicate with trachea [ * Least Comman yall) } = foe *Cistulus Communication lw trachea & desophagus: * Also called “H type" (Respiratony distress +P eophague is not patent + Cxersive drooling of Salva * Guanotic episodes on attemoing tp feed * Nasofore gastric tube goes no further than upper oesophageal Pouch cwiling of tube” Seen an chest x ray a Seen 5 Air goes {nto stymach in aazeg of patent oesophagus of when digtal end communiaies with trachea Dk! Contrast study [Tohexol 7 Dinostl > Barium] «Toc + 4ype & CH type) - combined tracheo-cesophagoscopy + Pssociaied anomalies! * Vertebral defects “Anorectal mal formations + Limb defeds +Renal_anornalies > Rule out others After diggnosis oF any oF absve*Monogement ealiaer %¢ Complications of Sy “Waterson's Criteria. Buéth wight Oneumania My + 78Skg Absent YeFinltive guraery + 15-95 kg Absent [Present __| Antibiotics + ia en Surgery Cwhen in right wh range) peers Absent f Antibiotics + e eed Gastnstomy for nutrition U Surgery (when in right wt range) Step 4 - Thoracotomy (Posterolateral) v Type A Types alc/ ple |@ehds of cesphagus close Gormeron Haight Surgery 4 Anastomosis 0 Dismante -istol @ Repair trachea (Pos sutures) (9 Ends of oesophagus détants hoy Q Arastomme 2 ends of oesophngus LGastrastomy Céor nutrition) v aaa # wait Oesophagen! ends grow close te normal Growth Anastormos!s l# Wilean- Cook's Floutish device 4 ee in both end Faster growth towards each other + Othert - + Recurrent fistulas * Gastro: esaphagea! refluxCongenital/Idiopathie Hypertrophic Pyloric Stenosie *Theldente| + male : female 2 4:1 +more comman in ist bom wale child + Maternal okyibromycin intake ca hypertrophic pyloric musde - Functional gastric olutet obstruction- * No symptoms at birth (Differentiate from duatonal atresia) + Sumptoms- Gort after 9-2 wks + rjectile Nom biliaus Vorntting *No PEM is usually geen . ination] peck time- When child is feeding (Test Feat) + \igible peristalsis’ going fran seen- + Paloable olive shape, “swelling in epigastrium * This followed by prajedile vomiting: * Signs + USG abdomen(Toc) - _@ Target gign Antral nipple sign ONE re Sr * X-ray dhdomen - Single bubble sign + (ontost ctudy -@ Decble tack ign g Mushroom sign Gring sign CAlso seen in Tnflammertory Bouse! digeaxe an barium follow +nrough) sthelatolic Abrorreality] Myperchloremic. Hypokalemic metabolic. alkalasis with paradoxical. ocid unio. wc foot (4 HL REL ee L— faved nat] wat een [elobstic ATRalesr= . “ik seek Toitcor secreed in urine eis p— Lae Cenk evement of K° into ale Cexorge wath) —* gaeeled im rine inghead of k* for Na* rebention Pavedovient Retiuria+ (Management| + Correct dehydration @ wnetabolic abaormality “Doct Avid - only ddded after rend! function recovers & Orine (0R] oulput i¢ adequate Ringer locate sol” (and choice) Surgery! Rarrstedt — Ayloremyotorny L, done through Semsa; Mucara is intact + Peeding of: Sur 0) Unevertful surgery (Mucosa nat infured) after 4-6 brs 6) _Mucogs infured while y- offer 24-42 breCongenital Diaphragmatic Hernia (CDH) «TYPES eT “etioleay| ~ Structures! *fathology| Bochdalek (mid) Ces-tor) Morgagni Left posterolate Right anteromedial Due to defective development Due to defective cental tendon oF plevroperitorea cana) (membrane development Stomach .gpleen, transverse color Transverge. colon (mic) Ss] will be pesent to thorax | Pulmonary hypoglasta (m/c couse of death) v Hypoxia v {ion vasels undergo hypoxic, vasoamnstriction Dutewonarey hypertension (And jc cavse oF death’) Maternal sly hydroarmnios *Scaphoid abdomen ~ |s Respiratory distress * Surgery = Dextoairdta Rules tube gels cofled in choch g seen in thorax] * Gest ventilation - Scere positive pressure ventilation) Fails Ecmo CExtracorporea! mernbrane oxygenation) * Thhaled nitrated are hebful for pulmonary hypertension Circumferential incigsim over diaphrogm feduce hemiated contents Close diaphragm using a large size Imesh (# Size of meth should fake in account normal growth of ow & mesh shrindage)Wilm’s Turnor + Types, REMIC Paediqtric rena) tuner P4903 mle abdominal paediatric Pee © Sporadic - More comma @ Camilial ® WAGR syndrome pWilm’s Anindia Cenitourinary ‘malformation Merttal Retardation GiJDenys- Drash syndrome p— wilm's | Tniersex abnormalities Mental Retardation Gi) Beckwith: Wielemann syndrame,—Wilins E Heibypertroohy ornphalocele Mental Retardation MParnilial tumors ‘end fo be bilateral *Ocours bw Q-S years "Abdomtnal (ump CAarely Crosses Ynidline) Cuniike Kevroblattoma| + Haerrotutia “fain *Cain algo spread along rehal vein (Not metastatic) *Metoxtasis— Lungs, LN- para dortic cect - TocNostiomal Tomar Stu I-Stage 1 - Turnor Confined fo kidney; Completly excised "Stage TL - Tumor outside Kidney; completely excised LN negatie) Stage mz - Non Haerratcgerous confined to abdomen (LN positive) |Cage TZ ~ Haematgenous metasioxes to Lungs | Uver Stage SF - Bilateral Wilms tumor International Society GF Rediatric onctlogy *Managerrent| + Surgical principles Same as Acc * Mx Plane sNUITS - Surgery (ist) + Chemotherapy 4 fadictherapy = Sl02- Neoadjuvant chemotherapy + Surgery + Badiotnerapy *Cherno_Agents| « Dactinomycin » Vincristine * Cyclophosphamide TIE progeste factor- Histology oF tumor - made of epithelial 4 blastemal compments +Histopatholeay| Wilms urer is * Higher blasemal compaments — Poor prognosis.Abdominal Wall Defects “Management Omphalocele/Exomphalos GCagtroschisig “Defect through umbilicus = Defect adjacent +o umbilicus : Commaly on right side 4 Bowel fails to retum back to abdaminal cavity duti emibryogenesls Cbttsiolotal Homia) + Bavel covered by & Sac «Bowel Not covered with gac CLiver may also be present in sac) + Other congenital anomalies can be | + Exposed bowel + dy Seen (cardiac defects m/c) : : + Malrotations can be seen PerSration — Pn fiannaticn + Correct dehydration = + Garch for other congenital abnormalities * Definitive. My An Mesh +o Cover the defect Staged reduction of contents <— ilo rresh_ @ Close the roof of mech Defect @ Reduce, the height of silo every week +i) are ig reached @ Cover defect with mesh ¢ repairAno-Rectal Malformations © Clascifications| + Winggpread ——_ —— oo oe eee Se — + anonaeee wo ene ate 7 Se High — Reciovesical isometry | | wana | ROA | wanes | Roca Tntermediate | Analagenesis | Wins rgula | Rectobulbar | With fistula ow ‘Covad ns -cooeto "Aad “ar pei a rete) Le Ansan omg) vaharsie nova ft Pena “Table 3: Pens classification of ARM [6] Wipes Te % Congenital Anomalies that may co-exist CyACTER L) + V -Verkebral defects. *TE - Tracheo esophageal defects +A- Anorectal defects +R > Renal defeds + C- Cardiac defects +L - Limb defectsrectal malformation 2 oct comer Ampere aru with redobulbar eretal sire : ) Girke Fistula opening in eosterior vestifule behind vagina or on fhe perineum * No anal opening * Fistula + Dnvertogram (done 24 brs afer bieth) © Mwert the 60. by ® Keep a marker at propaced anal opening site d= distance blu air bubble @ marke on chin LP, d>Qom = high defect d<8em = low defect T/MRE are beter investigations. * Rule out other congenital ansrmalies PSARP (Pasieriar Sagittal Aro fectoPlaste/) Low _anomal Higa Gnomalies * Single Stage PSARP + 9 ghage PSARP + Perineal approach + Abdominal + perineal approach = No tolostomy needed | + Coloshsmny required tnitialhy ¥Trtermediate - Decision mode after axcescment sComplitaion- fecal /Uvinary therntinenceVomiting in Infancy © Bile Stained Nepoate. Older Drfant + Triestinal malrofation with volullug * Trestinal malrotation with volvulus * Duodenal Atresia } Stenosis + Thearcetated jnguinat hernia. *Tejunal [Tleal atresia + Thiususception + Hirsch sprung’ disedae 'Coflen nanbilicus.irtally) > Anorectal malformatons + Meconium ileus Cafu Cystic Fibroste) + Necrotising entero colitis + Trearcetoted frguinal hernia, » Non-bilious| + Trfantile Hyperhaphic Ploric Stenosis * Qastro desophageal_reftux o ing difFiculttes * Non specific marker of tllnesses 4 — fnfectfongClagegow Coma Scale GCs Score © 18-15 represent mid injury + 8412 represent moderate injury scores <8 represent severe inary Head Inury Severity: Clinical classification ee : <7 3 ‘epaitsee 2 —— 1 Vwi 7 Ea dant ieied coer : Content ’ en 3 a 2 [No sounds 1 in a Merieat a ‘Obeys commands 6 Locatzes to pain 5 Wenarawavtixion ‘ ‘AanormalfexevDecereate posturing a ‘Ecenson Decersbrate posturing 2 No moter response 1 Non-testable nr Minimum value: 3 Maximum value: 15, © GCS, in particular, the motor score, is the best predictor of neurological outcome. “fan area cannot be assessed, no numerical score is given for that region, and it is considered “non-testable.” (NT) * Incase of endotracheal intubation or tracheostomy, the verbal component ofthe score is denoted as NT. ‘Anew parameter, "pupil reactivity score” has been added to GCS, and now, its referred to as GCS-P. P stands for *Pupils unreactive to ight” Both pupits 2 (One pupil 1 Neither o ‘The pupillary score is subtracted trom the GCS score to give the final value. Therefore, the range of GCS-P is 1-15.Seal injury TABLE 24.4 Glasgow Coma Scale score for head injury. Eyesopen Spontaneously 4 Toverba command 