Massive blood transfusion strategy

In patients with massive haemorhage with a loss of more than 40% of blood volume - rapid transfusions are given with colloids, crystalloids and packed RBCs.

This causes coagulopathy by diluting the a clotting factors.

Hence, prophylactic infusion of platelets and fresh frozen plasma is done.

Initially, it was given in a ratio of 1:1:4
One part platelet & ffp transfusion to every 4 bags of blood.

It has been renewed now to 1:1:1 ratio

It has caused significant reduction in mortality 40% versus 60%

Thank you!

40% blood loss translates to grade 4 hemorrhagic shock or grade 1 degree of urgency per the urgency grid for obstetric hemorrhage. I removed the grading in the initial part of the post to avoid confusion as different grades mean different severity of shock based on the scale used.

- sakkan

Cavernous transformation of portal vein

Hello Awesomites! :)

Let's start with clinical presentation.

The children may present with hematemesis due to variceal bleeding, failure to thrive, ascites or anemia and splenomegaly.

Portal cavernoma also known as cavernous transformation of portal vein, is an important cause of extrahepatic portal hypertension in children or young adults in developing countries.

After thrombosis of the portal vein, portoportal venous channels may form not only at the porta hepatis but also within the liver. Intrahepatic blood may be shunted from one segmental portal vein to another.

Cavernous transformation of the portal vein is easily diagnosed by sonography. Color and duplex Doppler confirms the presence of portal venous type flow within the tortuous channels at ports hepatis.

In adults, conditions associated with cavernous transformation of the portal vein include myeloproliferative disorders, hypercoagulable states, pancreatitis, pyelephlebitis and Behçet syndome.

Associated findings may include esophageal gastric junction, gastric varices, gallbladder wall varices as well as intra or extra hepatic biliary tree dilatation.

The individualized choice of shunt (Mesocaval/central splenorenal/distal splenorenal shunt) is ideal for treating PVCT, and the combined procedures of shunt and disconnection are useful. The Rex shunt will be the focus of PVCT surgery in the future.

Thank you.
-Upasana Y. :)

Simpson's Grading for Brain Tumors.

Hello Everyone!

So my Neurosurgery residency diaries continue and I continue sharing as I learn.

Learnt about the Grades of Tumor resection while operating on a Glioma.

These are Simpsons Grades of Tumor resection and are correlated as the degree of surgical resection completeness with with symptomatic recurrence. 

Grade I-complete removal including resection of underlying bone and associated dura.

9% symptomatic recurrence at 10 years

Grade II-complete removal and coagulation of dural attachment.

19% symptomatic recurrence at 10 years

Grade III-complete removal without resection of dura or coagulation.

29% symptomatic recurrence at 10 years

Grade IV-subtotal resection of the tumor.

44% symptomatic recurrence at 10 years

Grade V-simple decompression with or without biopsy

100% symptomatic recurrence at 10 years.

That was it!

Let's Learn Together!

-Medha Vyas 

Basics of Fat necrosis.

Hello, let's dissect fat necrosis in this post.

Fat necrosis is seen where fat concentration is more or lipase concentration is more.
Example- Injury to Breast or Omentum tissue or in Acute pancreatitis with gall stones or alcohol intake.

Alcohol intake leads to activation of lipase enzyme. This lipase enzyme converts lipids to fatty acids. Always remember fatty acids loves calcium! This love affair leads to formation of "Fatty acids - Calcium complex formation". This is called as "Saponification".
This gives yellow - white chalk like color. This helps surgeon to identify fat necrosis.

For prognosis we use serum calcium level. Why?

Suppose there is severe pancreatitis. This leads to more activation of the lipase enzyme. This leads to formation of the fatty acids. More fatty acids, more saponification. Hence less calcium level in serum!

Low calcium level suggest bad prognosis!

True or False #10

Hallux valgus is also known as bunion. T or F

T

●Hallux valgus (HV) deformity (ie, bunion) is a common, potentially debilitating deformity consisting of lateral deviation of the hallux on the first metatarsal . The etiology is unknown. The deformity is more common among women and shod populations.

