Baily & Love

AVO I DA B L E FAC TO R S T H AT COMPOUND THE RESPONSE TO ) , thus AVO I DA B L E FAC TO R S T H ...

AVO I DA B L E FAC TO R S T H AT COMPOUND THE RESPONSE TO ) , thus

Agonists and antagonists: an uncertain balance Within hours of the upregulation of proinflammato...

Alterations in hepatic protein metabolism: the acute-phase protein response The liver and skeleta...

Alterations in hepatic protein metabolism: the acute-phase protein response The liver and skeleta...

Alterations in skeletal muscle protein metabolism Muscle protein is continually synthesised and b...

C A a n Pyrexia C A a n Pyrexia C A a n Pyrexia

CHANGES IN BODY COMPOSITION FOLLOWING INJURY The average 70 /uni00A0 kg male can be considered to...

ENHANCED RECOVERY AFTER SURGERY Modern understanding of the metabolic response to surgical injur...

FURTHER READING Ahl R, Matthiessen P , Sjölin G et al . E ff ects of betablocker therapy on mor - ...

Homeostasis Homeostasis is the concept of maintaining a constant internal environment that allow...

Hypothermia Hypothermia results in increased production of adrenal steroids and catecholamines. ...

INJURY There are several factors that prolong the acute-phase response to injury ( Table 1.1 ) an...

Immobilisation Adreno-sympathetic activation Wound Hypothermia Hypotension Pain Cytokine cascade ...

Immobility Immobility has long been recognised as a potent stimulus for inducing muscle wasting. ...

INTRODUCTION As surgeons we are inextricably linked with tissue injury and its e ff ects, both fro...

Learning objectives To understand: How the body responds to accidental injury and surgery • Physi...

MANAGING THE CATABOLIC STRESS RESPONSE There are several key elements that determine the extent o...

MEDIATORS OF THE METABOLIC RESPONSE TO INJURY Tissue damage and inflammation Tissue injury is sens...

MEDIATORS OF THE METABOLIC RESPONSE TO INJURY Tissue damage and inflammation Tissue injury is sens...

METABOLIC CHANGES AFTER SURGERY AND TRAUMA The catabolic phase begins at the time of injury and ...

Modern surgical care The role of surgical critical care, including resuscitation and/ or organ s...

Neuroendocrine response to injury Patients also respond rapidly to injury by the classical neuroe...

RESPONSE It is important to recognise that, in general or population terms, the metabolic respons...

Starvation Figure 1.7 Factors that exacerbate the metabolic response to surgical injury include h...

Systemic inflammation and tissue Systemic inflammation and tissue Systemic inflammation an...

Tissue oedema During systemic inflammation, fluid, plasma proteins, leukocytes, macrophages and ele...

Volume loss During simple haemorrhage, baroreceptors in the carotid artery and aortic arch and vo...

b b o o l Insulin resistance Futile substrate cycling b b o o l Insulin resistance Futile substra...

l i i Muscle protein degradation l i i Muscle protein degradation l i i Muscle protein degradation

s s m m /H11001 /H11002 s s m m /H11001 /H11002 s s m m /H11001 /H11002

t a a Acute phase response t a a Acute phase response t a a Acute phase response

underperfusion xac - The vascular endothelium controls vasomotor tone and ter microvascular flow a...

Analgesia The type and extent of analgesic requirement will depend on both the patient and proce...

DEFINITION Minimal access surgery is a product of modern technology and surgical innovation that...

DISCHARGE FROM HOSPITAL The discharge of patients is based on clinical indicators and the patien...

Direct robotic systems and hybrid robotic surgery In addition to the remote master–slave platform...

Disadvantages of robotic surgery Cost Robotic surgery remains more costly than minimally invasive...

Drains The use of postoperative drains depends on the operation performed. Drain output should in...

Endoluminal endoscopy and natural orifice surgery Flexible or rigid endoscopes are introduced into...

Endoscopic surgery Lack of three-dimensional vision To perform minimal access surgery with safety...

FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts The future of minima...

FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts The future of minima...

GENERAL INTRAOPERATIVE PRINCIPLES Many minimal access procedures have a unique set of proce - du...

History of minimal access surgery The first experimental laparoscopic procedure was performed by K...

History of robotic surgery The first documented clinical robotic procedure was a computed tomograp...

Hybrid minimal access surgery Hybrid surgery may utilise a combination of flexible and straight s...

Introduction No content extracted automatically.

LIMITATIONS OF MINIMAL ACCESS SURGERY Minimal access surgery has limitations. A number of these ...

Learning objectives To understand: The principles of minimal access surgery • The advantages and ...

MINIMAL ACCESS APPROACHES Laparoscopy A rigid endoscope is introduced through a port into the per...

Mobility and convalescence Patients can get out of bed to go to the toilet as soon as they have ...

Operative problems Intraoperative perforation of a viscus or vascular injury Perforation of any ...

Oral feeding Provided that the patient has an appetite, a light meal can be taken 4–6 hours after...

Oral fluids There is no significant ileus after minimal access surgery , except in abdominal resect...

Orogastric or nasogastric tube An orogastric or nasogastric tube may be placed for some abdominal...

PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SURGERY PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SUR...

POSTOPERATIVE CARE The postoperative care of patients after minimal access surgery - is general...

Perivisceral endoscopy Body planes can be accessed even in the absence of a natural cavity . Exa...

Port site pain and numbness Pain in one or other of the port site wounds is not uncommon and is ...

Preparation of the patient Although the patient may be in hospital for a shorter period, - carefu...

Principles of electrosurgery during laparoscopic surgery Inadvertent electrosurgical injuries dur...

Principles of electrosurgery during laparoscopic surgery Inadvertent electrosurgical injuries dur...

ROBOTIC SURGERY A robot is a mechanical device that performs automated phys - ical tasks accordin...

SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND ROBOTIC SURGERY Most of the trauma of an open pr...

SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND ROBOTIC SURGERY Most of the trauma of an open pr...

Shoulder tip pain Patients should be warned about this preoperatively and informed that the pain ...

Single-incision minimal access surgery Single-incision minimal access surgery has varied in pop...

Skin sutures If non-absorbable sutures or skin staples have been used, they can be removed from ...

THE FUTURE Minimal access surgery has changed surgical practice; however, it has not changed the ...

THEATRE SET-UP AND TOOLS Operating theatre design is key to e ffi ciency . Modern theatres are desi...

Thoracoscopy A rigid endoscope is introduced through an incision placed - between the ribs to gai...

Uptake of robotic surgery Many surgical specialties have embraced robot-assisted techniques, incl...

Urinary catheter The requirement for a urinary catheter depends on the opera - tion. In shorter (...

surgery Arthroscopy was one of the earliest applications of endoscopic techniques, first being a...

ACKNOWLEDGEMENTS The authors are very grateful to the following contributors for assistance with ...

ASSESSMENT Light microscopy Most tissue assessment depends on conventional light micros - copy . ...

AUTOPSY In the past, autopsies (postmortems) allowed physicians and scientists to improve their k...

BRAF V600E mutation for detecting antigens in haematological neoplasms, usually in - blood sampl...

Basic methods in diagnostic molecular pathology In situ hybridisation H. In situ hybridisation (I...

Cancer ‘precision medicine’ This refers to the development of individualised cancer care plans, ...

Cytogenetics and fluorescence in situ hybridisation Conventional cytogenetics is the microscopic s...

Cytological assessment A cytological preparation consists of a sample of cells only . Assessmen...

Cytology specimen Samples for cytology can be smeared immediately onto glass slides, fixed (usuall...

Cytology There are various approaches to the procurement of a cytol ogy sample. Some samples are...

DIAGNOSTIC MOLECULAR PATHOLOGY The broad heading of diagnostic molecular pathology refers to m...

DIGITAL PATHOLOGY AND ARTIFICAL INTELLIGENCE The term ‘digital pathology’ usually refers to the e...

Deeper levels and extra blocks The pathologist may request ‘deeper levels’, whereby the BMS cuts ...

Detection of clinically relevant abnormalities in genes There are two broadly related areas of ...

Detection of clinically relevant abnormalities in genes There are two broadly related areas of ...

Detection of clinically relevant abnormalities in genes There are two broadly related areas of ...

Electron microscopy Electron microscopy allows visualisation of tissue at very high magnification,...

FURTHER READING Brierley JD, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumour...

FURTHER WORK Pathologists request further stains or other tests on a signif - icant minority of ...

Flow cytometry Flow cytometry is a laser-based or impedance-based technique used for cell countin...

Fresh tissue The most common indication for submission of a fresh tissue sample (i.e. without th...

Genomic changes in tumours In normal circumstances, there is precise control of the divi - sion ...

HER2 gene amplification HER2 status influences the selection of therapy for breast cancer and meta...

Histological assessment In a histological preparation, the microscopic structure of the tissue r...

Histological types of malignancy A malignant tumour showing features of epithelial di ff erentia ...

Histology specimen On arrival in the pathology laboratory , specimens receive a unique identificat...

Histology Specimens for histology are classified as biopsies and resec - tions, although strictly ...

Immunohistochemistry: tumour pathology Immunohistochemistry has multiple applications in tumour p...

Immunohistochemistry Immunohistochemistry emerged in the 1970s and has had a major impact on hist...

