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Mind Map for Medical Postgraduate Entrance Examination—General Introduction to Surgery
This is a mind map about the postgraduate entrance examination-a mind map of the general introduction to surgery, including burns, Surgical nutrition, surgical infection, water, electrolyte, acid-base balance disorders, etc.
Edited at 2023-12-11 16:08:42
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Mind Map for Medical Postgraduate Entrance Examination—General Introduction to Surgery
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General Introduction to Surgery
burn
Judgment of injury
burn area
Skill
333567, 3 13 perineums 1, covering the hot butt will cause athlete’s foot, the key to whether the aunt is beautiful or not depends on the thighs, women’s buttocks and feet are as thin, 66 Dashun is smiling
3, 3, 3 → head, face, neck
5→Hands
6→double forearms
7→Both upper arms
3 13 → front of torso, back of torso, both calves
1→Perineum
Cover the hot butt: 5→double buttocks
Athlete's foot: 7→Both feet
Whether an aunt is beautiful or not depends on her thighs: 21→Double thighs
Women’s hips and feet are as thin, 66 Dashun is smiling
6→double buttocks
6→Feet
Notice
Unilateral/bilateral? Women? Palm/back of hand?
Burn depth (third degree to fourth degree)
“The first degree is in the epidermis, the second degree is in the dermis, and the third degree is in the subcutaneous layer.”
"I degree redness, II degree blisters, III degree skin completely damaged"
Shallowness
I degree
Depth of involvement: Superficial layer of epidermis
The germinal layer is healthy
Clinical appearance: erythema
Feeling: Mild allergy, burning sensation
Healing: 1W
Shallow II degree
Depth of involvement: superficial dermis (papillary layer)
germinal layer remains
Temporary appearance
Blisters (serous inflammation)
Redness and swelling of the wound
Feelings: Severe pain, hyperesthesia
Healing: 2W
full regeneration No scars
depth
Deep II degree
Depth of involvement: Deep dermis (reticular layer)
Remaining skin appendages
Temporary appearance
Blisters (serous inflammation)
The wound is red and white
Feelings: Severe pain, numbness
Healing: 3W
III degree
Depth of involvement: full thickness of skin, subcutaneous tissue, fascia, muscles, blood vessels, bones
Temporary appearance
The wound surface is waxy, brown, and charred eschar
embolized dendritic vascular network
Feeling: no pain
Healing: >4W
burn grade
Look at II degree or III degree or the total area of the burn
Mild
II degree
<10%
Moderate
II degree
<30%
III degree
<10%
Severe
II degree
<50%
III degree
<20%
burn area
31~50%
Shock/inhalation injury/complex injury
Extremely severe
II degree
＞50%
III degree
＞20%
burn area
＞50%
Inhalation injury (respiratory burns)
Diagnose based on
Burns that occur in a closed room
Burns on the face, neck, front and chest, especially deep burns around the mouth and nose
Burnt nose hairs, swollen lips, redness, swelling, blisters, and whitening of the mouth and oropharynx
Irritating cough with charcoal particles in the sputum
Hoarseness, difficulty swallowing, pain
Difficulty breathing and/or wheezing
Fiberoptic bronchoscopy (the most direct and accurate): airway mucosa congestion, edema, paleness, necrosis, and shedding
Prevention and treatment of burn shock
Early stage: hypovolemic shock
Late stage: septic shock (major cause of death)
Rehydration
1st 24h
Total fluid volume = II/III degree burn area × body weight (kg) × 1.5ml 2000ml (basic requirement)
Example: 50kg burn area 60%→60×50×1.5 2000=6500ml
Principle: Fast first, then slow
The amount of fluid replacement in the first 8 hours = the amount of fluid replacement in the next 16 hours (half and half, 3250ml)
2nd 24h
Total fluid volume = 1/2 × (II/III degree burn area × body weight (kg) × 1.5ml) 2000ml (basic requirement)
Example: 50kg burn area 60%→60×50×1.5×0.5 2000=4250ml
surgical nutrition
body energy metabolism
Bedridden, no fever or abnormal consumption
BMI＜30
25kcal/kg·d
BMI≥30
70~80% of normal requirement
Elective/deadline surgery
10% more than basic requirement
Severe trauma, multiple fractures, infection
An increase of 20~30% compared with the basic level
Extensive burns
Increased by 50~100% compared to the basic level
Metabolic changes in the body under traumatic stress
Energy metabolic rate↑
←Blood Sugar↑
Source↑
gluconeogenesis
←glycerol←fat mobilization
←AA←Pr decomposition
glycogenolysis
The way to go↓
G oxidation utilization by tissues and organs↓
Glycogen synthesis↓
Peripheral tissue resistance to insulin
nutritional status assessment
clinical examination
Muscle atrophy, hair loss, skin lesions, edema or ascites, signs of essential fatty acid and vitamin deficiencies
Anthropometric measurements
Weight, BMI, skin thickness, arm circumference, hip circumference, grip strength...
Biochemical (laboratory) tests
Plasma Pr, nitrogen balance, total lymphocyte count
parenteral nutrition
way
Center V Pathway
Commonly used Vs: cervical, subclavian, head, and basal V
Indications
Long-term (>2w) parenteral nutrition is required
Patients who require hypertonic nutritional solutions
advantage
The central V tube has a large diameter, fast flow rate, large flow rate, good tolerance to hypertonic fluid, and is less likely to produce V inflammation and V thrombosis.