●Although HV is easily recognized by clinical examination, radiographs may be necessary to determine the presence of articular damage . Neither radiographic nor clinical appearance provides the basis for surgical referral, which is determined by patient pain and disability.

●There is little evidence that conservative treatments are useful in the treatment of HV. Nevertheless, we suggest patients without debilitating symptoms avail themselves of conservative therapies before being referred for surgery.

Possible treatments include:

•Shoe modification: wide, low-heeled shoes, or specially altered shoes with increased medial pocket for first metatarsophalangeal (MTP) joint to minimize deforming forces

•Orthoses to improve support and alignment

•Night splinting to improve toe alignment

•Stretching and/ormobilization/manipulation to maintain joint mobility

•Medial bunion pads to prevent irritation

•Ice applied after activity to reduce inflammation
•Analgesics: acetaminophen or NSAIDs

●We suggest that patients with severe pain or dysfunction and those whose symptoms do not improve under a conservative treatment regimen be referred for surgical repair.

Approximately 150 surgical procedures for the correction of HV deformity have been described. Few prospective, randomized trials evaluating these procedures have been performed. Patients should be referred to a foot surgery specialist with experience repairing HV deformity.

●Managing patient expectations about surgery is important. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months. Most patients will remain unable to fit into narrower shoes.

Do not forget to look up pictures of how a bunion looks.

Over and out.

Mnemonics for special orthopedic tests

1) TEST: BRUDZINSKI 'S SIGN --

   *Description: Flexion of neck elicits reflexive flexion of knee.

   *Significance: suggests meningitis.

   * Mnemonic : a) Imagine as if the patient is in SKI position on the bed (neck and knee flexed) .
     b) The neck is stiff from the freezing in the snow.

2) DIX HALLPIKE MANEUVER --

   *Significance : suggests BPPV.

   *Mnemonic : Spike your drink and see the hall spin around you (vertigo) .

3) FINKELSTEINS 'S TEST :

  * Significance : for dequervain's tenosynovitis .

  *Mnemonic : a) Ask the patient to flick a coin of ten.
     b) The head's side of the coin has de (the) queen embossed on it.

4) HAWKIN'S TEST : 
   *Description : Internally rotate the shoulder to produce pain if rotator cuff pathology.
   *Mnemonic :Imagine a hawk flying in circles (rotate) , waiting to attack the shoulder of its prey.

5) LHERMITTE'S SIGN: 
   *Description : Passive forward flexion of head causes electric sensation down the spine.

   *Mnemonic : Imagine a hermit (sadhu)  giving his blessings (aashirwaad)  which induces some electric power down your body.

6) LACHMAN TEST:

   *Significance : indicates anterior cruciate ligament injury.

   *Mnemonic : Imagine anterior cruciate ligament to be a latch which keeps the tibia and femur locked to each other.

7) O'BRIEN TEST:
    *Description : With shoulder at 90 degrees flexion, instruct patient to point thumb at ground and resist downward force. Repeat with palm facing upwards.

  *Significance : Pain suggests labral tear.
   *Mnemonic : a) This is a story of O'Brien who worked as a labourer.
     b) He got thumbs down for his work.
     c) So he had to beg (with palms facing upwards) to make end's meet.

8) SPURLING TEST    

    *Significance : Tingling or pain along cervical nerve root suggests cervical radiculopathy.

    *Mnemonic :a) Spurling test is for spine.
     b)  Imagine if there are spurs formed in spine, they will compress the spinal cord causing radiculopathy.

9) McMURRAY'S TEST :

   *Significance : positive test suggests meniscal tear.

  * Mnemonic : a) Tennis players are very vulnerable to meniscal tear.
     b) Imagine Andy Murray to be suffering from meniscal tear.
     c) Also Mc Murray and meniscus both have M and C.