INTRODUCTION Pre-nineteenth century tissue diagnosis depended on naked eye examination of autops...

Learning objectives To understand: The value and limitations of tissue diagnosis • Approaches to ...

Microscopic features of inflammation Acute inflammation is characterised histologically by neutro -...

Mismatch repair gene abnormalities in tumours High levels of microsatellite instability (MSI-H),...

Molecular changes and drug therapy An increasingly common reason for molecular testing and relate...

Molecular profile: examples of specific tumours Colorectal carcinoma In CRC, the anti-EGFR monoclon...

Non-neoplastic and inflammatory conditions The diagnosis, assessment and management of non-neopla...

Other terms Other specific tissue abnormalities are also detectable by microscopy . Histopathologi...

PRINCIPLES OF MICROSCOPIC DIAGNOSIS Diagnosis of malignancy Neoplasia is a broad term that includ...

PRINCIPLES OF MICROSCOPIC DIAGNOSIS Diagnosis of malignancy Neoplasia is a broad term that includ...

Polymerase chain reaction The polymerase chain reaction (PCR) amplifies DNA, yield ing millions of...

Prognosis Tests that help determine the selection of therapy for tumours may also have additiona...

Prognostic factors for malignant tumours Tissue assessment is important for cancer prognosis. Sta...

REASONS FOR ASSESSMENT OF TISSUE The contributions that tissue analysis makes to clinical - manag...

RISK MANAGEMENT Safety and risk management are priorities in the labora - tory . The use of warn...

SPECIMEN PROCESSING SPECIMEN PROCESSING SPECIMEN PROCESSING

Special stains A ‘special stain’ is a stain that is not routine, i.e. not an H&E stain. Immunohis...

Specimen adequacy There are many reasons for an inadequate specimen. The operator may fail to sam...

Storage Resection specimens are generally stored for about 4–6 weeks. Tissue blocks and slides ar...

TISSUE SPECIMENS Routine tissue specimens received by a histopathology depart - ment include thos...

Cancer staging It is not su ffi cient simply to know what and where a cancer is; its extent must al...

End-of-life care End-of-life care is distinct from palliative care. Patients treated - palliative...

Introduction No content extracted automatically.

Learning objectives To understand: The biological nature of cancer • That curative treatment is o...

Oncological emergencies There are a limited number of true emergencies in oncology . Those that ...

Prevention There is much written on the evidence on the preventable causes of cancer. It is conc...

Principles of cancer surgery For most solid tumours, surgery remains the definitive treat - ment a...

Principles of combined treatment Non-surgical treatments are often used in combination. For examp...

Principles underlying the non-surgical treatment of cancer Medical and clinical (radiation) oncol...

Principles underlying the non-surgical treatment of cancer Medical and clinical (radiation) oncol...

Screening Screening involves the detection of disease in an asymptomatic population in order to ...

Symptom control and palliative care The distinction between palliative and curative treatment is ...

THE CAUSES OF CANCER The interplay between nature and nurture Both inheritance and environment ar...

THE CAUSES OF CANCER The interplay between nature and nurture Both inheritance and environment ar...

THE CAUSES OF CANCER The interplay between nature and nurture Both inheritance and environment ar...

THE MANAGEMENT OF CANCER Management is more than treatment The traditional approach to cancer con...

THE MANAGEMENT OF CANCER Management is more than treatment The traditional approach to cancer con...

The growth of a cancer If it is accepted that a cancer starts from a single transformed cell the...

The hallmarks of cancer Cancer cells are able to proliferate in an uncontrolled fashion; - their ...

The range of non-surgical anti-cancer treatments Radiotherapy Half of all patients will receive...

Therapeutic decision making and the multidisciplinary team As the management of cancer becomes m...

Therapeutic decision making and the multidisciplinary team As the management of cancer becomes m...

WHAT IS CANCER? History The word ‘cancer’ is credited to Hippocrates (460 /uni00A0 /b.sc/c.sc/e.s...

ANAL YSING A SCIENTIFIC ARTICLE The simplest way to analyse an article from a scientific journal i...

AUDIT AND SERVICE EVALUATION Clinical audit is a process used by clinicians who seek to improve p...

AUDIT OR RESEARCH? Health professionals are expected to undertake audit and service evaluation as...

Computer software packages available Statistical computer packages o ff er a quick way of analysi...

EVIDENCE-BASED SURGERY Surgical practice has been considered an art: ask 50 surgeons how to manag...

Eliminating bias It is important to imagine how a study could be invalidated by thinking of thin...

Ethics In the first instance, common sense is the best guide to whether or not a study is ethical....

FORMING A TEAM One of the most common reasons for the failure of an other wise good research pr...

FURTHER READING Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with confi - dence , 2nd ed...

I SE R essure dressing for R eduction I n S urgical E mergency laparotomy 840 patients Inclusi...

IDENTIFYING A RESEARCH TOPIC Research is designed to generate new knowledge and might involve tes...

INTRODUCTION Surgeons are innovators and a key aspect of a surgical career is to constantly adapt...

Learning objectives To understand: The planning and conduct of surgical audit and • research How ...

ONLINE RESOURCES AcoRD: https://www .gov .uk/government/publications/guidance-on - - attributing-...

PRESENTING AND PUBLISHING AN ARTICLE There is no point in conducting a research or audit project ...

PROJECT DESIGN During the first phase, it is important to keep in the mind some important question...

Peer review Once the protocol is finalised, formal peer review is needed. In the UK, evidence of ...

Regulatory approvals Interventional clinical or device trials are regulated by the Medicines and ...

Regulatory framework In the UK, the implementation of the UK Policy Framework for Health and Soc...

Research integrity In 2013, Universities UK, in collaboration with major funders of research, de...

SUNRR that enhances the integrity of the study and includes require ments for sponsorship by an ...

Sample size Calculating the number of patients required to perform a satis - factory investigati...

Study protocol Now that the research question has been decided, and it has been checked that su ffi...

ADUL TS: PEOPLE 18 AND ABOVE Capacity in adults is presumed, but this may be challenged on the ba...

CHILDREN AND YOUNG PEOPLE In England and Wales, a person is a child until their 18th birthday; ol...

CONCLUSION Surgeons have combined duties to their patients: to protect life and health and to res...

CONFIDENTIALITY BALANCED AGAINST THE RISK OF SERIOUS CONFIDENTIALITY BALANCED AGAINST THE RISK ...

CONFIDENTIALITY BALANCED AGAINST THE RISK OF SERIOUS

DECISIONS IN THE BEST INTERESTS OF INCAPACITATED PATIENTS We are all well aware that adults with ...

DECISIONS IN THE BEST INTERESTS OF INCAPACITATED PATIENTS We are all well aware that adults with ...

DISCLOSURE PRIOR TO CONSENT In surgical practice, respect for autonomy translates into the clinic...

DO NOT ATTEMPT RESUSCITATION? Furthermore, the decision to discontinue life-sustaining treat ment...

DOCTRINE OF DOUBLE EFFECT Surgeons could find themselves involved in the palliative care of patie...

DUTY OF CANDOUR Equal consideration should be given to disclosure of informa tion that was gener...

FURTHER PRACTICAL APPLICATIONS OF CLINICAL LAW IN FURTHER PRACTICAL APPLICATIONS OF CLINICAL LA...

HARM Respect for autonomy does not entail only the right of capac - itous patients to consent to...

INCAPACITY Absence of capacity in adults does not vitiate the requirement, where possible, to ta...

INTRODUCTION This chapter incorporates references to English common and statute law . Nevertheles...

Learning objectives To understand: The importance of autonomy in good surgical practice • The nec...

REFERENCES 1 Kings College Hospital v C & V [2015] EWCOP 80 2 Montgomery (Appellant) v Lanarkshir...

RESEARCH As part of their duty to protect life and health to an acceptable professional standard...

RESPECT FOR AUTONOMY Surgeons have a duty of care towards their patients that goes beyond merely...

SHARING INFORMATION WITH THE POLICE It is not uncommon to receive a request from the police for p...

STANDARDS OF EXCELLENCE To optimise success in protecting life and health to an accept - able sta...

SURGICAL PRACTICE Thus far, the moral and legal reasons why the duty of surgeons to respect the ...

THE ROLE OF THE COURT The question has arisen regarding the circumstances in England in which cli...

TRANSPLANTATION The law and ethics of organ transplantation require more space than this chapter...

CLINICAL OUTCOMES, AUDIT AND IMPROVEMENT tients Clinical audit, a function of clinical governanc...

COMMUNICATION Professional behaviour and maintaining fitness to practice Professionalism is an imp...

Checklists Checklists in the operating theatre environment are now accepted as standard safety pr...

Clinical microsystems A clinical microsystem is an interdependent quality improvement unit made u...

Communicating openly with patients and their carers and obtaining consent A patient-centred appro...

HUMAN FACTORS The healthcare setting has become increasingly complex. Patient and societal demand...

Hospital level Clinical governance Patient safety requires a team approach. Many national and int...

INCIDENTS Understanding the concepts underlying patient safety inci - dents is useful because it ...

International Since 2009, WHO has embarked on a series of global and regional initiatives to imp...

INTRODUCTION In recent years, increased emphasis has been placed on the study of healthcare syst...

Lean Lean improvement methodologies originated in industrial settings among frontline workers and...