3 “opal stinaus 2 Verba Normal orented covereaton 5 real a Minor head injury GCS 15 with no loss of consciousness Inappropriate/words only 3 (Loc) Sounds only 2 Mild head injury GCS 14 0r 15 with LOC No sounds 1 Moderate head injury GCS 9-13 Intubated patent 1 = a eran 4 Severe head injury GCS 3-8 Locales to pain 5 Witharawaltesion 4 ‘Abnormal eon 3 xtonsion 2 No motor response 1 Summary box 23.4 Primary survey ‘¢ Ensure adequate oxygenation and circulation The cABCDE of trauma care © Exclude hypoglycaemia * ¢—Control of massive external haemorrhage ‘© Check pupil size and response and Glasgow Coma Scale © A~Airway with cervical spine protection ‘score as soon as possible eee peetinaenivenisian * Check or focal neurlopica dfs bofore intubation, © C-Circulation and haemorrhage control: apply apelvic — P° binder and do not remove until a pelvic fracture is excluded D-Disability (neurological status) © E~ Exposure (assess for other injuries) GCS 15/15 with no focal deficits Normal CT brain if indicated (see below) Patient not under the influence of alcohol or drugs: Patient accompanied by a responsible adult Verbal and written head injury advice: seek medical attention if: © Persistent/worsening headache despite analgesia ‘© Persistent vomiting © Drowsiness © Visual disturbance ‘© Limb weakness or numbness ‘Secondary survey © Battle's sign, periorbital bruising and blood in ears/nose/ mouth may point to base of skull fracture ‘© Cervical spine fractures are common and must be actively excluded '* Log-roll to check whole spine for steps and tenderness, and for per rectum exam Indications for CT imaging within 1 hour GCS <13 at any point GCS <16 at 2 hours Focal neurological deficit ‘Suspected open, depressed or basal skul fracture ‘More than one episode of vomiting Post-traumatic seizure Indications for CT imaging within 8 hours ‘Age >65 years ‘Coagulopathy (e.9. asprin, warfarin or rivaroxaban use) Dangerous mechanism of injury (e.g. fll from a height, road traffic, accident) Retrograde amnesia >30 minutes ‘© The ptt wil eed to be og-rlo to plpate fr thoracic o amber efor, and ary corvial colar should be rercued ot tie stage to lew flpton ofthe ceria sine, before replaned. IF here essncoed pina injury, a thoracic soncory el ig ch more easily estbished by sensory examination onthe back «© A por retl examination eso performed a ool, asssing fr ‘ne one, sensation in he suse ptint ord andl wrk (epinoter coon to cerita in razon oaprrik fide © rapa s a srong preter of severe cord inry exe in intbatd point,PA see HAEMATOMA 4+ Itis collection of blood inthe extradural space between the dura and skull # Most common site is temporoparietal region. It can be unilateral or bilateral. corm “© Middle meningeal veins {> Anteriar branch of middle meningeal artery “@ Posterior branch of middle meningeal artery Usually, it is associated with fracture of temporoparictal region. + msty arterial: middle meningeal artery + Young patients «+ High veoety pack + Cieicaly presents with lucid terval i no pathagromie oF EON Seen in other bean juries a wel + Investigation ot eee ncct (Other — X14, ~ sieanvex lens shaped bleed. vex!) > beige betieen sul are cra ‘+ management = indications > 20. cet see >'Sirm midline hit >isem thennese cnn oped = ert Ca-tad ‘surgery ———_, ete of bleed, unable fo ocale side one en same side (eg: no CT avaiable) ‘sucgery done onthe side of pupillary diataton Fale bealang cap! Hernchan netsh phencmena ‘example! Left sided eo —> —— Somat: can press on cortical tact of the cpposte side ght se) 4 Lett pp diated Lett sided hemiparesis -Complications: +Pogt-traumatic epilepsy +Meningitig +Pogt-traumatic amnesia ical Features + History of transient loss of consciousness following a history of blow or fall, + Patient soon regains consciousness and again after 6-12 hour starts deteriorating (Lucid interval) + Later the patient presents with confusion, irritability, drowsiness, hemiparesis on same side of the injury. Initially pupillary constriction and later pupillary dilatation occurs on the same side, finally becomes totally unconscious— Hutchinsonian pupils. Initial pupillary constriction is due to irritation of the ipsilateral 3rd cranial nerve (oculomotor) by the herniation of the temporal lobe at the tentorial hiatus. But eventually pupillary dilatation occurs by constrictor paralysis due to persistent compression of ipsilateral 3rd cranial nerve. There is ischaemia of the nucleus of 3rd nerve at midbrain due to compression of the posterior cerebral artery. So burr hole decompression is done on the side of Hutchinsonian pupil. + Death can occur if immediate surgical intervention is not done. ¢ Features of raised intracranial pressure like high blood pressure, bradycardia, vomiting is also seen. Occasionally, convulsions may be present. 4 Wound and haematoma in the temporal region of scalp may be seen. + Glasgow coma scale gives clear idea about the neuronal injury. + Autonomic disturbances with bradycardia, systolic hyper tension, deep, slow respiration and later Cheyne Stokes ventilation. Cushing's triad of raised intracranial pressure is obvious—bradycardia; hypertension; respiratory irregu- larities. + Features like—restlessness, irritability, headache, vomiting, progressive deterioration—are common, Treatment Immediate surgical intervention is a must to save the life of ‘the patient. Cranioromy is done and eranial flaps are raised. The dura js not opened and the clot is evacuated. The dura is fixed to ‘galea using interrupted sutures—Hitch stitches. ‘+ Antibiotics and anticonvulsants are given postoperatively. + Recovery is good after surgery. “Treatment of extradural haematoma ‘General measures—catheter fluid therapy Prevention post-wraumatic complications ‘© Earliest surgery and evacuation the need '@ Sem vertical incision in parietal region above the zygoma_ + Galealsincised Skulls opened using perforator and bur @ Meningesare kept aside + Blackcurrant jely clots evacuated + Bleeding vessels are cauterized—bipolar cautery '& Duralhitch stitches are placed '& Opposite side ifneeded shouldbe evacuated 4 Antbiotcsianticonvulsants © Analgesics eSUBDURAL HAEMATOMA ee heros £ T 1 Aeute Sub-acute Chronic. <3doys 3-aldays ? al days * Chronic subdural hematoma, = elderly = venous = Cortical bridging veins = Clinical Features * Trivia trauma, Jeays / weeks Gradually developed altered sensorium Acute Subdural Haematoma tts ton ctalbouen Satan wd objy ered ht of di elon franks el go li abr en rig shen Hasta erate in Talal Te ann pinay ap * Heo sb of oles bg ee eeeteree eeteneett eeteerreed Comitia somin Fs oud peril ehh Pdr neg Caso © eo omre ae rhe © CT scan chun rnoncroane kn, eatment Aetities,eteomnart, Surg doconpression done by entry, Chronic Subdural Haematoma Ite due to the ptr of venebotneon dura ad brain (cert heisghere), causing gradual ecllcton of lod in subdural space * tia commeriy seen in edry ppl flowing any minor trauma li al, siping utich might ae gone untied. in ley pele, brain arghies and een minr injuries can cause shearing and blading fom thee vine Bloc colnte gradualy over 2-6 uedks. Plasma ard extlar componente got soparated Eventualy cellar part gots absorbed leaving only fuid component ie caled ae ohroriceubdral ygroma sul haematoma elletin ig 60-120 ml. fen n 5% of og iti biatral, Clinical Features + Common in ld age, uth ihry of nor trauma, «+ Patintprsent with conser, cecrientton, raul with rd oof eoneciousese ard rousinese Later conukion, features of nracrania hypertension feahurs of coring develope ‘© Extensor plantar response and pupilary changes develop swentually Investigations CT xan (chowe eoncavo-convex lesion) + Serum dotralyiee, + Blood grouping and eroes matching Treatment {+ Craniotomy and evacuation of clot is done when requited ‘on both sides, + Antibiotics. ‘© Anticonvulsants for 3 years © Epilepsy > Meningts % coning 1 Newological dfsBuus ata rd “ Thermal injury - Scald—spillage of hot liquids - Flame burns - Flash burns due to exposure of natural gas, alcohol, combus- tible liquids - Contact burns—contact with hot metals/objects/materials Electrical injury Chemical burns—acid/alkali Cold injury—frost bite lonising radiation Sun burns eo oe Oo o Classification of Burns Depending on the Percentage of Bume (Burn Severity Classification) Depending on thickness of skin involved Mild (Minor): + Firgt degree Parfal thickness burrs 5% in act cr <10% in cidren _«eyidemi ek apn, obit, © Fi thslve buna le than 2% hal rpy in 5-7 dae by eit tout soaring + shows cai fing * Can bo treated on outpationtbacie 2. Moderate : : + Second degree: Second degree of 15-25% burne (10-20% in children) ere a Thitd degree between 210% bums. «eal by opithlation in 14-21 dye Burne ugh are not invching eyes, ears, fae, hand, fet, perineum « Supereilsocond degree burn hel, casing pigmentation ‘» Deep eecond degree bum heal, causing scaring, and pigmentation + Sensation ie present but no blanching 3, Major (severe): Souind degree bume more than 25% in adit, nciken mre than 20%. « Third degree: + Al third degree burns of 10% or more. «The afoted area ia charred, parchment a, painless and inaansive, with Burns involving eyes, eare, feet, hands, perineum, thrombosis of superficial vessela «, Alinhalation and electrical burne. Ue reguires grating + Charred, denatured sence, contracted il hckrass bum ia cal at eschar. + The ured ust heal by e-opihlicatn from weurd eo «+ Burne with fracture or major mechanial trauma. + Fourth degree: Involves the underlying tiseuee—muscles, bones.