10) PHALEN 'S TEST :
 
   *Description : Instruct patient to bring dorsal aspect of hands together.  
    *Significance : Tingling or paresthesia in lateral 3.5 fingers suggests carpal tunnel syndrome.

    * Mnemonic : a) Imagine a felon who is handcuffed with dorsal aspect of his hands together.
   b)  The handcuffs are tight and compressing his median nerve causing tingling and numbness.

Submitted by Abuzar Asif

Measuring size of OPA and NPA mnemonic

The oropharyngeal and nasopharyngeal airway are temporary airway devices. You need to select an appropriate size before inserting the airway.

MCQ mnemonics series: Mnemonic for a condition causing lower abdominal pain

A 60-year-old male is admitted with a two day history of lower abdominal pain and marked vomiting. On examination he has abdominal swelling, guarding and numerous audible bowel sounds. What is the diagnosis?

1) Gallstone ileus
2) Ischaemic colitis
3) Large bowel obstruction
4) Sigmoid volvulus

Answer given below:

Complications of massive blood transfusion

Hii everyone! 

Massive blood transfusion is defined as

Complications from massive transfusion include :
1) Hypothermia
2) Hypocalcemia - because citrate present in transfused blood is a calcium chelator, it decreases the available calcium.
3) Acidosis - as citrate is acidic in nature.
4) Hyperkalemia - as Hydrogen ions are present in excess due to acidosis, it is compensated by H+ loss in urine and K+ is regained back into blood. So this causes hyperkalemia.
5) Hypokalemia - in stored blood, the Na+-K+ pump is less functioning,  so there is decrease in intracellular K+ in stored blood.  But after blood transfusion, the Na+ K+  pump again starts functioning and increases intracellular K+, this leads to decrease in the available K+ outside the cell causing hypokalemia.
6) Dilutional coagulopathy - massive blood transfusion leads to dilution of clotting factors . It later manifests as DIC-like leading to multiorgan failure and death.

Thanks for reading.

Madhuri.

Complications of blood transfusion

Hii everyone!
This post is about the complications from a single blood transfusion.

1) The most common complication is febrile nonhemolytic tranfusion reaction(FNHTR). -- this occurs due to anti-HLA antibodies in the recipient which kills WBCs leading to release of interleukins and cytokines which are pyrogens. So the treatment is antipyretics.
2) Urticaria - it is due to IgE antibodies in plasma. So we give antihistamines to control it.
3) Hemolytic transfusion reaction - due to antibodies against RBCs. This is rare.  It may occasionally occur due to clinical errors in pretranfusion tests.
4) Infections - bacterial infection due to faulty storage, hepatitis, HIV, malaria.
5) Air embolism
6) Thrombophlebitis
7) Transfusion- related acute lung injury - usually occurs within 6 hrs after transfusion.

Hope this helps.

Madhuri

Step 2 CK: Blunt abdominal trauma

Hello!

When you are presented with a case of blunt abdominal trauma (BAT) in your exam, first determine whether the patient is stable or unstable.

Varicose Veins : Overview

Varicose Vein

Hello Awesomites!
Through this post I'm trying to share the high yielding points on Varicose Veins.

VARICOSE VEINS
Primary:
Congenital absence or incompetence of valves
Inheritance with FOXC2 gene
Klippel-Trenuanay syndrome
Congenital AV fistula
Cutaneous hemangiomas
Hypertrophy of involved limb
Absence of deep venous system

Secondary:
Recurrent thrombophlebitis
Occupational – prolonged standing
Obstruction to venous return –abdominal tumors, retroperitoneal mass, Pregnancy.
Iliac vein thrombosis

Clinical features

Lipodermatosclerosis (brawny induration), pigmentation, thickening, chronic inflammation and induration of skin in calf muscle and around ankle.

Brodie-Trendelenburg test
To assess the competence of SFJ
Patient lies flat, elevate the leg and gently empty the veins, palpate the SFJ and ask the patient to stand whilst maintaining pressure. If the veins do not refill- SFJ is incompetent. If the veins do refill SFJ may or may not be incompetent, presence of distal incompetent perforators.