Learning objectives To learn: The importance of understanding human behaviour, • quality and valu...

Low- and middle-income countries Resource-poor countries share many of the aspirations and chall...

Model for improvement Based on the teachings of W . Edwards Deming ( Table 15.4 ), the model for...

Never events Many national health services and institutions now require that all incidents are ma...

PATIENT SAFETY AND RISK MANAGEMENT Patient safety can only be considered in a broader understand ...

PATIENT SAFETY AND THE SURGEON: PROFESSIONAL RESPONSIBILITY Among medical specialties, surgery is...

PATIENT SAFETY Medicine will never be risk-free. From the beginning of train - ing, doctors are ...

Prescribing safely Patients are vulnerable to mistakes made in any one of the many steps involve...

QUALITY MEASURES Measurement is a key principle of quality improvement. Although many changes ta...

Resource-rich countries Many countries and professional bodies in resource-rich coun - tries have...

STRATEGIES FOR PATIENT SAFETY As safety is everybody’s business, building and embedding a safety ...

Shouldering the burden of adverse event As primary care givers and clinical leaders, surgeons wil...

Situation awareness: identifying Situation awareness: identifying

Situational awareness: understanding the work environment and working well within it Nowhere is t...

Six Sigma Six Sigma refers to another business performance meth odology that has been adopted for...

Supporting a safety culture Adverse events and near misses go unreported for many reasons, includ...

Surgical Safety Checklist B efore induction of anaesthesia B efore skin incision (with nurse, ana...

Systems thinking and leadership In a system as complex as health care, ‘systems’ thinking allows ...

THE PROCESS OF SURGICAL CARE Patients attend surgeons in many di ff erent settings depending on w...

THE QUALITY IMPROVEMENT PATHWAY Quality improvement can be applied to almost any step, process or...

Technical and operative errors In surgery , the person rather than systems approach empha - sises...

The person approach Human performance principles tell us that humans are fallible and that errors...

The system approach Health systems add complex organisational structures to human fallibility , t...

UNDERSTANDING PATIENT SAFETY UNDERSTANDING PATIENT SAFETY

When things go wrong: open disclosure Communicating honestly with patients after an adverse event...

teamwork errors Operating theatres have been described as ‘among the most - complex political, so...

CLINICAL OUTCOMES, AUDIT AND IMPROVEMENT tients Clinical audit, a function of clinical governanc...

COMMUNICATION Professional behaviour and maintaining fitness to practice Professionalism is an imp...

Checklists Checklists in the operating theatre environment are now accepted as standard safety pr...

Clinical microsystems A clinical microsystem is an interdependent quality improvement unit made u...

Communicating openly with patients and their carers and obtaining consent A patient-centred appro...

HUMAN FACTORS The healthcare setting has become increasingly complex. Patient and societal demand...

Hospital level Clinical governance Patient safety requires a team approach. Many national and int...

INCIDENTS Understanding the concepts underlying patient safety inci - dents is useful because it ...

International Since 2009, WHO has embarked on a series of global and regional initiatives to imp...

INTRODUCTION In recent years, increased emphasis has been placed on the study of healthcare syst...

Lean Lean improvement methodologies originated in industrial settings among frontline workers and...

Learning objectives To learn: The importance of understanding human behaviour, • quality and valu...

Low- and middle-income countries Resource-poor countries share many of the aspirations and chall...

Model for improvement Based on the teachings of W . Edwards Deming ( Table 15.4 ), the model for...

Never events Many national health services and institutions now require that all incidents are ma...

PATIENT SAFETY AND RISK MANAGEMENT Patient safety can only be considered in a broader understand ...

PATIENT SAFETY AND THE SURGEON: PROFESSIONAL RESPONSIBILITY Among medical specialties, surgery is...

PATIENT SAFETY Medicine will never be risk-free. From the beginning of train - ing, doctors are ...

Prescribing safely Patients are vulnerable to mistakes made in any one of the many steps involve...

QUALITY MEASURES Measurement is a key principle of quality improvement. Although many changes ta...

Resource-rich countries Many countries and professional bodies in resource-rich coun - tries have...

STRATEGIES FOR PATIENT SAFETY As safety is everybody’s business, building and embedding a safety ...

Shouldering the burden of adverse event As primary care givers and clinical leaders, surgeons wil...

Situation awareness: identifying

Situational awareness: understanding the work environment and working well within it Nowhere is t...

Six Sigma Six Sigma refers to another business performance meth odology that has been adopted for...

Supporting a safety culture Adverse events and near misses go unreported for many reasons, includ...

Surgical Safety Checklist B efore induction of anaesthesia B efore skin incision (with nurse, ana...

Systems thinking and leadership In a system as complex as health care, ‘systems’ thinking allows ...

THE PROCESS OF SURGICAL CARE Patients attend surgeons in many di ff erent settings depending on w...

THE QUALITY IMPROVEMENT PATHWAY Quality improvement can be applied to almost any step, process or...

Technical and operative errors In surgery , the person rather than systems approach empha - sises...

The person approach Human performance principles tell us that humans are fallible and that errors...

The system approach Health systems add complex organisational structures to human fallibility , t...

UNDERSTANDING PATIENT SAFETY

When things go wrong: open disclosure Communicating honestly with patients after an adverse event...

teamwork errors Operating theatres have been described as ‘among the most - complex political, so...

ACCESS TO SURGICAL CARE The Lancet Commission on Global Surgery (2015) estimated that 5 billion o...

ESSENTIAL SURGERY THROUGH SURGICAL HEAL THCARE DELIVERY PLATFORMS The 44 essential surgeries list...

ESSENTIAL SURGERY THROUGH SURGICAL HEAL THCARE DELIVERY PLATFORMS The 44 essential surgeries list...

FURTHER READING Bath M, Bashford T , Fitzgerald JE. What is ‘global surgery’? Defining the multidi...

GLOBAL SURGICAL METRICS AND RESEARCH Surgeons are familiar with vital-sign-based scoring systems ...

INTRODUCTION AND DEFINITION Global health is the health of populations in the global context. Gl...

CH A P T E R

Learning objectives To de /f_i ne: The term global surgery • To describe: The role of a global su...

SURGERY AND IMPOVERISHMENT Surgeons are tasked to operate and, in so doing, aim to successfully t...

SURGERY AS AN ESSENTIAL AND COST-EFFECTIVE INTERVENTION With the decline in the burden of commun...

SURGERY AS AN ESSENTIAL AND COST-EFFECTIVE INTERVENTION With the decline in the burden of commun...

THE GLOBAL SURGICAL WORKFORCE A surgeon, anaesthetist and obstetrician (SAO) at the district hosp...

ENVIRONMENT Children, especially infants, should be managed in a warm environment. Compared with ...

INTRODUCTION In high-income countries paediatric surgeons have subspecial ised, whereas in low-in...

Learning objectives After studying this chapter, you will be able to: Outline subspecialisations ...

Anorectal malformations In an anorectal malformation, there is usually no opening in boys, and th...

Biliary atresia/choledochal malformation Congenital or acquired (e.g. cytomegalovirus) extrahepat...

Congenital mesoblastic nephroma This renal tumour may present as a large palpable mass in a newbo...

Duodenal atresia The obstruction in duodenal atresia usually lies just distal to the ampulla of ...

Exomphalos Exomphalos describes a central abdominal wall defect in which prolapsed viscera are co...

Gastroschisis In gastroschisis, an abdominal wall defect lies to the right- hand side of the umbi...

Hirschsprung’s disease Genetic defects (e.g. RET , EDNRB, EDN3 ) can a ff ect the - migration of ...

INTRODUCTION Neonatal surgeons are paediatric surgeons who manage life-threatening non-cardiac co...

Learning objectives To be able to: List /f_i ve aetiological classes underlying structural • cong...

Malrotation and volvulus Complex rotations in utero give the small bowel mesentery its broad, sta...

Meconium ileus Inspissated meconium may cause a distal ileal obstruction. A segmental ileal volvu...

NEONATAL GASTROINTESTINAL SURGERY Oesophageal atresia/ tracheoesophageal fi stula (OA/TOF) Five ...

NEONATAL GASTROINTESTINAL SURGERY Oesophageal atresia/ tracheoesophageal fi stula (OA/TOF) Five ...

NEWBORN PHYSIOLOGY AND THE PRINCIPLES OF NEONATAL SURGERY Neonatal physiology can pose challenges...

NEWBORN PHYSIOLOGY AND THE PRINCIPLES OF NEONATAL SURGERY Neonatal physiology can pose challenges...

NEWBORN PHYSIOLOGY AND THE PRINCIPLES OF NEONATAL SURGERY Neonatal physiology can pose challenges...

Necrotising enterocolitis NEC is a patchy haemorrhagic enteritis seen in about 10% of preterm bab...

Pulmonary airway malformations There are three groups: congenital cystic adenomatoid malfor - mat...

Sacrococcygeal teratoma These germ cell tumours arise from the coccyx and are usually diagnosed a...

Small bowel atresias Small bowel atresias may be isolated ( Figure 18.5 ) or multiple. If seen wi...

THORACIC SURGERY Congenital diaphragmatic hernia Several genes share roles in diaphragmatic, pulm...

WHY ADUL T SURGEONS NEED AN OVERVIEW OF NEONATAL SURGERY Rarely , malrotation, congenital diaphra...