« Clinical Features: * Higtory of burn. * Dain, burning, anxious status, tachycardia, tachypnoea, fluid logs. 4In covere degrees features of shock. * Tolerable temperature to human skin ie 40°C for brief period. Pathophysiology Heat causes coagulation necrosis of skin and subcutaneous tissue 4 Release of vasoactive peptides Altered capillary permeability 4 Loss of fluid > Severe hypovolaemia Decreased cardiac > Decreased myocardial output function L Decreased renal blood — Oliguria flow (Renal failure) Altered pulmonary resistance causing pulmonary oedema Infection L Systemic inflammatory response syndrome (SIRS) Multiorgan dysfunction syndrome (MODS).* Massive oadema in the body ie due to tered preeeure gradient because ofthe injury to bavement membrane. ‘Cardiac dyefunction ie due to: + Hypovolaeria, © Release of cardiac depressants. © Hormonal causee lke catecholamines, vacopreesin, angotensine. * Renal changes are due to: Release of ADH from posterior pituitary to cause maximum water reabeorption Release of aldosterone from adrenale to cause maximum sodium reabsorption * Toxine released from the wound along with pele causes coute tubular necrosis. Myoglobin released from muscles ln caee of electri injury or offen from exchar! ie most * injuricue to kicheye © Pulmonary changes are due to: * Altered ventilation-perfusion ratio. Pulmonary oedema due to burn injury, fuid overload, inhalation injury, AROS. © Aspiration. «+ Septicaemia © CIT changes are due to: « Acute gastro dilatation which oceure in 2-4 daye. Paralytic ileus, Curling’s ulcer (due to decreased mucosal defence; not due to increased HC) « Cholestasis and hepatic damage ‘e Acute acalculous cholecystitis, acute pancreatitis can occur. * Metabolic Changes ‘Hyper-metabolic rate (BMR). * Negative nitrogen balance. Electrolyte imbalance. Deficiencies of vitaming and essential elerents. + Metabolic acidosie due to hypoxia and lacti. acid Sepsis in Burn Patient Focus may be at the bum site, catheter site, cannula/CVP line site, or respiratory infection. ¢ Low immunity, loss of proteins and immunoglobulins, loss of barrier causes sepsis. Opportunistic infection is also common. Associated conditions like diabetes, HIVinfection,oldage,respira- in bum injury. . om Itmay be loca! infection commonly by Staphylococcus aureus in | @ Streptococci (Beta haemolytic—most common) early period, Pseudomonas, Candida, Aspergillus, herpes simplex. ® Pseudomonas virus in partial thickness nasolabial burns. It may be suppurative ae partial thickness nasolabial burns. It may be suppurat eee © Candida albicans thrombophlebitis also. + GERRI xs pocamonta,vacterscmis, septicaemia can occur, (cell-mediated immunit : spyeeniny a. REDManagement First Aid the burning area, Cool the area with tap water by continuous irrigation for elo yend aoc eee ove 20 ites (not cold wate Sn hy Cooling of the part by running water for 20 minutes rms (not old wera item one hyper), Cleaning the part to remove dust, mud, etc Chemoprophylxi-tetanus oxo: antibiotics antiseptic Feary moder end saree Bare Covering with dressings by different methods @ Airway bums of any type ‘Comforting with sedation and pain killer See pieces eeoeee Definitive Treatment # Admit the patient. . Naina Ga SERED TIED) (450). Emergency endotracheal intubation may be required in early period itself, in sucl ai cinyl 1ot be used. + Asst peng, ee de ¢ Keep the patient in a clean environment. ‘> aD # Patient should be in burns unit (ideally air-conditioned) with barrier nursing, sterile clothes, bed sheets with all aseptic methods. Fluid Resuscitation ‘Fluids used ate Ringer lactate, Hartmann fluid, plasma. Roger) “lactate isthe fluid of choice. Blood is transfused in late period Formulas to calculate the uid replacement: (after 48 hours). a. Parkla 2 Commonly used re copie: Commonly seed! First 24 hours only crystalloid should be given (Crystalloids neat ae one which can pss through capillary wall like saline ether alethe volume i siven in frst hours, rativen imei HYPO isoor hypertonic, dextrose saline, Ringer lactate). Sumi assessed fora: 0.52 mmol kg body weight = 17401044 mUkwhour. », Muir and Burclay regime: For colloid ater 12-24 hours °% body burns, piven at arate o 2% Bums * Body weight ink) Ration After 24 hours up to 30-48 hours, €6llolds’ should be given to ‘compensate plasma loss (colloids are one which are retained 2 Sarees Bee in ee 12 hom in intravascular compartment), Plasma, haemaccel (gelatin), 2 Rations in second 12 hours. ieee gunittaee dent hettchar ed Us ate 038-08 €. Galveston regime (pediatric: Ta be lend in thoes, _— 000 mlfm® burned 1500 mii? total TE: 4. Modlied Brooke formula: —— ren 4 Monitoring the patient: Houflypule, BP, PO. PCOS, cles=> cone, ely anal ue, logon, cn ton Colloid—none. is required. a ¢ IV ranitidine $0 mg 8th hourly. Second 24 hours : Cystallods—to maintain urine output QR —————eE Enteral feeding). For burns >1S% Colloids 0.3 mo 0.5 mkybums in 24 hours. Penicilins, aminoglycosides, cephalosporins, (Alana in RL soln) (Abn se shoul be gen * AU Fe lyri, cepa with care if really indicated only). «. Evan's formul In frst 24 hours: Normal saline | mikg/% burns Colloids 1 mlkg/% bums 5% dextrose in water, 2000 mi in adult. In second 24 hours Half ofthe volume used inf Culture of the discharge; total white ell count and platelet count at regular intervals are essential to identify the sepsis along with fever, tachycardia and tachypnoea. ‘4 In buns of oral cavity tracheostomy may be required to ‘maintain the airway. '¢ Total parenteral nutrition (TPN) is required for faster ‘ecovery, using carbohydrates, lipids, vitamins (through a CVP line). ‘¢ Tracheostomy/intubation tube may be required in impending respiratory failure or upper airway block, ‘+ Intensive nursing care.Local Management 4 Dressing at regular intervals under general anaesthesia using spastic films, vaseline impregnated {gauze of fenestrated silicone shest or biological dressings like amnicic membrane or synthetic biobrane. + Open method with sppicton of silver sulfaazine witout any sed commonly in SESE RESIS 4+ Closed method is with the wound to reduce the pain, as an absorbent ’ Tis usually dane in deep dermal bur wherein dead dermis is removed layer by layer until eh bleeding occurs. Later skin gating is done Advantages of tangential excision: ‘secondary infection, the hospital stay, and formation of hyper: the cost 4 Inburns of head and nec region, exposure treatment i advised ’ Wound Coverage ‘ointment is used, It is an antiseptic and soothening agent. It causes neutropenia, Other agents used are Sulfamylon (Mafenide acetate) and Silver nitrate. + Sulfamylon is antipseudomonal and anticlostridial agent, It penetrates well into the tissues but itis very irritant. It causes acidosis » Silver nitrate causes staining of burt area. + 0.025% sodium hypochlorite (Dakin’s solution) is effective. against Gram +ve organisms; O25%@1HCRHEIaIdIS effective against Gramy=ve organisms, but both mildly inhibit epithe- Tialisation. Regular culture and sensitivity for bacteria is required, to see for streptococcal growth which should be less than /,00,000 (10°) per gram of tissues. Once the area granulates well, in 3 weeks usually, split skin grafting _ is done (SSG, Thiersch graft). ¢ For wider area MESH split skin graft is used. @ Ifther s eschar, escharotomy is required to prevent compression of vessels. ¢ Incertain areas likesface and ear fall thickiiess graft Wolfe\graft) or flap is required. ¢ Cultured skin: Full thickness skin biopsy of patient’s skin is done immediately after admission. By specialized culture technology sheets of skin can be manufactured in 3 weeks as cultured epithelial grafts. It can cover skin of almost entire body. It is usually useful in burns of > 80%. Take up of cultured graft is 60-75%. Limitations are—time taken to develop cultured graft; more vulnerability for mechanical trauma; costly; time taken to manufacture; scarring. Sena Desi © Duoderna (Hydteclioid dressing) © Opste @Biobarre @yloseline impregnakd Suge, + Giologica) dreseings: ~ hucogretr —Mllo ~ kono — Pig SkinBall Carer * Risk Factore: © Pre fralignant lesions: © Smoki ~ High lek . aa quid ‘© Erythroplakia (Homogenaus i heckled) © AlcDho| © Proliferative verrucoue leukoplakia © Breed hut © Chronic Hyporplastic Candidiasig © Chronic ir mfahon Sharp ll Atting dentures . Infedions - HEV ,@ptein bar viruo © Oral Submucnus fibresig © Syphilitic glossitis = Low Bick ce a ae ae © oral lichen planus © Disenid lupus erythematous Ee eee © Diveoid Keratosie’ congenita A white patch or plague tat cannot be rubbed aff or charadorived clinically or pathologically