Cough impulse (Morrisey's test)
Locate the saphenofemoral junction(2-4 cm inferolateral to pubic tubercle) and ask the patient to cough. Impulse or fluid thrill felt indicates saphenofemoral incompetence.

Modified Perthes Test:Ask the patient to stand and tourniquet is applied at SF junction and ask to walk. Superficial veins become prominent – indicate deep vein thrombosis.

Three tourniquet test - To find the site of incompetent perforator
Tourniquets at SFJ, above knee level, below knee level.

Fegan's test:Detect the perforators

Investigations:
Duplex Ultrasound imaging – gold standard
Doppler examination – only when duplex is not available
Phlebography – not needed in primary venous insufficiency. Only performed as preoperative adjuncts when deep venous reconstruction is being planned
Ascending phlebography – differentiates primary from secondary insufficiency
Descending phlebography - identifies specific valvular incompetence suspected on B mode scanning.

Medical treatment:
Calcium dobesilate
Diosmin
Hesperidin
Toxerutin

Surgical management:
Trendelenburg's operation (juxta femoral flush ligation + stripping the varicose vein) for SFJ incompetency

Subfacial ligation of Cockett and Dodd :perforator incompetence with SF competency

VNUS closure(ablation catheter introduced into the SF junction and slowly withdrawn)

TRIVEX – veins identified by subcutaneous illumination; injection of fluid & superficial veins are sucked

Endo venous laser ablation (EVLA)

Sclerotherapy

That's all. Thank you.

-MD Mobarak Hussain (Maahii)

Types of meshes for hernia repair

Hey everyone, I've just started surgery, and realised that I love the subject! The first topic I started reading was the most commonly read one: hernia!

I realised something very interesting- hernia repair using meshes is a pretty difficult thing to do, because you need to find the right mesh for a particular type of hernia. This is a very dry topic but an important one, so I've tried to add some tricks to remember stuff about meshes!

Q. What's a mesh?
A. A mesh is usually a sheet which has been perforated to make very tiny holes in it, hence it could either be a net or a flat sheet. A mesh is supposed to have a good overlap over the area of defect, and it's margins should cover greater than 2 cm but less than 5 cm of the area with defect.

Q. What are the functions of a mesh?
A. 1. Bridge a defect, to form a tension free patch over the area.
2. To plug a defect if it is small and overlap is hard to achieve.
3. ‎Augment a repair by reinforcing it with the support of this mesh.

Remember it as: BPA (Bridge, Plug, Augment).

Q. Does a mesh cause complications? Which ones?
A. Although an amazing treatment for hernia, it does have its set of complications.
- Mesh plugs can cause meshomas which is a plug of the mesh substance and collagen which will grow over it. -‎migration of the mesh from its original place
-‎ Erosion of surrounding organs
-‎ Fistula formation
-‎ Chronic pain

Remember it as: Growth of a meshoma, pushes upon the surrounding structures causing erosion, eventually it grows so much that the mesh is pushed away (migration), eventually it grows so much it forms a hole (fistula) which obviously causes pain!

Q. How does a mesh work?
A. Net meshes allow fibrous tissue to grow between its strands and become adherent. This integration happens within few months. The initial fixation hence is by means of absorbable material such as glue, sutures or staples.

On the other hand, sheet meshes do not allow such growth between its strands, but gets encapsulated with the fibrous tissue.

Types of Meshes:
1. Synthetic Polymers: polypropylene, polyester, polytetrafluoroethylene.
These are non absorbable and provoke little tissue reaction. As polypropylene has strong monofilament mesh they will have no antibacterial properties, hydrophobic in nature and the monofilament nature impedes growth. Polyester has braided filament mesh and is hydrophilic in nature which hence allows rapid vascular and cellular infiltration.

Features of synthetic meshes:
- Very strong
-‎ Provokes fibrous reaction
-‎ More heavy hence more tissue reaction
-‎ Mesh shrinkage causes progressive decrease in size of mesh over time, leading to tissue pain and hernia recurrence if the defect is not covered fully by shrunken mesh.