WHY ADUL T SURGEONS NEED AN OVERVIEW OF NEONATAL SURGERY Rarely , malrotation, congenital diaphra...

Abdomen Intraperitoneal air mandates a laparoscopy or laparotomy . Penetrating wounds that have n...

DAMAGE CONTROL SURGERY Damage control surgery aims to break the ‘vicious cycle’ of hypothermia, t...

DEFINITIVE MANAGEMENT Chest A small pneumothorax detected on a chest radiograph may be observed r...

Imaging The choice of imaging depends on the mechanism of injury and the findings on examination...

Injury Severity Score An Injury Severity Score (ISS) (see Chapter 26 ) >15 predicts mortality in ...

INTRODUCTION Trauma is the leading cause of death in children over 1 /uni00A0 year old, and blun...

Learning objectives To be able to: Systematically assess an injured child • Give examples of how ...

Patterns of injury There are some well-recognised patterns of injury in children. Lap belt If a...

Resuscitation All children initially receive high-flow oxygen, preferably via - a non-rebreathe ma...

SECONDARY SURVEY The secondary survey is performed after resuscitation and stabilisation. The his...

Specific considerations Spleen There is a risk of splenic pseudoaneurysm after splenic trauma, wh...

Spinal cord injury without radiological abnormality (SCIWORA) Cervical hyperextension can occur d...

Spinal cord injury without radiological abnormality (SCIWORA) Cervical hyperextension can occur d...

THE PRIMARY SURVEY Injured children are assessed using the Advanced Trauma Life Support (ATLS) st...

Trauma-induced coagulopathy Tissue damage releases factors that encourage coagulation but acidosi...

After haemorrhage control Once haemorrhage is controlled, patients should be defini - tively res...

Blood and blood products Blood is collected from donors who have been previously screened before ...

Blood groups and cross-matching Human red cells have on their cell surface many di ff erent - anti...

Blood substitutes Blood substitutes are an attractive alternative to the costly process of donat...

Classification of shock There are numerous ways to classify shock, but the most common and most cl...

Clinical consequences of shock Unresuscitatable shock Patients who are in profound shock for a pr...

Complications of blood transfusion Complications from blood transfusion can be categorised as tho...

Conduct of resuscitation Resuscitation should not be delayed in order to definitively diagnose the...

Cross-matching To prevent transfusion reactions, all transfusions are preceded by ABO and rhesus ...

Damage control resuscitation Damage control resuscitation (DCR), also known as haemo - static res...

Degree of haemorrhage and classification The adult human has approximately 5 litres of blood (70 ...

Definitions Revealed and concealed haemorrhage Haemorrhage may be revealed or concealed. Revealed ...

End points of resuscitation It is much easier to know when to start resuscitation than when to st...

FURTHER READING Cole E, Weaver A, Gall L et al . A decade of damage control resusci - tation: ...

HAEMORRHAGE RESUSCITATION The conduct and goals of resuscitation change depending on whether the...

HAEMORRHAGE Uncontrolled bleeding will lead to a hypovolaemic shock - state, or haemorrhagic shoc...

Identify haemorrhage External haemorrhage may be obvious, but the diagnosis of concealed haemorrh...

Indications for blood transfusion Blood transfusions should be avoided if possible, and many pre...

INTRODUCTION Shock is the most common cause of death of surgical patients. Death may occur rapi...

Learning objectives To understand: The pathophysiology of shock • The different patterns of shock...

Monitoring The minimum standard for monitoring of the patient in shock is continuous heart rate ...

Pathophysiology Cellular As perfusion to the tissues is reduced, cells are deprived of oxygen and...

Recognition and diagnosis of shock Shock may be profound and easily recognised or it may be - sub...

SHOCK RESUSCITATION Immediate resuscitation manoeuvres for patients presenting in - shock are t...

SHOCK Shock is a systemic state of low tissue perfusion that is inade quate for normal cellular ...

TRANSFUSION The transfusion of blood and blood products has become commonplace since the first su...

Transfusion reactions If antibodies present in the recipient’s serum are incompatible with the d...

Vasopressor and inotropic support Vasopressor or inotropic therapy is not indicated as first-line ...

Antenatal fetal hydronephrosis Hydronephrosis /uni00A0 – /uni00A0 a dilated renal pelvis /uni00A0...

DISORDERS OR DIFFERENCES IN SEX DIFFERENTIATION Some, but not all, children with abnormalities of...

EMBRYOLOGY Four areas of developmental biology are relevant: (i) the two stages of testicular d...

Epispadias/bladder exstrophy Epispadias is a rare dorsal penile defect with an opening whose uppe...

Hypospadias The genital tubercle becomes a penis under the influence of androgens with a tubula...

INTRODUCTION Paediatric urologists are paediatric surgeons who subspecialise in the conditions ou...

Learning objectives At the end of this chapter, you will be able to: Explain the indications for ...

NEUROPATHIC BLADDER A myelomeningocele, lipomyelomeningocele, fatty filum or an occult tethered co...

Posterior urethral valves PUVs are membranous folds that obstruct the lumen of the posterior uret...

Radioisotope renal imaging 99m The metastable radioisotope Tc emits gamma rays during 99 an isome...

THE PENIS Foreskin disorders and circumcision Surgical referrals for foreskin problems are common...

URINARY TRACT OBSTRUCTION URINARY TRACT OBSTRUCTION URINARY TRACT OBSTRUCTION

UROLITHIASIS The prevalence of urolithiasis in children varies from around 1–5% in Asia, 5–10% i...

Ureteropelvic junction obstruction Ureteropelvic junction (UPJ) obstruction, also often called pe...

Ureterovesical junction obstruction/ megaureters Ureterovesical junction (UVJ) obstruction is t...

Vesicoureteral reflux V esicoureteral reflux (VUR) is the retrograde flow of urine from the bladder...

ARRANGING AN ELECTIVE THEATRE LIST The date, place and time of operation should be matched with ...

ASSESSMENT OF RISK Despite more comorbid patients presenting for surgery , the perioperative mort...

Airway assessment The di ffi culty encountered when performing airway manoeu - vres, i.e. hand vent...

COMMON PREOPERATIVE PROBLEMS AND MANAGEMENT Specific medical problems encountered during preoper...

CONSENT Consent is a key part of preoperative care. The process of consent has evolved over the ...

Cardiopulmonary exercise testing CPET is the gold standard measurement of a patient’s fitness. The...

Cardiovascular disease Perioperative cardiovascular complications are frequent. Patients who can ...

Cerebral vascular disease Patients who have su ff ered a cerebrovascular accident have been shown ...

Choosing the right operation for the high-risk patient There are situations in which the selectio...

Drug-eluting coronary stents (DES) Primary percutaneous intervention is the treatment of choice ...

Dysrhythmias In patients with atrial fibrillation (AF), β -blockers, digoxin or calcium channel bl...

EMERGENCY SURGERY In emergency surgery the principles of preoperative assessment should be the s...

Endocrine and metabolic disorders Malnutrition Body mass index (BMI) is weight in kilograms divid...

Examination Patients should be treated with respect and dignity , receive a clear explanation of ...

FURTHER READING Bainbridge D, Martin J, Arango M, Cheng D; for the Evidence-based Peri-operative ...

Factors contributing to risk Risk is a complex interaction of multiple factors that can be class...

Gastrointestinal disease Regurgitation risk Patients undergoing general anaesthesia or sedation h...

Genitourinary disease Renal failure Underlying conditions leading to chronic renal failure such a...

Heart failure Left ventricular failure is the end result of several conditions, including IHD, h...

Hypertension Prior to elective surgery blood pressure should be controlled to <160/100 /uni00A0 m...

Implanted pacemakers and cardiac defibrillators Checks and appropriate reprogramming should be don...

INTRODUCTION The stress of major surgery can lead to increased oxygen demand by up to 40%. Inflam...

Investigations Guidelines produced by the UK’s National Institute for Health and Care Excellence ...

Ischaemic heart disease Patients with angina that is not well controlled should be inves - tigate...

Learning objectives To understand preoperative preparation for surgery: Surgical, medical and ana...

Musculoskeletal disorders Muscular disorders have serious implications and require a tailored ana...

Neurological and psychiatric disorders Anticonvulsants and anti-Parkinson’s medication must be co...

PATIENT ASSESSMENT History taking A thorough past medical history , surgical history and systemic...

PHYSICAL FITNESS Functional physical fitness can be judged by the ability to tolerate metabolic eq...

Respiratory disease Postoperative respiratory complications, such as pneumonia, are a major cause...

Risk prediction The key to managing patients e ff ectively is the identification and accurate quant...

Role of critical care and outreach services Reports from the National Confidential Enquiry into Pa...

Valvular heart disease While anaesthetic management is altered to achieve haemo dynamic stability...

ARRANGING AN ELECTIVE THEATRE LIST The date, place and time of operation should be matched with ...

ASSESSMENT OF RISK Despite more comorbid patients presenting for surgery , the perioperative mort...

Airway assessment The di ffi culty encountered when performing airway manoeu - vres, i.e. hand vent...

COMMON PREOPERATIVE PROBLEMS AND MANAGEMENT Specific medical problems encountered during preopera...

CONSENT Consent is a key part of preoperative care. The process of consent has evolved over the ...