as. another disease © Causes: Stages: 1) Smoking 1) Mil thickening of surfaco, Hypertrophy oF papilla, Hyperkerafosis 2) Spices IL Stage of leukoplakia - fongue covered with white srmoafh paint 9) Spirit (Alcohol) = (1° Supfaco becomes irregular like dred paint: (ayskeratosis) 4) Sharp tooth ~ 10: Warty pryechare with crock ¢ Pasures (Orecanceraus) 5) Seis ZL: Desquarncttion of abrerrna) rrucosa —> Red glazed fongue © Spite «© Yorianie ) Speckled leukoplakia’ teukoplakia with erythernadus border; Wigh rate of malignant conversion 9) DrolPerntive verrucous leuloplatia: MutHfecal; Lack typical rick fodore ; 50/ chanwe oF malignancy om = Surgiatl excision oF {esion flowed by 9bin grafting ~ otretinoin can reverve Some casos of leukoplakia = Eruthy ibrosis e Hypersensitivity fn to pepe) nut A red velely plogue Hat can © CIE: Trigmut (due fo Fibrous bards) tt be classified efnioaly or Af Risk of cancer dit poor oral hygiene pathologically os any other Mx: disease = Stop Smoking] consumption of beetel put ~ Ankixidants — Intralesiana) Triamcinolone— Eabeinowe Tougue + cle: + Investigations: 9) Bleirg vicer 9) Warhe bipey < from ete of uber 4) in in dope 4) Orfoganiorinam — ray Shaw iregllar defect due 4 irvoen, esi, gathlogical 4 Prkylogsia. Cache 9) digarklaton 3) Chest xray: Pale cut spain 9) Syephagia CECT Neck Hhrax 4 Poor ong (due + rece) ss} ma Enlargerent of ckep ceria! rajor 1) Reutine- ca, 68, eg TMM _Stoaing Mo Wo evince of distant melatsis © T= Primary tumor Girt be assessed ‘No NOUN involved Mi Bvidonce of distant ymefnstan’s Gime Lungs *Tit- Cucama io ou Me Single lara Maem Stages: #7 Sie tin, Dat éom fe eNe se TE TuleMo 5 Bout NalNs Mos Ary Any N Ms °T: Tumor invades ohacent structures — Lb: BNE jue Dot’ Deeth OF Invasion ; ENE. Extranadal extersion Me [ T 1 ‘Surgery Chermathorapy. Radio therapy erage 0500 5 Fuori = Gracy therapy Oxplatin = Gxtorral Beara &T © Surgeries 1) Boral lassaoray 4) Hemiglossechmmy + Tongue reansincion 3) Modived radical neck digsechon (For LN) 49 comenando.epeation ~~ Hemigiossedtorny = Hoyrirnanibulefomy —Removal of Aor oF mouth ~ Ratlca! Neck diszechon ‘Flaps ured for_reconstruchon 1) Deltopectoral flops 4) Pecoalis major roysustanacus ap 2) Free Fibubr AP 4 vasoularied tone gratis 4) lig crest Pap Crranjtular revretrxtin) ‘Neck issedion Tv B/t sane at tearrone side ET to amet edema (focol” > adil CRD) ‘matted (CneND) enwely) 6 wieie one — a femoal of END. type * Supaomsbid Leal Dr Preserve Spinal accstony nerve = Removal of nodee in leele I, a1 ard ot yw ra i Serna) 1) eNO type + fer) rack a'tecton: tol 0,2 removed ‘ih Soira axessary —! Srvtures Preserve Spinal aaenery ¢ TIV 1) Submeandibulor gland © Central neck diasechin: Only level OT UN removed wi) Tall oF arokid it) RAD ype. Preserve all 3 ofalymehatic Sruckya, Cav Sem g Spin) axcesorg]Epa quis ® a ynucoprioieal apelin oeated on the gum fit Ms myeloid Granubratous Carcinomatous Most crite * Gort call pale * Competed oF grrulaion «+ Foithaioma arg fern. mucous © rises. Fann pertonteumn © Osteodlastoma arising in jaw sue at Bie oF dental rrombrane oF oheolar margin ‘© (|e ste: Incisor Prernolar ‘© Hyperacmic wostular, ederraue nis, ivan by Hon healing, painkss ule Slow growing, tr, Hon dendor ‘uns wih inva) undlyng mast dees + isoaled_ymphaderopatny + polyp tke feton + May ularats @ case Haoncrbage —* Cle Cpult (IE nats) © Con undergo (nalignaray Cibeosarenma, © Re: © Bloods on touch ok 0: Resetion ith sooth Dall? Goretioge 1m progarey- Grau? gravida tude een! exciton ith adequate Adjacent bone exson tare: ain exon +8 agi = Cauterse grovlain sue Treat uneertying cause = a} tupene Cleft lip * Che ip reaute Fron abnormal dewdopmnent of rnedian rom! ¢ —maxilary. proces Cleft polak results From Failure of fusion oF 2 palatine processes + Types: 9 Cental (Rr) 4) eal Cinromt) —Ginple or aeporn do ai cleft in oes) ~ Compile (ct tr fo Por ob rae) or Incomplete ae oF inetFere with Sucking = Welter in G0" cases 2) (fay te dally in botioteating = Mis cst palate (bor cas) 4) Sumo degree of asaralaton may be present = Noss widened Aw waldavooment ¢ malalignment of ‘exit oMx =Preainical cedures ite Nosbolvekar yrauling ~ Surgery: - Millards Rule of lo: Age »Bweek; Hb7I0gldl ; Wt7I0 Kg fost gurgeea for les lip ore dene around 3-6 mionlts oF age Unilateral et lip repair: DMlord Rotron @ adtorcoevent ap 9) Tennison ~fardall rfanguar ob mebted = 16 aheoti Involved Aid aingwoplarty = Orthadbnkes ond. primary natopisty iP vague + Billo OoFt tip parr: Cin be dove in Single gage or two Stages at infer) of &5 manthe ~ Single tinge yelteds 1) veay TL meltad 4) millara's ingle ago pocaore = Add qinaivoplaty, primary yaxopasty orthodontics i€ required* Pattology 2 Non ep the bial~ 25/ w/lynph ~ Gp ee psi mses or vay Omar in fn of ceri eae) Abort - WEL type 6 — mmyoegithekal cat hich proifante in cheels Caled apinile shape cel) >. 5 Lyre ha epithelial = Torror produces mLcnid makna} which ditplaer & separates colk ——» Resemble cartilage an hictologiaa! Seckion — rumor compreset partid os i qt ond brorc panes Hin capaule- lence enxeokin ul result in resurerce ce . lignan = Age 7 UO years — Comales > males Peororphic stunt ried wnignant fama = Painless slow growirg ewelling feo car Rana amen (axchora © soph ran cenidcol Pod +n ga ms ~ Raises dar lobe = Involvement of Facial nerve = Pelromandibular grove i& obliterated ~Invemont of Ls ~ Girtain Sign: Upper burdor oF welling ie alaays Beret cra) limited to lower border of zygomatic proes c = addon onseF of pain teeauce of attachmont oF parohid Rascia * lnvestigatione: ) @NAC (Lod) 4) Xray mandible ¢ mastoid 3) CT Scan + pyent of Swelling @ if yralignancy suspected mn zt Sup+derp — Toto Conrowabve eo NK: Radial— Remove facia, ') Copgonative Guportivial Darstideclomy - Reroral of entire lobe containing tumor Superficial to facial norve - (Facial nerve preserved) 2) Exacupgular diegectan - Altemative lese invasive method of dicseckon oF parolid glared Complications oF _pardtide to rn {) Flap necoss 8) facial nerve palsy 8) Sevorna 4) Fistula ealivaty duct 5) Frey Syndrome (107 Cases)—————— Breast es ee ee o Surgical anal % ModiRad weak gland ® Extent % bulk L OY fo 6 ri be Srxnom tl ant oxilon fold Aprillany 4ail oF cponce — part of byeakt in cyille 4 deepen te deep fascia Ligament oF wopen- Fibrous bande eomhecting ‘in fo Fascia oven Pmajor Provides Cuppont : lobules join 4 Form Lobes: (15-29 in rombos) ouch ‘Lobe it drained by | Lachifenous duct (1s-20 in juynbex) Waar | Usemen aresopan Uaecia ° atic Axillary \ntetnal mar Wwoacr (15-861) c ) L- betaw # lateral — AP tatoo) F ZB -betuind — contra Clinical division Surgio) division srtéxpertoral DB ~ abowe % radial - apical, 1 Aaa” = Based om P vninor ‘gions = Ura! Fedo aden Lotoa! (medial = Pplead t = Posknioy” i ai fater’s Ws cecal iN Pminoy © Aricnios, Veins . — lateral thoretele Perforating branchel oF frgral indmmasy — Antennal mana mary tributaries of anvilaty veins fecal branches of Horceoabdom’al Posterior intercostal > drain fo Balsont veinow plow lat branches post intercostal+ Trine escescrnent Oistory @ fas'ology + Physiall exarn UO rs Ud yeas v 4 prsceentg VSG preaat— ‘Maremegiaphy §— Ub yo, Cran iocaudal Medoldkral Oblique > Taorgninasls 2p Bul Geld inarnrregan’) emp =< nmulhibcat ¢ ulticenf furnace - Des ~Yourg high risk pakenks screen, — Feqvales with implanis Vue +08 © Witopathological Sam — FNOC4 03-206 neadle -Calt dif liv invasive @ inste = Hegh False -ve — Ee,PR Hetney aan't be determined ~ Oore ext biopy Cinasiaral) Grrucat biopey 18 node — Gold Gardaxd Bxutianal bina Ly scape b reas aBireall cr —— 4 Ghoraatc : 407 > Familfal 10/ ( m# oc +o latest Robbins) ppcad mutation (174) G Responsible for bredit A oviniam cancer Braz (a)> Mak byedst Gi, Caneredtic , Prostate - 4 isk Cartons tor sporadic © on modifiable + Sox - Female Dye > 35 > Carly mepanche > Lele rnencpatue, Modifiable - Nllipaity — Obesity = Alcohol = Srvokiing ~ HET Cahor proyat vil’ (yovsdbse aplls safe) ~ Mokaval oge a Lot live bith <2o yous —pratedive - Break Reding Soc | yet + protective ~ExXpoawe to ionising vadiation* Histological ClagsiAaution : ® Non Invasive - Do not invade basement membrane, * bull Grcinona in sit (Oe) - foivratn of aligant Appaning cial celle with evidence of 1 invasion beyond DI J Prosunterfon- Pulpable lump, calcifications en marmogram, incidental Firding on bi Thre > foilony, ent, Bo sted esas) ‘i eee pea? Van Nuys sooyiny tyskin 9 Age, Size @ HJeeot tos, margin patos Lotllan Carcinaina im Gd (LAS) ~ eos not present chintenly and ean be deleted On mammogram + Don biopsy; Tenis tr be BIL £ yulteconkne: — PR sve ® Invasive | inéll frating 4 trvasive opus ((o1) - Soon imottty in postyeneoauil women = Do not form distind maser or mammographic Cindirgs ; diFfiault 4 diagnose = B-cadhenin mutation ~ Sriall round cals bland in appearance €| have scanty cyteplasm (Single Cile pattern) — Tend to be wultifocal $ wulticortric + vase ineitrating ducal ~ invasive ductal with tt epccial type (ust) | Nos C NoF othenvtte gpeified) (meet cere) ~ Tubular = ello Craucintys) - odes 775 yous @) Presence of mucin Withiny swrduidiy Career call ~ wmoluloyy 5S ~ cornmenly triple ve , Oceans in Younger wamen = eals yore $oFF tan hard a infor ~ Histology - High woke Grunt, Clreumtoribed edges, come! necee's, Lamphoaypic inti: ~ Papillary ~ jmetoplaeitc - inlarmrnadory. — vrigyasmen <1 = phapical Hiings: 6] ony trauma. 