2. Biological Meshes: Materials used are usually human or animal dermis, bovine pericardium or porcine intestinal submucosa. These are sterilised, decellularised, non immunogenic connective tissue materials. It has a scaffold structure upon which enzymes work to break down the biological implant and replace and remodel with host fibrous tissue. It's expensive.

3. Absorbable Meshes: polyglycolic acid is a common material. It is for temporary abdominal wall closure.

4. Tissue Separation Meshes: Polycellulose and collagen are widely used. these are for intraperitoneal use, their one side is sticky and the other is slippery. These have good adhesion, with host tissue on parietal side of mesh using the sticky side, and the other side, the slippery one, needed to prevent adhesion is on the visceral side.

There are a lot of Polys here. Let's try remembering which one is under which type?

Ester, Propylene, Tetrafluoroethylene: sound like fake names, so will probably be synthetic!

Glycolic acid is used a lot in skincare products, especially soap. Soap is absorbable, hence a mesh made out of it will also be absorbable, right?

Cellulose and collagen used in the 4th type of mesh are naturally available materials. So can be definitely used for intraperitoneal procedures! Hence can be used in tissue separation!

FactFatigue: Meshes greater than 80 g/ sq m are called heavy meshes. Those less than 40 g/ sq m are called light meshes and are preferred in surgery.

Hope this was an interesting and easier way to remember hernia repair!

This awesome post was written by Devanshi Shah

Causes of a Non Healing Ulcer : Summary

Hi everyone !

This is a short summary on what causes an ulcer to have delayed healing.
Most cases in the wards and the boards are Traumatic ulcers that have now failed to heal due to some or the other reason. Most commonly the reason is Diabetes , other common ones including Poor general health and Varicose veins.
This post summarises the causes.

Causes of Non healing ulcer

Local :
- Site of high pressure / mobility
- Repeated trauma to site
- Foreign body at the ulcer base
- Local infection at ulcer site

Focal :
- Varicose ulcer (Generally at the Medial malleolus)
Reason : Venous congestion eventually causes the trapped macrophages etc to release their mediators producing Inflammatory changes + Pigmentary changes occur due to microruptures of congested venules causing Hemosiderin formation and irritation of skin by the Pigment.
- Deep Vein Thrombosis (Same as above).
- Peripheral Arterial Disease ( Arterial blockade -- causes tissue Hypoxia and thus impaired healing ) 
- Neuropathy ( Impaired sensations cause repeated trauma at the site of the ulcer delaying its healing ).
- Lymphatic D's ( Lymphedema -- can cause skin hypertrophy and other odd changes due to mediators from the Lymph causing ulceration)

Systemic :
- Malnutrition
- Anemia
- Low proteins
- Vitamin deficiencies - esp Vit C , K
- Diabetes Mellitus
- Hypertension (Martorell Ulcer)

_________________________________

Why Diabetes causes non healing of any ulcer ?
3 important reasons :
- Microangiopathy : Due to deposition of various Glycated end products into the microcirculation causing Hypoxia and thus impaired healing
- Neuropathy : due to diabetic Neuropathy , the sensations to the area may be diminished and this will cause repeated trauma to the ulcer.
- Infections : High glucose levels serve as a pabulum or conducive manure for growth of various microbes.  Infection causes impaired healing of the ulcer.

Hope this was helpful!
Happy Studying!
Stay awesome !
~ A.P. Burkhodleria

IV cannula color code and size mnemonic

IV cannula color code and size mnemonic

Here is  an interesting way of remembering the colors of the IV cannulas that I found in the comments section of Quora. Hope it  is helpful!

We start from gauge size number 14 upto gauge size number 24.

All we have to do is remember the layers of the earth from the core right upto the sun.