Cardiopulmonary exercise testing CPET is the gold standard measurement of a patient’s fitness. The...

Cardiovascular disease Perioperative cardiovascular complications are frequent. Patients who can ...

Cerebral vascular disease Patients who have su ff ered a cerebrovascular accident have been shown ...

Choosing the right operation for the high-risk patient There are situations in which the selectio...

Drug-eluting coronary stents (DES) Primary percutaneous intervention is the treatment of choice ...

Dysrhythmias In patients with atrial fibrillation (AF), β -blockers, digoxin or calcium channel bl...

EMERGENCY SURGERY In emergency surgery the principles of preoperative assessment should be the s...

Endocrine and metabolic disorders Malnutrition Body mass index (BMI) is weight in kilograms divid...

Examination Patients should be treated with respect and dignity , receive a clear explanation of ...

FURTHER READING Bainbridge D, Martin J, Arango M, Cheng D; for the Evidence-based Peri-operative ...

Factors contributing to risk Risk is a complex interaction of multiple factors that can be class...

Gastrointestinal disease Regurgitation risk Patients undergoing general anaesthesia or sedation h...

Genitourinary disease Renal failure Underlying conditions leading to chronic renal failure such a...

Heart failure Left ventricular failure is the end result of several conditions, including IHD, h...

Hypertension Prior to elective surgery blood pressure should be controlled to <160/100 /uni00A0 m...

Implanted pacemakers and cardiac defibrillators Checks and appropriate reprogramming should be don...

INTRODUCTION The stress of major surgery can lead to increased oxygen demand by up to 40%. Inflam...

Investigations Guidelines produced by the UK’s National Institute for Health and Care Excellence ...

Ischaemic heart disease Patients with angina that is not well controlled should be inves - tigate...

Learning objectives To understand preoperative preparation for surgery: Surgical, medical and ana...

Musculoskeletal disorders Muscular disorders have serious implications and require a tailored ana...

Neurological and psychiatric disorders Anticonvulsants and anti-Parkinson’s medication must be co...

PATIENT ASSESSMENT History taking A thorough past medical history , surgical history and systemic...

PHYSICAL FITNESS Functional physical fitness can be judged by the ability to tolerate metabolic eq...

Respiratory disease Postoperative respiratory complications, such as pneumonia, are a major cause...

Risk prediction The key to managing patients e ff ectively is the identification and accurate quant...

Role of critical care and outreach services Reports from the National Confidential Enquiry into Pa...

Valvular heart disease While anaesthetic management is altered to achieve haemo dynamic stability...

Admission and list planning Day surgery patients should follow the same starvation guidance as an...

Anaesthesia and surgery It is not expected that there should be any di ff erence in surgical techn...

DAY SURGERY In the UK the definition of day surgery is the admission of selected patients to hosp...

DELIVERY OF DA Y SURGERY Facilities National guidance from the Royal College of Anaesthetists, R...

Discharge The expectation by the patient and healthcare team should be that the patient will be g...

EMERGENCY DA Y SURGERY Many emergency surgical procedures are minor and non-life-threatening. Pat...

FURTHER READING Bailey CR, Ahuja M, Bartholomew K et al . Guidelines for day-case surgery 2019: g...

Introduction No content extracted automatically.

Learning objectives To understand: The key components of the day surgery pathway • Which surgical...

Medical With the developments of anaesthesia and surgery , there should be very few restrictions...

Preoperative assessment A key component to successful day surgery is a well-informed, well-prepar...

SELECTION CRITERIA Surgical Surgical techniques have progressed significantly and now cause less p...

Social Social criteria for day surgery include: /uni25CF Adequate housing conditions such as heat...

Chronic pain Chronic pain is defined as pain that persists or recurs for more than 3 months. In ch...

Common local anaesthesia techniques Topical anaesthesia /uni25CF EMLA (eutectic mixture of local...

GENERAL ANAESTHESIA General anaesthesia is commonly described as the triad of unconsciousness, an...

HISTORY Anaesthesia, as we know it today , was first successfully demon strated by William Morton,...

Introduction No content extracted automatically.

KEY PRINCIPLES OF ANAESTHESIA Optimum patient care is dependent on a collaborative approach by th...

LOCAL ANAESTHESIA Local anaesthetic drugs ( Table 23.2 ) may be used to provide anaesthesia and a...

Learning objectives To gain an understanding of: Techniques of anaesthesia and airway maintenance...

Management of the airway during anaesthesia Loss of muscle tone as a result of general anaesthe...

Monitoring and care during anaesthesia A minimum basic monitoring of cardiovascular parameters i...

Muscle relaxation and artificial ventilation Pharmacological blockade of neuromuscular transmissi...

PAIN Pain is defined as ‘ An unpleasant sensory and emotional experience associated with, or resem...

PREPARATION FOR ANAESTHESIA A surgeon’s role is to carry out, in cooperation with the anaes - the...

Pain control in malignant disease Pain is a common symptom associated with cancer, even more so d...

Paracetamol and non-steroidal anti - inflammatory drugs Paracetamol was first synthesised in 1878 b...

Paracetamol and non-steroidal anti - inflammatory drugs Paracetamol was first synthesised in 1878 b...

Principles of chronic pain management Non-pharmacological treatment This involves a multidiscipli...

Regional anaesthesia Regional anaesthesia involves central neuraxial or peripheral nerve or plexu...

Ventilation during anaesthesia Mechanical ventilation is required when the patient’s spon taneous...

Abdominal surgery The abdomen should be examined daily for excessive disten - sion, tenderness or...

Cardiovascular system Thirty per cent of patients undergoing non-cardiac surgery will have at le...

DISCHARGE OF PATIENTS Patients discharged home need a ‘discharge letter’ detailing the postoperat...

Deep vein thrombosis Deep vein thrombosis (DVT) is a well-known and, when complicated by pulmonar...

Drains Drains are used to prevent accumulation of blood and sero sanguineous or purulent fluid. I...

ENHANCED RECOVERY Enhanced recovery is an approach to the perioperative care of patients undergo...

FURTHER READING Goren O, Matot I. Perioperative acute kidney injury . Br J Anaesth 2015; 115 (Sup...

Fever About 40% of patients develop pyrexia after major surgery; however, in most cases no cause...

Follow-up in clinic Patients should be reviewed in clinic if a key decision on management needs ...

GENERAL POSTOPERATIVE COMPLICATIONS Bleeding Postoperative haemorrhage is most common in the imme...

GENERAL POSTOPERATIVE PROBLEMS AND MANAGEMENT This section provides an overview of selected impo...

INTRODUCTION Perioperative care is integrated care delivered to the patient by a multidisciplinar...

Learning objectives To understand: The integrated approach to caring for patients in the • periop...

Neck surgery Patients undergoing neck surgery , e.g. thyroid surgery , must be observed for accum...

Orthopaedic surgery Neurovascular supply to the extremity Patients who have undergone extremity s...

POSTOPERATIVE COMPLICATIONS Postoperative complications are an important cause of morbidity , mor...

POSTOPERATIVE OBSERVATIONS The patient’s vital signs (including pulse, blood pressure and pulse o...

PREHABILITATION The functional capacity of a patient can be reduced following major surgery . Th...

Plastic surgery The viability of flaps is crucial and the perfusion needs to be monitored regular...

Pressure sores Patients undergoing surgery for a prolonged period of time are vulnerable to the ...

Pulmonary embolus PE is not usually an immediate complication but can present in the early postop...

Renal and urinary system Acute kidney injury Renal failure occurring during the perioperative per...

SURGERY-SPECIFIC COMPLICATIONS This section provides an overview of selected important complicat...

SYSTEM-SPECIFIC COMPLICATIONS Respiratory system Early detection of respiratory complications is...

Thoracic surgery Careful fluid management is important in patients undergoing a lobectomy or pneum...

Urology Catheter patency must be checked regularly following urolog ical surgery . In patients wh...

Vascular surgery The patency of grafts and anastomoses, for example femoro popliteal bypasses an...

Wound care Within hours of the wound being surgically closed, the dead space fills up with an infla...

Wound dehiscence Wound dehiscence is disruption of any or all of the layers in a wound. Dehisce...

Abdominal surgery The abdomen should be examined daily for excessive disten - sion, tenderness or...

Cardiovascular system Thirty per cent of patients undergoing non-cardiac surgery will have at le...

DISCHARGE OF PATIENTS Patients discharged home need a ‘discharge letter’ detailing the postoperat...

Deep vein thrombosis Deep vein thrombosis (DVT) is a well-known and, when complicated by pulmonar...

Drains Drains are used to prevent accumulation of blood and sero sanguineous or purulent fluid. I...

ENHANCED RECOVERY Enhanced recovery is an approach to the perioperative care of patients undergo...

FURTHER READING Goren O, Matot I. Perioperative acute kidney injury . Br J Anaesth 2015; 115 (Sup...

Fever About 40% of patients develop pyrexia after major surgery; however, in most cases no cause...

Follow-up in clinic Patients should be reviewed in clinic if a key decision on management needs ...

GENERAL POSTOPERATIVE COMPLICATIONS Bleeding Postoperative haemorrhage is most common in the imme...

GENERAL POSTOPERATIVE PROBLEMS AND MANAGEMENT This section provides an overview of selected impo...