4 warn : = ray be pnisdiognated a abscess - differentiated oy Pea d' orange oppeanaha - Pratnrinontty Sun ring pregnancy are! lactatthe = Uonifed gs Lane 9 met On PR-ve ¥ mMolewlsy Classr © Lumina! A - ERP ve, Hon -ve ; KiG7 low ir Imajarty 9 ER PR. Han +ve » Hi6T lowlHigh {Liar BT tants ERPR ve j Han -ve 4 Ki67- High @® Basal £e,pe non ve, Ks igh © Chudin low: £2,P2Won ve, ki6r High Cviole +e) Cito ketatin $b ve ® Ver 2yew ehrichett- 0,2 ve, (aie4 Staging: Te -Tumor tan't be asseaced To- No audience 6 tumor Tis- Tum in Situ clon mie @: C08, ORR - Wa San Tal a) ABD, Ty > o- chestwall (Rib ,gonmbus, Ternuseles) b- kin c- AB = inPlommatory No - Ne LN Ni 7 Mobile axillary LN % (pvolvement oF contraldterd| Seep Pe alert LN is considered M, - He Internal mormory @ , BaillanyO Ng —a) _Infreloviewlor . a Tntanal wammory & Pxillon® Q Yupraelouiculon Mo — No wide vn) > DiGontyels Lace ES ow nyc ~ bane (, Lumbar vovebas) Early Breast Co Boge 4 A= Ty NoMo B= Toft Ni me Mo Gog? Sem ® fadical astectomy: Halsted - Qruchuies Yeimoved - Broast Toller Mastectomy — Pal chemo breast + whateney Paseitte to prrement Y Gruchine preswed Nipple dreola complex(Nic) —Ayillanu vein P major ~ Ceppalic vein P. minor = Long Horacic nerve ivi T.2.0 W @ MAM: nasi Eilipical stewart Chuctures vemnoved Q © brenst + NBC = fxillony vein Flaps © Pectoral is fartior = Thordcndayeal trunk tava ete - 0- major ebm PREY — WA Tyr fo] LY - (Transverse Rechis Pbdomina = Pminor removed ree myoculwubus Pap) @ Haemorr hage 9) Scanlon - D minor dive freracled jot removed Pee ee ae a Ty Seroma p Inferior erge lool Dt Or-eyoyird @Q newe jajurt Onay peatorttr ) Puchindsss~ Pminer retracted Ee ueanal — level Taond © LN —therawdersa Bear vecurence @ Siaple mmartedomny @ brut + Nac @ Prctoralis fascia © tb WW emwed ind - Phyllobss tamer SLNB = Indicalion- No Clinical enlatgimart of LN Q Blue dye- methylene blue, Wsosulehan 2 1Sce injeded in periarenlan vegion (Guba) 3 Blue colour (N- Sentinel Woda © fodionuckotide (Te? tagged sul eat) © Ormbined method © senha Period intel. agree erences% Chemo - te LN — triple -ve = Uan ne (chemo + Reycepin (trashzinmab) = nec © Traditiona!— cpp [cme C Cyclophospramide, F- S- Fluorouracil Be Pdtamydn M- methotrexate © Lote 4 dude of AC U axdoe of or Followed by Tavahet (Paclitaxel) Uoyde & Ec D- Ptriamyein C= Cydophesphaynide @ = Epirubicin 4% Radiotherapy — — Post acs, = Wve LN = Unec. (D Conventional topole. breast (cradiason (€0-<% gy) ® Pouloraled porkel breabh ir— (20-2€'yy) > 2eitinys (day © ySoued © Negative margins © fevet AAC out be mot @ No Wyrmphowasculas ineiser © vrifocal AYormonal therapy? only in 2 OR +ve 4 Pre vnenopausel — segin (Tamsin ) sysor Cosrtien ) lo Years (atlas tra} DOR - © Hot ures @ wr @ Erdomotnial byperptay Post menopawal- (ofrozale , Prnastrazole —_Syear Coarlier ) to gos (ots bia) ADE osteoporosis4% — Gatky Breast Ca (Stage 2 cs) He Binal tle. -SINB A Breast conservation cubgony + RT 4 DO ombaindicaled v Maxleclorny. WN@> Chemo ER PRE Yormandl thonacy Heraie- t 2 Heneophin. Crrabkuure) © TyNoMo- lange oponable beast ca Nedddjuvart cherie v Chink tumor ‘ “ecg » UNec: Neoadjuyant chemo —? No response wv mem 2nd line theme v RT, odjuvant chemo, £2 PPG) Usrmond) therapy Vernav- t 2 Heneophin Crrabhucumat) A Inoperable |metowtalic - Palliative fk (ver LE Hormone Henapy Resi rlawe > Creme Wo visexxal of €b PR ~ve WN sve Uneine + Hercenlfr Ves ther de Pal bouitlab Dipelisib OlaparibBenign Oreagt disease D ANDI - Aberrations oF normal development and involution 'S-28yrs- —Pibroadenoms Pipette a Summary box 53.2 Oigt Benign breast disorder classification ac Wo Prorocyte drs Congenital disorders tle © Inverted nipple Ciboadonorna ‘© Supernumerary breasts/nipples ‘© Non-breast disorders including Tietze's disease Prylodea (costochondrtis) Cyaicmastallgia. © Sebaceous cysts and other skin conditions. yudurs— — Fibrowbtic sea Injury dud ectasia Inflammation/infection ‘* ANDI (aberations of normal differentiation and involution): | Cyclical nodularity and mastalgia 4 £ibroodenoma Cysts ee of break lump Cees) Duet ectasia/periductal mastitis, Peale {SAE yaa © Pregnancy-related: Galactocele A UE Firm mobile wre Lactational abscess Painless mouse in. veer — Du: UG ymanmapram— Poecom Calc Ploaton Type - — OPenicanatioulan, @ Ireratanabiular tx > = Indiestiona — Cosinalic Painful fapid + in size Giant Prbreadenoma (> Scr) NON - © Perigreolan — clown by Sibsuteular sede ®@ Gillod thomas - Irfromammary, tne &omlas KO CtoaioPrequarcy ablation © mammotome Cidoctum asvisled plopey sypenn) beutlabiany ef size.» L > Cant be Oa lor > dom stint4 Phyllodes tumor > Qyetytareama Phyllodes = Ocunrs in 3-uth decade. = Benign or tclignant Gano 08 mitotte Mbures an orn —PNBC has no tele in Ox- Oue - Rapialy enlarging breast (amp Dx - Ong -well Ccuntoribe Bsiors ~ Pha vetns = Biopey — Stretched Shiny skin Notignaney + Haematogenous bpread —> Lurys UM gpead > <(o/ Canes AM x= Luvnpedrng (wide local avetsin,) Cemmple asker OP beanrence lange tame worodtgnent 4 Gunecomdsita. - Enlargement of male breast tissue Causes of ‘gypecomastia, re Usq ———— balieat 8cm dlomeler Physiological Pathological Use of breatt Hesue D Puberty D Idiopathic WD Newborn org Induced oe Wi Senile 0 - Digoxin 5 Todi onal - See dy 1 = Wo Ciconiazia) eee ee 2 Dosen - Upowuekion + C= Cimetidine , = Ketoconazole Qlara exelsian 0 - Oestrogen W Lepromatous / mumps orchitic W) Cirrhosis WD Hinefetter syndrome vd Tumors - Renal cell cancer Hepatocellular eancer Testicular concer ossocioted with para-neoplastie syndromemastalgia 7 cyclical > Non-Cyelical 1. Seen in Fibroadenosis / |. Causes - Tietze syndrome Fibrocystic disease Ceostochoneritis ) . occurs in aS-40 yrs 3, clinical features Treatment - Intralesional triamcinolone * Pain C Begining of cycle J a. mondor’s disease * Superficial thrombophlebitis of 4,.0n examination chest veins * Lumpy Breast * Cord-like structure S. Diagnosis * Presentation - Pain use * most Common vein Involved Management J * Life style changes Lateral Thoracic vein * Weight reduction * Treatment - Analgesics * | tea/ coffee * Vitamin E $ primerse. oi! capeules elow Close favnoxifen ®@ Danae! Breast cysts ones L Diagnosis use, a. Aspiration - indications * Symptomatic individuals, Stale ae + Complex cyst (solid features +) Aspirote -——_ * Non Bloody * @loody * Cyst resolves # Residual cyst B completely 4 to— management ~ &xcision of cyst = monitoring + * Fuid cytology not required uid cytology CTo rule out cancer]1. Duct Papilloma + most common cause oF bloody nipple discharge * 10% cases —+ multiple * 10% cases —+ associated with OCIS ( Ductal carcinoma in situ) Clinical Features. Bloody nipple discharge Srom a single duct — Duse — ectatic duct C mass inside o dilated duct J 1D Cytology of nipple discharge —> low sensitivity ii) Ductoscopy ‘Discharges from the nipple (the principal causes are in ota) management Discharge from the surface microdochectory Feet ere eee 1 ar coues og choc) = Temis racquet incision Discharge rom a single duct, Bed sane ~ Singje duct {ump —* excised IESE aera a. Duct ectasia, (eeegenet “+ Pbrocyatic disease * Age - >40yrs (perimenopausal women) | Dvetectasia Clinical presentation Bch rom mare anon et Dilated ducts Sey | 1 ercyac deca Sucker geen 1 Ductoctaia ' Puntert Stasis of secretion is | rote dae detects Periductol mastitis, facecners Causka’s disease] 1 Raw ones Potton, pny to Periareolar abscess/ Bish / Ereenish Sinus formation discharge Cmultiple ducts] Diagnosis uSG —** Multiple dilated ducts * Rule out cancer (x- Antibictics + If ports Hod eld procedure. [fone exeigon of multiple ducts)Has Q lobe connected by isthmus 5 Enclosed in pretracheal Faxcia Projection From thurs Cut on bt fide) is calbd Pyyarnidal (be: Lt is abuthed fo Wyoid bone by Lovatey glardulas thyroideae Capeules — True — can not be separated —Falie~ Can 62 dparated - patsy Ugannant of Bony Binds tyro Firmly to each Aide of cuienid cnvtiloge ¢ Uppox ‘rockeal yirys: Pretratheal Satcia 4 lig. of ery ane Hepornible Fer thyroid movry with degbuthian * Blood Supply : Op. Hyyroid ont Cor of ext. canotiq) © OnF thywoid ant (Br of thyrecenveal trunk br. of eutchvon) © Thyroid ima (2-34) direct brarch Crom och of atta enfens (burr port ff ietiupas + Veins $9 TIL ov © Superior Myoid vein (rain into Dsv) DTG @ middle thyr vein (drain into Cav) @ mF Hyyroid ven C drains into brachiccephalie. vein’) Tryfina Aint aa + \lewve supply : \Bochiouphalie DOExtenal laryngeal ~ Awoip from antay core to gland: (wear usper pole) ee = Use ney led pfard @© Popout lwyngeal wto int pole & Non reuunrent laryngeal pewe- Right Reoutrent Lax Ne in 2% cagesoaGoilte = Gonenalite enlargement of sAyrid gland = Goitre Cassificaton: 1) Gmiple Qoitre: * Diffuse Hyper plastic ‘ol fea! Pubs