1) Core of the earth is the innermost layer which is orange - number 14
2) Layer of clay which is grey - number 16
3) Layer of grass which is green - number 18
4) Flowers which are pink - number 20
5) The blue sky - number 22
6) The sun which is yellow- number 24
7) Beyond the Earth is the galaxy which is purple / violet - number 26

This mnemonic was written by our Medical Student Guest Author, Daksh Mehta!

Foreign body aspiration - Flexible or rigid bronchoscopy?

Foreign body aspiration (FBA) - Which bronchoscopy should you do? Flexible or rigid?

#TLDR:
Life threatening - Rigid bronchoscopy
Diagnosis not clear - Flexible bronchoscopy

Children - Rigid bronchoscopy
Adults - Flexible bronchoscopy

Mnemonic: childRen thReatening - Rigid bronchoscopy

So first ask - is this a life threatening FBA? Yes - Rigid bronchoscopy (after airway stabilization of course)

Then ask - Is the diagnosis clear? No - Flexible bronchoscopy

If the diagnosis is clear and the FBA is not life threatening - See the age.

If it is a child - Rigid bronchoscopy
If it is an adult - Flexible bronchoscopy

Here's a looooong copy paste explanation from UpToDate:

MELD score mnemonic

Hello everyone!

Model for End-Stage Liver Disease (MELD) The Model for End-Stage Liver Disease (MELD) is a reliable measure of mortality risk in patients with end-stage liver disease. It is used as a disease severity index to help prioritize allocation of organs for transplant.

MELD uses the patient's values for serum bilirubin, serum creatinine, and the international normalized ratio for prothrombin time (INR) to predict survival. Sodium was recently added to improve predictive value.

Post - intubation Cardiac Arrest : possible mechanisms

Hey Awesomites

Early post - intubation Cardiac Arrest ( within 10 minutes ) is a serious major complication of emergency intratracheal intubation associated with high in - hospital mortality, and occurs with approximately 2% frequency in the ED.

Various retrospective and case- control studies have been well designed to establish the connection and factors associated in the causation. One of the studies by Heffner et al. found that a higher pre - intubation shock index ( PISI ), that is defined as heart rate divided by systolic BP, and a higher weight of the patient are independently associated with post - intubation CA.

Systolic hypotension ( BP less than 90 mmHg ) is independently associated with post - intubation CA.

Emergency intubation can cause hypotension potentially as a consequence of actual intubation acting as a sympatholytic stimulus, mechanical ventilation ( positive pressure ventilation with subsequent fall in venous return ), and/ or the induction agents used.

Also important to note is that the association between pre - intubation hypotension and post - intubation progressive decline in BP and subsequently pulseless electrical activity arrest raises the question of whether treatment of hypotension before intubating by fluid resuscitation and vasopressors can decrease the rate of post - intubation CA.

That's all
- Jaskunwar Singh

Joll's triangle in thyroidectomy

Hello friends,

This post is about the importance of Joll's triangle in thyroidectomy.

Joll's triangle is used to identify external laryngeal nerve during thyroidectomy.

Boundaries of this triangle are :
Laterally: Upper pole of thyroid gland and superior thyroid vessels.
Superiorly: Attachment of strap muscles and deep investing layer of fascia to hyoid.
Medially: Midline of neck.
Floor: Cricothyroid muscle.

This triangle contains superior laryngeal nerve which gives rise to external laryngeal nerve.

Given below is the diagram of this triangle:

Image Based MCQ on Instruments

Hello awesomites!
Yesterday we posted an Image based MCQ on Instruments and here is the answer to the question.
#Image_based
#Instruments
Q. What is the inner diameter of the device shown in the picture if it is to be used in adults?

A. 2-3 mm
B. 8-9 mm
C. 12-15 mm
D. 21-23 mm
The correct answer is B. 8-9 mm. The image given shows an Endotracheal tube that is available in different sizes for different age groups.
Internal diameter 3mm - 6mm is used for Paediatric cases.
Typically, an 8.0 or 8.5 mm for adult men and 7.5 to 8.0 mm for adult women is an ideal choice.

Thanks for your active participation in the question.

MD Mobarak Hussain (Maahii)