INTRODUCTION Perioperative care is integrated care delivered to the patient by a multidisciplinar...

Learning objectives To understand: The integrated approach to caring for patients in the • periop...

Neck surgery Patients undergoing neck surgery , e.g. thyroid surgery , must be observed for accum...

Orthopaedic surgery Neurovascular supply to the extremity Patients who have undergone extremity s...

POSTOPERATIVE COMPLICATIONS Postoperative complications are an important cause of morbidity , mor...

POSTOPERATIVE OBSERVATIONS The patient’s vital signs (including pulse, blood pressure and pulse o...

PREHABILITATION The functional capacity of a patient can be reduced following major surgery . Th...

Plastic surgery The viability of flaps is crucial and the perfusion needs to be monitored regular...

Pressure sores Patients undergoing surgery for a prolonged period of time are vulnerable to the ...

Pulmonary embolus PE is not usually an immediate complication but can present in the early postop...

Renal and urinary system Acute kidney injury Renal failure occurring during the perioperative per...

SURGERY-SPECIFIC COMPLICATIONS This section provides an overview of selected important complicat...

SYSTEM-SPECIFIC COMPLICATIONS Respiratory system Early detection of respiratory complications is...

Thoracic surgery Careful fluid management is important in patients undergoing a lobectomy or pneum...

Urology Catheter patency must be checked regularly following urolog ical surgery . In patients wh...

Vascular surgery The patency of grafts and anastomoses, for example femoro popliteal bypasses an...

Wound care Within hours of the wound being surgically closed, the dead space fills up with an infla...

Wound dehiscence Wound dehiscence is disruption of any or all of the layers in a wound. Dehisce...

ARTIFICIAL NUTRITIONAL SUPPORT Given the importance of adequate nutrition in recovery from illne...

Anthropometry Anthropometry uses several di ff erent parameters to obtain an estimate of body com...

Biochemistry Biochemical tests can be used in conjunction with clinical history , examination, co...

Clinical evaluation Clinical assessment of nutritional status should begin by consideration of ...

EFFECTS OF INTESTINAL RESECTION ON FLUID AND NUTRIENT ABSORPTION The main role of the intestine ...

EFFECTS OF INTESTINAL RESECTION ON FLUID AND NUTRIENT ABSORPTION The main role of the intestine ...

Enteral nutrition Enteral nutrition (the delivery of nutrients into the gastrointes - tinal tract...

FLUID AND ELECTROL YTE REPLACEMENT Daily fluid balance els Fluid intake consists of liquid ingest...

FLUID AND ELECTROL YTE REPLACEMENT Daily fluid balance els Fluid intake consists of liquid ingest...

FURTHER READING British Association for Parenteral and Enteral Nutrition. Parenteral nutrition . ...

INTRODUCTION Optimal nutritional status, both pre- and postoperatively , is a key factor in reduc...

Learning objectives To understand: The importance of assessment of perioperative nutritional • st...

Metabolic response to trauma and sepsis This is described in greater detail in Chapter 1 , and co...

NUTRITION SUPPORT TEAMS Multidisciplinary nutrition support teams are essential to ensure that al...

NUTRITIONAL ASSESSMENT The nutritional status of an individual can be assessed by the ABCD of an...

NUTRITIONAL REQUIREMENTS Patients who are considered to be unable to consume enough nutrition via...

PHYSIOLOGICAL RESPONSES TO NUTRITIONAL IMPAIRMENT Metabolic response to fasting or starvation The...

PHYSIOLOGICAL RESPONSES TO NUTRITIONAL IMPAIRMENT Metabolic response to fasting or starvation The...

PHYSIOLOGICAL RESPONSES TO NUTRITIONAL IMPAIRMENT Metabolic response to fasting or starvation The...

Parenteral nutrition Indications and composition of parenteral nutrition Nutrition may need to be...

SUMMARY Appropriate and safe assessment and administration of fluid therapy and nutritional sup...

The effect of the metabolic response to surgery on nutrition The metabolic response to surgery is...

The effect of the metabolic response to surgery on nutrition The metabolic response to surgery is...

solutions Intravenous fluid replacement may be necessary in conditions of gastrointestinal absor...

ASSESSMENT AND RESPONSE ASSESSMENT AND RESPONSE ASSESSMENT AND RESPONSE

CONCLUSION Trauma can a ff ect all patient age groups. The severity of injury depends on the type ...

DEFINITION OF TRAUMA Trauma can be defined as an injury to any part of the human body as the resu...

FURTHER READING Department for Transport. Reported road casualties in Great Britain: 2019 annual ...

Introduction No content extracted automatically.

LOCAL PROTOCOLS AND GUIDELINES While the ATLS protocol has become the standard of care for the i...

Learning objectives Become familiar with the timeline concept in trauma • management Understand h...

Planning an individual operation Operative procedures in a multiply injured patient in a crit ica...

THE MAGNITUDE OF THE PROBLEM In western industrialised countries, trauma accounts for the largest...

THE RESPONSE TO TRAUMA Completion of the initial patient evaluation according to the formula (pa...

The assessment of trauma Traditionally , and especially when learning the theory of the various ...

The medical response to injury Initial management After initial assessment of the patient’s cond...

The patient’s response to injury Immediately after the traumatic event, physiological reactions a...

The response to patient factors Injuries presenting with increased frequency in an individual pat...

The response to the mechanism of injury (injury prevention) Not infrequently , two or more patie...

The response to the mechanism of injury (injury prevention) Not infrequently , two or more patie...

The significance of time in the outcome Injuries can happen at lightning speed. Time point 0 (time...

A: Airway with cervical spine control All trauma patients should have their cervical spine immobi...

B: Breathing and ventilation All patients should receive high-flow oxygen. Life-threatening chest ...

C: Circulation and haemorrhage control All patients require adequate intravenous (IV) access with...

D: Disability and E: Exposure On admission, the GCS score should be calculated ( Table 27.1 ), th...

DAMAGE CONTROL SURGERY VERSUS EARL Y TOTAL CARE As discussed in Chapter 26 , the concept of dama...

FURTHER READING Sierink HJC, Treskes K, Edwards MJR et al ., for the REACT-2 Study Group. Immedia...

IDENTIFICATION OF SEVERE TRAUMA The severely injured patient, with multiple injuries to di ff er e...

Introduction No content extracted automatically.

Learning objectives How to identify and assess the severely injured patient • Early treatment goa...

ROLE OF THE TRAUMA TEAM All hospitals managing severe trauma should have a dedicated trauma team ...

SECONDARY SURVEY All severely injured patients require a detailed top-to-toe exam ination after l...

Venous lactate V enous lactate is a useful marker of resuscitation and phys - - iological state....

c: Exsanguinating external haemorrhage Experience from war zones over the past 20 years has shown...

A: Airway with cervical spine control All trauma patients should have their cervical spine immobi...

B: Breathing and ventilation All patients should receive high-flow oxygen. Life-threatening chest ...

C: Circulation and haemorrhage control All patients require adequate intravenous (IV) access with...

D: Disability and E: Exposure On admission, the GCS score should be calculated ( Table 27.1 ), th...

DAMAGE CONTROL SURGERY VERSUS EARL Y TOTAL CARE As discussed in Chapter 26 , the concept of dama...

FURTHER READING Sierink HJC, Treskes K, Edwards MJR et al ., for the REACT-2 Study Group. Immedia...

IDENTIFICATION OF SEVERE TRAUMA The severely injured patient, with multiple injuries to di ff er e...

Introduction No content extracted automatically.

Learning objectives How to identify and assess the severely injured patient • Early treatment goa...

ROLE OF THE TRAUMA TEAM All hospitals managing severe trauma should have a dedicated trauma team ...

SECONDARY SURVEY All severely injured patients require a detailed top-to-toe exam ination after l...

Venous lactate V enous lactate is a useful marker of resuscitation and phys - - iological state....

c: Exsanguinating external haemorrhage Experience from war zones over the past 20 years has shown...

CLASSIFICATION OF HEAD INJURY The severity of head injury is classified according to the post- re...

Concussion, second impact syndrome and postconcussive syndrome Concussion is defined as the altera...

Concussion, second impact syndrome and postconcussive syndrome Concussion is defined as the altera...

Examination: primary survey ATLS guidelines address a fundamental priority: ensuring uninterrupte...

Examination: secondary survey A full secondary survey will be required. Particular attention must...

History Mechanism In moderate and severe TBI, a history must be obtained from witnesses and param...

INTRACRANIAL PRESSURE Intracranial pressure and cerebral blood flow The brain depends on continuou...

INTRACRANIAL PRESSURE Intracranial pressure and cerebral blood flow The brain depends on continuou...

† INTRODUCTION Head injury accounts for 3–4% of emergency department attendances, with around 15...

Learning objectives To be familiar with: The physiology of cerebral blood /f_l ow and the • patho...

MINOR AND MILD HEAD INJURY After exclusion of associated cervical spine injury , it is import - ...

MODERATE AND SEVERE TRAUMATIC BRAIN INJURY Resuscitation and evaluation Resuscitation is performe...

MODERATE AND SEVERE TRAUMATIC BRAIN INJURY Resuscitation and evaluation Resuscitation is performe...

Medical management From initial resuscitation, through surgical intervention and into the subsequ...

Non-accidental injury Head injury in children and vulnerable adults may be due to abuse. Significa...