Pre © Multinodulan gottre a Q) Tove.» Diffuse Toxic hyperplasia, ( Graven) * toxic Multinoedular goitre, * Text adenoma 8) Inflammatory * Dutoimmune + Chronic Wywphocytic. Hayraditis ( ) osicinmoto's tyes * Gyanuleratows - De Quervain's ty ° Pibrosiny - Riedel’s 4, © Infechive Acute - badenial ~ Viral Subsenke. Chronic. ( 78, 8yphilitic) OHon- amy lord * Ul NeoplanheMullinedular * topos eats -lodine deficiency, — Puberty ~ Goitragene (Brossicaceae, cassava root, gulphonanndes) Yysed levels of Ts, Ty y Compensatory OF Sout TSH Hyportrophy. @ Uyaplaia of Thyroid fallculah colts (Offuse parenchymatous Goite) Phase oF colloid involution g obundant caloid causer enlargement of falliclee Colloid Goitre) Contra) Nevres!s J Hodules J Aoumont epigntes oF hypenplaila @ involution Multinodulas Goitre ae: 1 Common in Remal (9:07 = 10-1). Age qioup 20-U0 yeane D Mase in anterior aspect of neck 3 Utuably ympromaic Gs palit fe euthyroid 9) Frostune Symptons vay be precnt - Dyspner dur to comprestion of tyachua 4 tracheormalana = Voancones 64 voice due to compression of LN S)on tom; Mutiple nodules, Arma, rontenden? Suell’ng eves wutth —degluthitin Hond ayeas > Calcification, Soft aso? > Newest 9 Gecdon * in 20 with pain — duly que to Hadhorrhae + Complications— © Calabeation © Suddeh Hacmarrhage © Toric tmuttinodulan Goctre CClummos dsease) (10-20) © follieulor Qrinarma (87)Investigations DX voy Aleck (APA lateral) — took Gor deachenl tomptebsion — Rule Gut robwstennal oytensdon Chole for calalcalim in long. sharing ous ( Bing [eim caluiticakin A Clexible laryryoezooy — check Vocal gore yrobill ty 9) U8G ack Y) Pune from mest dbminant 4 guipieibw nodule(u% guided UAC for move reltability) 5) mer fer in double caves 6) Ratioisstope iodine youn-in selected cater T) Rousing blood 4 urine investigations thy Asymptomatic. MING With preagure éymptone Carly case Rebrosternal extension | long standing crn TH Elkin O1 rg Bay v Cecenvotion $ Sarg legato follow uo t 4 Mo iimprovrnent “Total Thyroidecorny Gubboiat sthyrvidectany Hartley Duntill Procedure wNlo chances of recurrence ~Bayn of Hi — Awd ves if to in tie Lobectomg + Dstumucectiny chletted an Hesfopath. + Subtotal lobectomy on other side Permanent HypothyroidWayrelexicosig ts + Hyperthyroid refer to overactivity of the thyroid gland leading to exeeecive production of thyroid hormones. * Thyrotoxicosie refers to the clinical effects of unbound thyroid hormones, whether or not the thyroid gland is the primary source * Clinical Typos D Graveh disomse /pifruse Toxic Goitre (Prima, Hr 4 toxieoeis) A) Tox Mullinadular Goitre | Plummens disecte ( Voondory thyvolorieasis) 3) Toxic Adenoma \) sypertiyrnive due +> other rane causes (TO seeretng pitutany. alercma) @ Graves, cisease = IMC case of Hprerparattyratio Hey pertrugrverchiarn * Exology ) Putoimmune a har a strong genetic component Triggening factors Tholp sensitisation re Of B lymphocytes Putoantibodies = O Thyroid Chmblating, Q Tutoid growth simulating Cy @ Anti TSH recepior aniibaly. DilFuse Hyperplaria df -Hyrnid Production F eicor hormanes ole - bye >20-Uoyn, Q>o? ~ Irritable — Heat intolenan co = Weight (088 despite good appottia ~ Excessive Wweating @ thirst = Fine frehavs ~ Diowrhoeo ~ Palpitations ~ Pmenorrines { Digoyvierarhea in 9 ~ Prominent stehiry took ~ Catique, ~ Diplopia.* Signs 1 Local exam- prildly ontargad thyroid + emodth no nodules . soft fo Firm in consistency Gightly warm ( Haghly veaulox) 2) ONS- Fine tremors Hupentinelic movements 9 OS- Tachycardia 4) Eye Signs: |) eropthalmes - due to retrobulhoa depetition of inlarrmatory cells 3 Ld retraction due to overadtiviy oF involuntoay yank of levator palyebr gupeian's 2) Dalrymple’s sign: Uppo> stlera visible due to vetraction of upper Oyelid a Yon amet SiQh Upper oyelig lage behind tre excbals when gakiont aaked 0 look down 5) doffrou's stan: Mbgencence of uirintliny of Forchead whan patiert took) Upusnds 6) Stellung’s gign: infreyert blinking ¢ Uitening oF palpebral -Aseure Tiloebivs sign: Inability to converge eyeballs 9) Entath sian - dedomna of eyelids ard conjunctive 9) Gifford Sign - DFcwlty in eventing upper oyolid 16) Opihalmmoplegia - tfc inferior rectus 5) Thyrolento. reyopatiy ©) Derrmopaihy - Pelbial myxoedema 1) Thyroid Acropachy- Subpeniovkal bone — Ssxmation. © Blood investigations- Cac , Blood sugar A Urine routine ® Youn Ta iTat , rum TSH low ® Rasioisotope thymid ecan- OfFuse uptake @ meamrsment of ankibedes, Specially. Thyra ¢imulating © Meoping pulse rafe -rwild 90-40 bpm wmodomle 0-110 byw Senne (V0 bore+R: D Antittyroid druge: Carbimazale , pro pylthiourad | = Prognatrcy- Ie trimester - propyliniowtal ond 4 2% - ynothimazale Pdy- No Surgery use oF radiocttive matnials Disod- failure “re 507 Prolonged 9) Gurgesy-— Prefernd ~ Total thynaidedorrey Sub total thypnidectorny - 57 recurrence. Fv Rood cure, High wre rate Diad - Pick of permanent Hypothyroidism @ howe injury 9) Roditodine 60: Destroys thyroid cells fay - No sunny @ asseclaled compltations No prolonged drug theapy DIS — Rotope Faults require Must be quarapiined while radiation eyels ore high- ¢ avoid pregnancy Eye ans may be aggravated °M% of Toxic Nodular Goite: * Treated surgically * Does hot (eeord to dig therapy or Radio iodine ‘Thyroid operations All hyroid operations can be assembled fom three basic ments + Mx Toxic Adenoma: Suigory | Radiviodine 1 Tota lebectomy, 2 Iethmusectomy 3 Subtotal lobectomy he z . Total thyroidectomy = 2 tote lobectomy + ithmuseetomy’ Complicahore of Thyroidectorny Suboal tyridectoy=2wubttal bacon + ishrusectomy Noartota thyroidectomy = total lobectomy + sthmusectomy + © Haerorchage subtotal lobectomy (Dunhill procedure) + Cwerpal laryngeal n- palsy CELN? en] Lobectomy = total lobectomy + ithmusectomy « PLN paley © Thyroid insuficiency * Rypoparatiyro com * Post op respiratory divress — Laryngeal edoina — 6 LN inju = LOhyryoalaa - Tension haehratorna, * wound infection Sitch granuloma + thyrod Storm - LP patont inclequatdy piepaned for surgeryThyroid storm / Thyrotoxic crisis: Pearl #784 + Medicine, Surgery Itis an emergency caused by an acute exacerbation of hyperthyroidism. Precipitating factors: * Abrupt cessation of antithyroid medications * Thyroid or non-thyroid surgery * Trauma in patients with untreated thyrotoxicosis, * Amiodarone administration or exposure to iodinated contrast agents * Following RAI therapy. Clinical features: * Central nervous system agitation or depression ~ Cardiovascular and Gl dysfunction, including hepatic failure Treatment of thyroid storm: IV Fluids, ice packs Rehydration and external cooling Block adrenergic effects Propranolol Reduces peripheral T4 to T3 conversion Propyithiouracil . (p00) Reduces peripheral T4 to TS conversion Inhibits the release of thyroid hormone from the gland Corticosteroids Reduces peripheral T4 to T3 conversion Lugol's iodine/ sodium ipodate Inhibits the release of thyroid hormone from the gland Digoxin Controls the associated atrial fibrillation Diuretics and administration of oxygen To manage the cardiac failure.eaSolilaty Uyroid nocCu(cmm = Dicerete ledion| nodule in Hyyoid which is Palpably ¢ radiolegically distinct fern othetwise normal gland Gree — © Thyroid alenorra @ at @ Concer — Papill + Gata = Medul fr tenet tupes § Otoric Don toxic investigations + O Thyrord Punction det- Ty, Ty TRH © UM peck ~ gland enlargement ~ rodulanity (chet for impalpable nodules) - Youulanity D Fe — prefenably VSG guided (cant differontiae blw Folliwor adenoma 4 Cancinond) @ thyrwid seah- Te 99 — conveys ada Todtne 123 — Uplate +Organifiuttin of glard Ditfore T- Graves ehot - Uypextunckoning (Ur. rreatignent) Difeue 1 Thyreidit’s © Warm —Normak Functioning, # Cold -Non Functieniny (207. makignent) © Cr check for retosteral evtensions © SQum thyroglobulin -tumer wranksr po Malignant —? old 2 Fac | Inlogile —> Exlefsntpe —) San = Hot fallow vp + Benign —» follow ve Indications of InguPeicient © Maligna @ Toric nodule in young Suan tyyahic Nodhulecade QuneWwain Viy\oid ili, Painful neck enlargement Me Meroids , symplomatic. ann Ried el Ky rill 1 Pibasing tyre ~ Ao yea Fibrosis —> Within gland~ Woody hard thyroid L. in vieinlty- QLN tov. > Hoanseher of voice ta iyv> Undoy 9 CF - Painless neck anlar Woarserens of yoite 2 De- Biopsy 9 My- Gonos tamaxiken Tryuotine meplrcoment - if requiredee Mayroicl caer’, “Benign — Follicular odenorra Functional Non Functional » Malignant Folliulan tell dorived Nourendocine € coll douived Piri t difdrentided Annplattic. Qa Medillary Ca Papillany Co CPt) Palioulan Co, (Et) Hurthle cell thyroid Ca Syndromes : IRAP - Papillaxy ca with crionfonn gaHenn 2) Gandnos - PTC 3) Werner — 9TC] ETC} Hurthle call @ 4 towden - Pre [Fre 9) MeN2 syndrome: Medullay thyratd Ca© Most cornmman thyrid Ga (60-66) overall abd mic in thyroid tufMciant orens- 2nd ost cornman (16-2077) and m{c, in Thytoid deficient areas 1) Hovey “fenekca elas: ene (mic) .2Er, ene = Sypatomet ERP, Gordner® Bydhome, Worrers, Cavden 2) Expire fp rdiatn © long Handing ca of Thyrbseal cyst SD Cormpcahan. oF Hashimab's rue ' Horetory —Gercits wish: preN , p53, RAS = Siaomet = auden oyarome, rrr? syrtore a Long Ctahding case OF multinodular goitro ~ Hard fatmor with mute lire = Cut trfac- Dia fosions with ores oF Calafate = Miceseapy: Shows capillary epttlial projeons, psammatnn bodies © Orphan annie. aye ruck 1) Word mer with airy tin 2} Malignncy It gue by Cayaular iovasin @ Yonnln van 9) Microscopically, mest turnare dee well encapsulated: ‘mic ty Lymplatc. toute (wl 6 Delian (x) Haeraiogereds Grax| ean be Seen 40 lungs Cals Cormm) mic by Haematoqensis. route — Genes (Pubaile bony tebsinus) = Age 38-50 yeast ore eran Famles = fge > 40-60 years fore cemon feral = Vay exis ~ Gunly extiyid = Painless Slow grwing had mas that moves with deglutition = Painless Slow growing had mas? Hat mover with deolutHon = lyrophadernpathy = lumphadeopatiy rare = Micecarcinoma (Gout ts): < lamin sie = Leal obetrant shuns: Lypnph nao. resat® fom on palpable raul gpiary carcican ~ may present af gulatle bony telaganis =Princ: Cannot diffeentile blu Falliculan aderama € Cordinoma: = Uitpatolegy. of frzen seen (0c) = Yay neck and chest = 9G 17 mete ~ Pleite. Lorunacicony = Fake (20) = Tuoi Funsin feck US neck [CECT pack = ray ack Ord st = bienbi lanygoscony PHA 4 Poller Nogplaas 1) Gurgay- ofal Thyrideclimy — Proalure oF choice Hemi thrypridechany ~ In cote o micro garcinera t ~ tena neck WN dlasechon ht ed ~ Ipalotrd crodifed rica! nek disseton (opty if UN involvement is M Contra) fron Seetion = Prphyjodic. lateral neck diseion for ott LN is vot done falcon teller 4) Thorne not qh fr 4 unsk pat suger derorna Garrone 4 lualeboiy ide Scan | “Talal thyroidectomy esd. disor] residual dase 4 ek dissection ueully rot required butte Ln are ot inched metatauie | + Post op Rdoiire I Por melatasis Rai indine bition CE) “Thyroxine © Tyrotine fer TSH Suporeston (Ror 12H cup reson) High dese fr high itt a Resistant to Radia indine Dhusilogial dove Far lou st 4 (ore i 3 seendent) Exlarol beam laste * Falta ap starve as pasilay ca + Falow up by 6 monty Thyrmglobulin estat and onal Cervo! uss ‘= Sour Tayrogiobulin > 20qirat | Uhl bely tre sonfbgpetpatatlyteicignn cause Mer 4 Parad rama Agenatener Be pen 2) Roruthgroid bycer plasia (Chie coll hyperplatia) gard } floral dystunchin —> ygocalcemia. — Parathyroid. hypertunckon Hyperplasia 9 EN g MOLL yrdome | Rome ay & ) fadiaton expsure ©) Postmenopausal Rime 35. Bicphagphonoles. ce ununghc 29ers. i) Bone diseaser- Ockopenia , ostooporosic, osteitis fibrota Cystic. - Pain = Vathological ractures ~ Cysts tn phalanges randible (Pooudotumors) 2 Rehal Sone - Caleium photphate! oxalate Renal Hypertension Nephrocalcinosis 3) Abdominal groans - due fo Stimulation of gastrin by Caleiom- - Caldum may cause pareredttis — Metastatic caldificatin ynay be soon 4) Psychiatric moans - Depression , faigue, ankiely, psychosis S) fatigue overtones Orhor_ Features: = Corneal calesficatian] Band koratopaty on Slit lamp exam — Proximal myopathy Irwestigations « 81 To prove Hyer piri ~ Sau Cakium 4 ~ Sam Phospiak ~ Seu aoa ~ San fealormene assay Catgrts) = Mlkalire posphase # = Yay of forer ~ Subpeninn? azine ©) Bx patalhyri glade =08§ nek = Thallium ¢ ¢echretiom scan = Sestamib’ scanning- Buerger’s Disease (Thromboangiitis obliterans) - Itis anon atherosclerotic inflammatory disorder involving medium sized and distal vessels with cell mediated sensitivity to type I and III collagen. - It is segmental, progressive, occlusive, inflammatory disorder involving small and medium sized vessels with superficial thrombophlebitis and may often present as Raynauds Phenomenon with microabscesses, along with neutrophil and giant cell infiltration, with skip lesions. - Very commonly seen in young and middle aged adults, smokers and tobacco users : not seen in females due to genetic reasons. Rare even in female smokers. - Almost always starts in lower limb, may start on one side and later on other side. Upper limb involvement only occurs when lower limb is diseased. UL involvement can occur but its rare. - Hormonal influence, familial nature, hypersensitivity to cigarette, altered autonomic functions are probable causes. - Lower socioeconomic group, recurrent minor feet injuries, poor hygiene are possible factors. Pathogenesis :- Smoke wrtalns CO and nicotinic acid 4 + Carboxyhaemoglobin Causes fnitialiy vosospams and hypesplosta, of fintina v Thrombos?s and co obliteration of vesds occurs, Commonly medium eed vessels ave involved. v Panayteries ts Common Twolement i¢ cegmental L Eventually artery vein and nerve get fnvolved.Nerve trwolvement Causes Yeast pain. Uy, of Buying a rus Posvent presents sith feateres of ischaemia th limb. V Onee blockage occurs. plenty of collaterals open up, through these collaterals blood supply ts maintatned to isdnaemic ovea. This f called Compensatory PVD v ‘UR pk- continues to emote, diéceare progresses Sto collateral blocking them eventually couging severe, fechaemfa, K/a, Decompencatory PVD. presenty Ko Critical lino ischaemia Tr Catiged est pain, ulceration, Qengrene Vosospacm —> Intimel hyperplasia. —> Thrombocis Obltteratyon.s bender, word like veins with euperfielal migratory Ymombophienttte C30). * Important :- - Smoking index (SI) - Number of years of smoking Number of cigarettes smoked per day, Sl » 300 is a risk factor. - Pack years index (PYI) -Number of years of smoking Number of packets of cigarettes per day, PYI > 40 is a risk factor. Shianoya's criteria for Buerger’s disease :- - Tobacco use, only in males - Disease starts before 45 years - Distal extremity involved first without any emoblic or atherosclerotic features. - Absence of DM or Hyperlipidemia - With or without thrombophlebitisClassification :- Type 1: Upper limb TAO - rare «Type II : Involving leg(s) and feet - crural or infrapopliteal «Type III : Femoropopliteal Type IV : Aortoiliofemoral Type V : Generalised Clinical features :- - Common in male smokers between 20-40 years of age, Known as Smoker's disease. - Intermittent claudication in foot and calf progressing to rest pain, ulceration, gangrene. - Recurrent migratory superficial thrombophlebitis - Absence or feeble pulses distal to proximal: dorsalis pedis, posterior tibial, popliteal, femoral. - May present as Raynaud's Phenomenon. Investigations :- - Hb%, Blood sugar, ABPI(ankle brachial pressure index) - Arterial doppler and duplex scan (Doppler + B mode US) - CT angiogram useful especially when intervention is planned. - Transbrachial angiogram - done when femorals are not felt - Ultrasound abdomen to see abdominal aorta for block or aneurysm. - Vein, artery, nerve biopsy.Treatment :- ¢ Fe,toxyphylline Xanthire noohnate ny - Stop smoking | ASP%I5_ 6 lopidogrel. Najprdofury) improve | S?akns. E © Drugs- Vitelo intestinal duct / ornphalo meconteni, duct hormrlly oblitenates by ct to (th wk of Th) life Anomalies 1) Pasisent vr duct - Lenk 4 Fecal csi at umblius fe) © Mekal’ cliventiuum - goenat anki metentenic border } d| 3) Umbitiaad sinus LI 4) Smphalo mesenteric Quah f+ 5) Pwsits at Frbrow band Hl tay culue inlestina) obetruction ov Volvuled * congenital anomalies of umbilicus : 0 Uemiat Lomphalocele) 9 Dicovder of patent vi duct — Umbilical ins Foca) fishula at umbilicus - mortey ened; only mares Conteh dm 9) Sotent Utachus: % Urinary discharge fron urnbilicus 7 Eptive urachus is excised after Grrettiny iste obstruction © Umbilical Qranuloma ~tomnmanly Seen Od benign abnormality in neonates “Detived OX wotet Heshy and pink gromulotian Hawe af contre o% wmbitlau. —Gernulora becomes apparent after gepoation af ce — Granule Frequerity exdvta gral omountof Gibrinow exudate - = Mimics umbilical denPwo Pravellonce ~ 1/600 pawberns> Ekology + Unknown Dnblamrrabin 4 doled cord separation Ge Dooliakion oF Cy Sulphate or allver ritate: = Antibietics, — Rory «ya requice ovationCad yageedl mage aituoay A laryngeal mack airway (LMA) — algo known ae laryngeal mack — ig a medical device that keeps a patient's airway open during anaesthesia or uncongciousness. It ig a type of supragiottic airway device. A laryngeal mack ig composed of an airway tube that connects to an elliptical mack with a cut which is inserted through the patient's mouth, down the windpipe, and once deployed forme an airtight ceal on top the glottie (unlike trachecl tubes which pass through the lottie) allowing a eecure airway to be managed by a health care provider. They are most commonly uged by anaesthetists to channel axygen or anaesthesia gas to a patient's lungs during surgery and in the pre-hospital setting (for instance by paramedics and emergency medical technicians) for unconscious patients, Bp Fy * Technique ‘- Hold the laryngeal mask airway (Lms) like a pen and pass it along the hard palate until resistance is Felt § inflate the cuff . °A good alternative to provide oxygenation e technically-easy . * Less invasive and requires minimal anaesthesia. * Sits in hypopharynx - Forms a. seal around periglottic tissues. * Invented by - Dr. ARCHIE BRAIN * Si2g - | to & in number (used depending on the weight of child ) * Precaution - pressure should not exceed 60 cms . Advantages of LMA ° Simple © Less invasive * In emergencies / difficult airway * minor sugeries Disadvantage of LmA * Does not prevent Aspiration “. Contraindicated in —Pregnant women -C-spine injuries Laparoscopic surgeries* ClaasiFinkton : fosed on durastian of ackian OShort duration - Procaine Chlor procal ne, 4) Interrrediote - Lidocaine mepivacaine Priloeaine Cocauine 3) lorg duration Bupivacaine, Tehacaine Popivacaine loci! anaarthotic Converts * ionised form in extracalulan pH Can paste coll yew, ph i oo infracollu [andy dug & wmieited to tonised/ Qutive Foren Bind t> Nat danmls g blocks Prem Berl ocaal of [vqpuler * Toxtetty Systemic. foxlcty is Coan when drug reaches high levels Deperds on — @ dose injected site some ses OM ighly voseueLe (air dys affected - © as - Tingling numbness ih perioral aren = Halos > Convulsions 2 Lignocaine. @ CVS- perhythmios, ® PR interval > bupivacaine oh tovlety: Rec, emnvulsions» diazepam aryhythwmias Ont Orrhythenics cus elapse > fonotropes, CPR. 4% Intralipid 20/. > Now recommended for LA foxicity with cvS collapseCie couieg centers Dose: Skin intilteation: 0 8-17 Miner nerve Heck: 1. Epidural a} Spinal + St. hyperbaric, Topical = jelly- 21. bs ‘Sprays - Yi. Max Yecbenmended dase > argl * May be Used with adrenaline for prolonged duration of axtian $ 7 ( sl( si * when local anaetthetic i¢ injected into cerebrogpinal fluid , bathing he Spinal cord it i$ called Gpinal araestresia ( Gubarodhnoid black) * indications Pry surgery below the (evel oF umbilicus Cle ) Patient retusa) ) Hypovolemnia 2) Infection at site oF injection Stenotic valvular heart disease 2) Boating, diborders Limitations — limited duration of block © Dositins. - 1) Loft [Right lateral 2) Siting © Peprach - Doniiline - 1p peadle inserted midway biw pines penpendiculan to skin 2) Pardynedion- Needle inserted 1 Firgsn breadth lateral to Spine and odvanced towords midline. + Complications Infadion— Arachnoitit’s, ynehigrtis Nerve injury ~ Gwuda cqsina gyndtome,loc anaesthetic i$ injected to obidural Space 1 block arver eimerging Fram ginal cord Spinal, j D dome in lumbar agian ely 2) Confirtration of corned: placement oF veal by free flow oF OF 9 Swall Omdunt of LA Usod 4) 22-20g LP neadle used 9) Tat doser wot required ©) Fost onsot oF blockade ) Al verves below lovel of andesthesia blocked *) Linvited duration 4) Postdiural puncture headache (PDP) ostibe Epidlusal anaesflesia Gon pe done in lumbar, Socral, Hhemacic ,cerviatl regions ALonAirmeaon by using loss of rosidance 1 injeckan of Saline Dlorge amount injectay 4) larger neadies (16-204) used YT dows advisable 6) Sluser than Spinal 7) LO grade both caucla! nd cobhalad - Sogmerta block (Chip be achieved %) Gan bo prolonged by repeated boluses as epidural comers ar yioutivaly introouced 9) POPH Mot seen hkl! dura in inadvertently puncturedSSS Endoyopic Utasoyyl * EUS ie a matiéal procedure in which endoscopy and US are combina fy oblain Image of internal organs © Tf can bo uted fo viwualite walls of ootophoxus , ¢forrath colon etc. wmbimed th doppier nearby biood vervels tan ako be évaluakel © Veo: ~ Detedion ond T Saginy of oarophayal @ Stomach careers ~Deledion ot pancreatic cancers ( 907: gentitivity) = Delection of (CBD Memes [dc Poy detection dt wiendliH in 8d: — Go visualise (Nin chest Yrrounding ofrway and thelp in Paging of Lung cancen 4 Quality oF Image of Frequency used: 4 High frequency = etter image Low Frequency = deepen penetration * Doppler effed IS a nt in poresived Prequeney oF sound emitted by moving dource © Tt measur bloc! Ho Types 0 Continous unuer @ Pale woes, Colour doppler — digplays , Red- Bloc Flows fosd transducer Blue Blood Aloud away Fram Arantducen- * Us: ) study cordiovascules system 2) Yudy vosulahity of dames 3) Study blood ow and velocity iW arterial drconser 4) Asseas DVT, vanicnte veind , uanicoceles * diortages~ 1) Raliable 4 von invosive 2) Has replaced venogram 4 angiogram ay diagrestic fool at many places & Duplex- Doppler + Usq* Vasuslar Angioplasty + Use of intralupmina) balloon cathelesr and may be used in almost any cigente vate 2) Embolisation’ Used os |) Gupatie & for vasoulas inallermations, G4) bleed ete. 2) preoperatively fo reduce vasullartty OF same kumar 9) Intravascular USq 4) Gent placement - Self expanding tents, Balloon expandtible stents ) Popoign body etraction using cxfpeker 4) Blood Clot fitters (LVC Filters) 1) Administration oF canen medications directty fo tumor site «Non Vdsedloun © ') Hepatobiliary - Porattinenut Honshopabic biliawy drainage. , Biliary skert placement 2) Urinaay- Pereutonecus hephrestomy, Skenbing and nepbralithotomy 3) Usq[cr guidal biopsies @ Ounce - 4) Catheter drainage of abscesses © Advattage: of Inienverrional procedures © ) Patient Compliance fs high & Suryeny is dvoided 2) Highly lost effective 9) Low infechian rates 4) Relatively non invasive , So can be repeated— FilKevernous pyelogiaply D Diagnos’s oF congential anomalies of kidney - 2) Diagnosis of —hydtorephrasis , Hydrouroten D Obetrudion of pelviuretic jundex, were . mepaunetn can be detecked 6) Diagnose renal 18 Procedure: 1) fat fro non residual div for 2-3 days prior to procedure 2) Dimol prior to procedure t> Ovpol gat 3) Patent should be nil per oral for Shours before pcocedure. 4) Radiologie dye, Urograttin (US. sium diatriacak) 20 m!-Uomnt injeded through median” cubital vein 9 Radfography ~ = Carly Films afer 2-€ minutes = Pelvicalyceu! system visualised- © minujes Hater - Ureler , Bladder usualied - IF-20 ying faded = Post voila) pidure to domorsiate rewdba) cybast in bladder * qp- ) Abrorrra) renal funckem | Rona) faibure 3) lalosyreracy to fodine 9) Hypendeconnia. 4) Multiple pyolra 9) Sicko call arauynia 9) Dehydration + TW signs- D Horse shoe kidrey- lower vase/ Hand shake appearance 1) Dupler pelvis(t malralated pelvis) ~ Droopang lily sign 2) Uvelnocele- Cobra /paiden Head appearance, Y) Rehocaval ureten— Reverse J/ Cichhook appoarance 2) Rohopertoreal fibesis~ Maidens waist appecnanee §) Transitional coll ancnoma oF pelvis- Champagne glass appeanance— Qacicllietapy © Radiation unit - Grey © Qurees oF radiction- Cobalt 60 machine ( mc) Linear cecelanatoy microton Rilovologe vnachinss Cudioachive walenials— Cesium 137 (pelle) ~ Iodine 2 (seads) ~ bidiom 142, * Methods of dolivery: 0 external pain irradiation 2) Brachytherapy —— Inha cavitatory Intostittal Surface troulls [plaques *Drincle~ Radiation Lilk adivly proliferating wralignant oplls oF mitotic level Used : sec 1) malhiple rayelona 9 Bee 2) prostate. BCA Convix 4) @ Redum 4) Serinoma HH? We)Post opehatively in BCS Hodgkins Lymphoma WY Oral Z'2) for secmndenies in follicular Ca of Hyroid 6) G lung 8 Bdio resistant Tuynors = GI Walignancies — Melajoyna : ~ Modula cx thyroid * (omplicatiows of PT* Ord mbcosol sadoma, Oral thrush * Cope marrow suppression © d1igospoumio * tlasea Vomiting diayrhoen © Radiation previnonitis + Radiation dermatitis © Tnfections Radiation irducnd malig pancies* Royle From —Cobene Chott injuries and nid Practunes © Proce oF 2 or more ibs Gt 2 places vantehiovty @ povteriorly ; so that uxdain Coymulch Gf vib have no atachmoyit “to choi wall * the vids bourne irdrawm due to intathorotlc negative presure.as patent inhale Ond i Griven Gulwords on expiration Crowkiy inshabi ity, (Paradoxical hetpiration), . Types Antedior - Proce of costo chondnal junction on ool gider Of Afennum Postorior - uu wiby G podtutor wall Loto - fracture soft of vibs- © © ut - Gtobilite Hail Soqimenks with plales, Stews From cpdtal CahHlaye to Geumuy 4 Pe - No &- rapulr ack oJ guppnt- 9) lana Treated by chest wall stabiliser on , by postive prosw ventilation or velono rib belt Roduckion of respiratory dedd spaced fy intoredttal chert tube - MY ch pulmoany Cotton and pain corto Cyidural avalgeia secommended for palin yx Other ynoHads O Open reducton of vib frockure | ofetfixatin with metal plates and. Screux Q Infenal preuwvatic Pixation: ® Physiological ctabilreation with intubation 4 intermittent Positive preset Vow oonTension Pneumo thorax Injury fo lungs v Continuous Ualvulor air leak Actumulating air colagses (Ung on came side $ pusher ywodtastirum to other side v Ped intro pleural pressure above Otmenphodic press. a M me Of expiratin V ventilation 4 Vorow return 40 heat qe Tachypnea Tachycardia Tymodnie Note ot porcussion Total absence of byeath sounds rawhea. ¢hitr MK 4 Eypergency = Diagnose immediately - Do not wart for chert xray — Noodle +ordecontetts in 2nd eSpace in middavicwlan line Geoments enilon prournatharax 40 gimble Preumothernx — Dryer Led insertion and connect to Uderwater seal% Collection of pus in ploural space baci : ~~ © Phevmenin in oxudative phase @ end troge cedult of plural effusion ¢ infection © puphns of tubphrenic dbecose , hydatic cyst, liver abscess e of Chest pain Dyspnea Todenness Toxic feadius of aclite empyema loves 3 Chest Xray ® Aspiredion of plourod Puid ~~ Analysis Hure @ CV xan Split puna sig: My pts — Video dssitted trovacnsenpte Hungenly Bib vemctin & drainage Herough windows Eloisions rethad - _Lerwolivakivs OToxi oi ty Q Sop &hotk @ mulWargay, Calum