Surgical pathology Fractures: skull vault Closed linear fractures of the skull vault are managed...

TRAUMATIC BRAIN INJURY IN THE CHILD Head injury in children is common and presents specific chal ...

ABDOMINAL COMPARTMENT SYNDROME AND THE OPEN ABDOMEN Raised intra-abdominal pressure has far-reach...

ABDOMINAL COMPARTMENT SYNDROME AND THE OPEN ABDOMEN Raised intra-abdominal pressure has far-reach...

ANTIBIOTICS IN TORSO TRAUMA There is no level 1 evidence to recommend the use of antibiotics for...

Anatomy The surgical anatomy of the pelvis is key to the understanding of pelvic injuries. /uni...

Biliary injuries Isolated traumatic biliary injuries are rare and occur mainly from penetrating t...

CRITICAL PHYSIOLOGY Resuscitation of all injuries to the chest and abdomen should follow the lat...

Classification Pelvic ring fractures can be classified into three types, using - the Tile classifica...

Clinical examination Pelvic fractures should be easily identified if ATLS guidelines are followed...

Colon Blunt injuries to the colon are relatively infrequent; penetrating injuries occur more ofte...

Computed tomography scan CT has become the ‘gold standard’ for the intra-abdominal diagnosis of i...

DAMAGE CONTROL Following major injury , protracted surgery in the physio logically unstable patie...

Damage control resuscitation The concept of damage control has been broadened to include the tec...

Diagnosis Radiograph Examination of a plain radiograph of the pelvis requires an understanding ...

Diagnostic peritoneal lavage Diagnostic peritoneal lavage (DPL) is a test rarely used in modern-d...

Duodenum Duodenal injury is frequently associated with injuries to the adjoining pancreas. Like t...

EMERGENCY THORACIC SURGERY Emergency thoracic surgery is an essential part of the arma - mentari...

Emergency department thoracotomy or sternotomy Emergency department thoracotomy (EDT) should be r...

INDIVIDUAL ORGAN INJURY Liver Blunt liver trauma occurs as a result of direct injury . The liver...

INJURY MECHANISMS ASSOCIATED WITH TORSO TRAUMA Injury consistently traverses di ff erent anatomi...

INTERVENTIONAL RADIOLOGY Interventional radiology can be useful in the management of torso trauma...

Immediate life-threatening injuries Airway obstruction Early intubation is very important, partic...

INTRODUCTION Injury seldom respects anatomical boundaries, hence the divi sion of the body into ...

Investigation Routine investigation in the emergency department of injury to the chest is based ...

Junctional zones The key junctional zones are: ). /uni25CF between the neck and the thorax; /uni2...

Laparoscopy Laparoscopy or thoracoscopy may be a valuable screening investigation in physiologica...

Learning objectives To understand: The importance of physiology over anatomy in the • management ...

Management The operative management of liver injuries can be summarised as ‘the four Ps’: /uni25...

Planned emergency thoracotomy Planned emergency thoracotomy implies an emergency thora cotomy per...

Potentially life-threatening injuries Thoracic aortic disruption Traumatic aortic rupture is a co...

Rectum Approximately 5% of colon injuries involve the rectum. These are generally from a penetrat...

Renal and urological tract injury In physiologically non-compromised patients, CT scanning with c...

Retroperitoneum Injury to the retroperitoneum is often di ffi cult to diagnose, especially in the p...

Small bowel The small bowel is frequently injured as a result of blunt trauma. - The individual...

Spleen Splenic injury occurs from direct blunt trauma. Most isolated splenic injuries, especially...

Stomach Most stomach injuries are caused by penetrating trauma. Blood presence is diagnostic if ...

Summary In summary , a haemodynamically normal patient can be safely transferred for stabilisatio...

THE PEL VIS Although mortality following severe pelvic fractures has decreased dramatically with ...

THORACIC INJURY Thoracic injury accounts for 25% of all severe injuries. In a - further 25%, it ...

ABNORMAL WOUND HEALING Various factors can adversely a ff ect wound healing ( Summary box 3.1 ). S...

ACUTE WOUNDS Bites Most bites involve either puncture wounds or avulsions. Wounds over the metaca...

Acute compartment syndrome Acute compartment syndrome occurs when there is increased interstitial...

CHRONIC WOUNDS These wounds fail to progress through the normal stages of wound healing in a time...

CLASSIFICATION OF WOUNDS Wounds are diverse and there is no standard classification system that in...

Contractures Scar contractures can cause severe functional, psychological and aesthetic problems ...

Degloving Degloving is the avulsion of skin and subcutaneous fat from the underlying fascia, mus...

Haemostasis Disruption of the vascular endothelium following injury causes vasoconstriction and ...

INTRODUCTION Wound healing is a complex and dynamic biological process. In human adults, the norm...

Inflammation In the early inflammatory phase (days 1–2), platelet activation causes an influx of ...

Learning objectives To understand: Normal wound healing and how it can be adversely • affected Ty...

Leg ulcers 12 In developed countries, the most common chronic wounds It are leg ulcers. An ulcer ...

NORMAL HEALING IN OTHER SPECIFIC TISSUES Bone Bone healing occurs in similar phases to those for ...

NORMAL WOUND HEALING IN SKIN Classically , wound healing has been arbitrarily described in three ...

Necrotising fasciitis This is a severe, rapidly progressing infection of the soft tissue and fas...

Post exposure management for Tetanus Prone Wounds underappreciated and is not as simple as is oft...

Pressure ulcers Pressure ulcers occur over a bony prominence or under a medical or other device (...

Principles Clinical judgement is crucial in managing wounds. Some general principles of wound ma...

Proliferation The proliferative phase starts around day 3 and lasts for 2–4 weeks. It consists ma...

REFERENCES 1 Berard F , Gandon J. Postoperative wound infections: the influence of ultraviolet irr...

Remodelling The remodelling phase begins 2–3 weeks after injury and lasts for a year or more. Thi...

SCAR MANAGEMENT Principles The remodelling and maturation phase of wound healing results in scar...

TYPES OF WOUND HEALING There are di ff erent types of healing ( Summary box 3.2 Primary healing is...

Tendon Although repair follows the normal pattern of wound healing, there are two main mechanism...

WOUND MANAGEMENT Assessment Wound management is guided by the timing and mechanism of injury as w...

A system for evaluation of the lateral cervical spine radiograph 1 Assess prevertebral soft-tissu...

A system for evaluation of the lateral cervical spine radiograph 1 Assess prevertebral soft-tissu...

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy The vertebral column is composed of a...

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy The vertebral column is composed of a...

Atlantoaxial instability This is defined as non-physiological movement between C1 and C2. It can b...

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles Spin...

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles Spin...

Complete versus incomplete spinal cord injury A spinal cord injury is incomplete when there is pr...

Computed tomography Computed tomography (CT) scanning with two-dimensional reconstruction remains...

DIAGNOSTIC IMAGING Plain radiographs A full cervical spine series includes anteroposterior and la...

Dynamic imaging Lateral flexion–extension radiographs of the cervical spine should not be underta...

EVOLUTION OF THE MANAGEMENT OF SPINAL CORD INJURY The development of specialised spinal cord inj...

FURTHER READING American Spinal Injury Association. International standards for neurological clas...

Fractures in patients with ankylosing spondylitis Ankylosing spondylitis is a seronegative inflamm...

INJURY The incidence and causation of spinal cord injury vary globally and reflect the demographi...

Identification of shock Three categories of shock may occur in spinal trauma /uni25CF Hypovolaemi...

Introduction No content extracted automatically.

LEFT Light Touch (LTL) Pin Prick (PPL) C2 C2 C3 C2 C4 C3 Elbow flexors C5 C4 C4 UEL Wrist extenso...

Learning objectives To be familiar with: The accurate assessment of spinal trauma • The basic man...

Magnetic resonance imaging MRI is indicated in all patients with neurological deficit and where as...

Neurological examination The American Spinal Injury Association (ASIA) neurological evaluation sy...

OUTCOME The goal of spinal cord injury rehabilitation is based on a multidisciplinary approach. ...

Odontoid fractures There are three types of odontoid peg fracture ( Figure 30.27 ). Neurological...

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury This is the direct insult to the neural ...

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury This is the direct insult to the neural ...

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury This is the direct insult to the neural ...

PATIENT ASSESSMENT Basic points The Advanced Trauma Life Support (ATLS) principles apply in all c...

PERTINENT HISTORY The mechanism and velocity of injury should be determined at an early stage. A...

PHYSICAL EXAMINATION Initial assessment The primary survey always takes precedence, followed by a...

Prognosis of spinal cord injury Despite continuing improvements in patient care, life expec - tan...

RIGHT Light Touch (LTR) Pin Prick (PPR) C2 C3 C4 C3 Elbow flexors C5 Wrist extensors UER C6 (Upp...

Regional variations Upper cervical spine anatomy is designed to facilitate motion ( Figure 30.3 )...

SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2) Occipital condyle fracture This is a rel...

SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2) Occipital condyle fracture This is a rel...

Spinal examination The overlying skin should be inspected (e.g. for possible penetrating wounds) ...

Spinal neuroanatomy The spinal cord extends from the foramen magnum to the L1/ L2 level, where i...

Spinal stability Spinal stability is the ability of the spine to withstand phys iological loads ...

Subaxial cervical spine (C3–C7) The pattern of lower cervical spine injury depends on the mechan...

The secondary injury Haemorrhage, oedema and ischaemia result in a biochemical cascade that cause...

Thoracic and thoracolumbar fractures The system developed by the AO (Arbeitsgemeinschaft für Oste...

cord injury Pressure ulcers Many are preventable. Patients should be turned regularly on an appro...

CLASSIFICATION OF FACIAL INJURIES Bony injury Maxillofacial bone fractures can be divided into se...

CLINICAL ASSESSMENT History The history should include the mechanism of injury , past medical his...

Dental injuries The first permanent teeth usually erupt around the age of 6 /uni00A0 years; usuall...

EMERGENCY ASSESSMENT AND MANAGEMENT Maxillofacial injuries that require hospital attendance are c...

Examination Primary survey The primary survey is aimed at protection of the airway , control of ...

FURTHER READING Brennan PA, Schliephake H, Ghali GE, Cascarini L. Maxillofacial surgery , 3rd edn...

Introduction No content extracted automatically.

Investigations The nature of the injury sustained will determine the specific investigations requ...

Isolated nasal and nasoethmoidal fractures Isolated nasal bone fractures are common, and the full...

Learning objectives To understand and identify potentially life-threatening • injuries to the fac...

Mandibular fractures Fractures of the mandible are common in the context of facial injury and m...

Orbital fractures Orbital fractures may be isolated or more commonly occur in conjunction with zy...

Panfacial fractures Combined fractures involving multiple levels such as the mandible, maxilla, z...

SPECIFIC INJURIES Soft-tissue injuries Lacerations Soft-tissue injuries of the face are a result...

Soft-tissue injury Lacerations are a result of crushing injuries where the soft tissues are comp...

Zygomatic fractures Zygomatic (cheek/malar) bone fractures are often the result of blunt trauma ...

Achilles tendon rupture Complete rupture of the Achilles tendon is a common injury; 20% of acute...

Ankle fractures Ankle fractures are very common. As with all intra-articular fractures one should...

Bony injury Description Describing the bony injury depends on several characteristics and include...

COMPARTMENT SYNDROME Compartment syndrome is raised pressure in a fascial compart - ment to a lev...

CONCLUSION The correct identification of extremity trauma, combined with timely and appropriate t...

Carpal instability The most commonly involved carpal bone is the lunate. A lunate dislocation is ...

Clavicle fractures Diaphyseal fractures of the middle third of the clavicle have traditionally ...

DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-tissue injury There are several classification s...

DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-tissue injury There are several classification s...

DIAGNOSIS The diagnosis of extremity trauma begins with the taking of a pertinent history follo...

Diaphyseal fractures Extra-articular fractures do not require an anatomical reduc - tion, but rat...

Distal femoral fractures Metaphyseal osteoporotic fractures of the distal femur are amenable to ...

Distal humerus (supracondylar fracture) Supracondylar humeral fractures are very common injuries ...

Distal radial fractures Extra-articular (type A) fractures of the distal radius may displace in a...

Examination An initial general examination, including vital signs and general assessment, should ...

FRACTURE HEALING It is useful to review fracture healing, as it relates to treatment and outcome....

FURTHER READING Blom A, Warwick D, Whitehouse M. Apley’s system of orthopaedics and fractures , ...

Femoral shaft fractures It is possible to treat diaphyseal fractures of the femoral shaft non-op...

Forearm fractures (radius and ulna) Fractures of the diaphyseal shaft of the radius and ulna ar...

Fractures of the proximal humerus In fractures of the proximal humerus consideration is given to ...

Heal Time to fracture healing depends on several factors: patient comorbidities, the age of the ...

History It is important to ascertain the mechanism of injury and the amount of force involved in...

Hold If the fracture fragments are in an acceptable position, or have been reduced into an accep...

Humeral fractures Fractures of the diaphyseal portion of the humeral shaft are extra-articular ...

Intra-articular fractures AO type B and type C fractures are intra-articular and as such the prin...

Intracapsular femoral neck fractures Intracapsular fractures are further broken down into whether...

INTRODUCTION In several chapters the importance of life-threatening trauma is emphasised, but nu...

Investigations The mainstay of extremity trauma investigation remains radi - ography of the a ...

Lateral condylar mass fracture of the elbow Lateral condylar mass fractures of the elbow are eas...

Learning objectives To gain an understanding of: How to identify whether an injury exists • The i...

Metaphyseal fractures In the AO classification metaphyseal fractures are classified into A type – e...

Olecranon fractures Olecranon fractures may be displaced or undisplaced. Undisplaced fractures wi...

Open fractures Any fracture with an overlying wound should be considered an open fracture. The t...

Osteoporotic fractures Osteoporosis is a condition characterised by low bone mineral density and ...

Patellar fractures Similar to olecranon fractures, undisplaced fractures in which the extensor ...

Pathological fractures When abnormal bone fails under normal load this is referred to as a pathol...

Peripheral nerve injury Seddon classified nerve injuries into neurapraxia, axonotmesis and neurotm...

Proximal femoral fractures The blood supply to the femoral head is a prime consideration in treat...

Reduce The first thing to consider is the degree of displacement of the fracture fragments. It is...

SPECIAL CONSIDERATIONS Special consideration needs to be given to osteoporotic and pathological f...

SPECIFIC PAEDIATRIC INJURIES Distal radial fractures Fractures of the distal radius are very com...

SPECIFIC PAEDIATRIC INJURIES Distal radial fractures Fractures of the distal radius are very com...

Slipped upper femoral epiphysis A slipped upper femoral epiphysis classically occurs in a child a...

TO TOE) Scaphoid fracture The blood supply to the scaphoid enters distally and supplies the scaph...

TREATMENT BY FRACTURE LOCATION In general, the principles of treatment described above are depen...

TREATMENT OF FRACTURES IN THE SKELETALL Y IMMATURE The treatment principles that were described f...

TREATMENT The main principle of extremity fracture management builds on the classical concept of...

Talus fracture The talus consists of a head, neck and body . The most common injury is a talar n...

Tarsometatarsal (Lisfranc) joint injuries Injuries to the midfoot are associated with significan...

Terminology of bone healing after fracture Union The fracture has healed su ffi ciently from a clin...

Thumb metacarpophalangeal ulnar collateral ligament Injury to the thumb metacarpal ulnar collater...

Thumb metacarpophalangeal ulnar collateral ligament Injury to the thumb metacarpal ulnar collater...

Tibial plateau fractures Intra-articular fractures of the tibial plateau are common. Injuries ma...

Tibial shaft fractures Tibial fractures in children are often very amenable to non-operative tr...

0 0 I I II II III III Figure 33.7 Triage tags ( (a) courtesy of TACDA & METTAG products, The Amer...

0 I II III First aid Care for patients with minor injuries involves cleaning and dressing wounds,...

COMMON FEATURES OF MAJOR DISASTERS Any event that results in the loss of human life is disastrou...

Coordination with relief agencies A laudable aspect of globalisation is the outpouring of help ...

Crush injury and syndrome A crush injury occurs when a body part is subjected to a high degree of...

DEFINITIVE MANAGEMENT The hospitals designated to undertake de�nitive management should be sele...

DISASTER PLANS Disasters are unforeseen events and planning for them may seem paradoxical. It has...

Damage assessment The first objective in disaster management is an assessment of the damage and t...

Dealing with the media Disasters act like a magnet for the media. In today’s world of 24-hour new...

Debridement Taken from the French, meaning to ‘unleash or cut open’, debridement plays a crucial ...

Designated centres Initially , the casualties may be scattered among many hospitals. After the fir...

Establishment of a national disaster management organisation This is the first step in the plannin...

Establishment of a national disaster management organisation This is the first step in the plannin...

Evacuation of casualties Decisions regarding the best destination for each patient need to be bas...

Evacuation planning Evacuation of large population centres as a prelude to, or in the wake of, a...

FACTORS INFLUENCING RELIEF EFFORTS AND PROVISION OF MEDICAL AID Good communication is critical fo...

FACTORS INFLUENCING RELIEF EFFORTS AND PROVISION OF MEDICAL AID Good communication is critical fo...

FURTHER READING Bartholdson S, von Schreeb J. Natural disasters and injuries: what does a /uni00A...

Facial injuries The management of facial injuries follows the same general principles of debride...

Field hospitals The decision to deploy field hospitals depends on the location, the number of cas...

Frostbite and immersion injuries (trench foot) Frostbite occurs when a part of the body freezes. ...

Gas gangrene (clostridial myonecrosis) Gas gangrene is a dreaded consequence of late-presenting m...

HANDING OVER Follow-up and secondary problems The medical aspect of disaster management does not...

Hospital reorganisation In hospitals receiving mass casualties some reorganisation of services is...

INTRODUCTION Natural disasters provide a constant reminder of the power and capricious nature of...

Learning objectives To recognise and understand: The common features of various disasters • The p...

Limb salvage The Mangled Extremity Severity Score (MESS) and its modi - fications are useful in de...

Management in the field Field hospitals principally function in three main areas ( Table 33.2 ). S...

Mobilising resources The next step is mobilisation of human and material resources appropriate t...

Necrotising fasciitis Necrotising fasciitis is a rapidly spreading infection that produces necros...