Can be used repeatedly to avoid pain caused by V puncture
shortcoming
Complications are many and severe and can be fatal
Peripheral V pathway
Commonly used V: upper limb distal V
Indications
Short-term (<2w) parenteral nutrition
advantage
Convenient and safe application, few and mild complications
shortcoming
prone to V inflammation and V thrombosis
Total parenteral nutrition (TPN)
Indications
——Influence the absorption of nutrients in the small intestine
Can't eat
High intestinal fistula, congenital malformations of the esophagus and gastrointestinal tract, short intestine (short bowel syndrome), cancer patients before and after surgery, and severe gastrointestinal reactions during radiotherapy and chemotherapy
severe burns, infection
The gastrointestinal tract needs rest
Ulceration, severe pancreatitis
Notice
TPN is not required after external colon fistula and cholecystostomy surgery
complication
Intravenous catheter related
non-infectious
PICC intraoperative pneumothorax (most common)
Supplementary routine chest X-ray
After PICC surgery
Osteosarcoma
Closed chest drainage before extubation
Air embolism (most severe)
Blood vessel and nerve damage
Infectious
Central V line-related infection (catheter sepsis)
metabolic
Glucose metabolism disorders (most common)
→Hyperglycemia (hyperosmolar hyperglycemia syndrome), hypoglycemia
Hypophosphatemia (phosphate consumption in glucose metabolism)
Organ (liver) damage and cholestasis
Lack of food stimulation in the intestines due to long-term fasting
Gastrointestinal hormones (eg.CCK, gastrin)↓
CCK↓→Cholestasis→Bacterial infection→Acalculous cholecystitis (5%)
gastrointestinal mucosal atrophy
→Intestinal epithelial permeability↑—Bacterial translocation→Portal V→Liver damage
Parenteral nutrition solution does not contain glutamine (Gln)
Intestinal mucosal epithelium c70% energy source
Gln→Glu→α-ketoglutarate→tricarboxylic acid cycle
Intestinal mucosal epithelial c proliferation raw materials (i.e., purine and pyrimidine synthesis)
Excessive energy supply, inappropriate nutrient intake → G overload (hyperglycemia)
→Fat↑→Fatty liver
→Hypophosphatemia
metabolic bone disease
Gastric acid↓→Ca2 ↓→PTH↑→Bone calcium loss→Osteoporosis→Pathological fracture→High calcium
Pain treatment and perioperative management
Three-step therapy for cancer pain
The basic principle
Choose analgesics based on pain level
Generally administered orally (not intramuscular injection, intravenous infusion)
Administration on time (Q12h, Q8h)
personalized medicine
three steps
mild pain
NSAIDs (ibuprofen)
moderate pain
Weak opioid (codeine)
severe pain
Strong opioids (morphine)
perioperative period
concept
Preoperative preparation
Hyperthyroidism/pheochromoma
intraoperatively
Postoperative: Recover as soon as possible
Classification of surgical procedures
emergency surgery
Do it immediately (life threatening)
Traumatic intestinal, spleen, liver rupture, strangulated hernia
Time-limited surgery
do it as soon as possible
Malignant tumors—radical surgery for x-carcinoma, etc.
elective surgery
Do it "whatever"
Benign Tumor - Thyroid Adenoma Removal
Preoperative preparation
Gastrointestinal tract preparation
Start fasting 8 to 12 hours before surgery and stop drinking water 4 hours before surgery.
Purpose
Prevent vomiting during anesthesia → suffocation and aspiration pneumonia
gastrointestinal surgery
Pyloric obstruction surgery
Gastrointestinal decompression (gastric tube placement), gastric lavage before surgery (warm NS)
Correcting hypokalemic and hypochloremic alkalosis
No need for routine use of antibiotics before surgery
colorectal surgery
Take oral antibiotics and laxatives 2 to 3 days before surgery
Start taking liquid food 2 to 3 days before surgery
Cleansing enema 1 day before surgery or early morning on the same day
Anti-tumor drugs should not be used during colon cancer surgery (to avoid necrosis, perforation, and adhesion)
High blood pressure
Continue taking high blood pressure medication to avoid withdrawal syndrome
If Bp is less than 160/100mmHg, no special preparation is required (it is not required to lower it to normal before surgery)
Bp>180/100mmHg, choose appropriate antihypertensive drugs to stabilize blood pressure, not required to lower to normal
If Bp rises sharply when entering the operating room, you should work with the anesthesiologist to decide whether to perform the operation now or postpone it based on the condition and nature of the operation.
renal insufficiency
Patients with severe renal impairment can tolerate surgery under effective dialysis treatment.
diabetes
Those who are on a diet, no special preparation is required before surgery
Oral hypoglycemic drugs should be maintained until the night before surgery, and long-acting drugs should be discontinued 2 to 3 days before surgery.
Fasting patients need to inject G I intravenously to maintain a mild increase in blood sugar (5.6~11.2mmol/L)
In severe cases, GI maintains blood sugar at 7.77~9.99mmol/L
Coagulopathy
When plt＜50×10^9/L, platelet transfusion is recommended
Major surgery/surgery involving blood vessels, plt>75×10^9/L
Nervous system surgery, plt>100×10^9/L
Appropriate treatment before elective surgery
Postoperative treatment
surgical drainage
drainage
infectious pus
Non-infectious fluids: oozing blood/fluid, tissue fluid, bile...
Purpose
Treatment of disease (not prevention)
eg. Anastomotic leakage
Drainage tube removal
Latex sheet: 1~2d
Cigarette: 3d
T tube: 4w pull out (2w)
Gastrointestinal decompression tube: after defecation and exhaustion
Postoperative diet - abdominal surgery
Fasting for 1 to 2 days
Eat liquids after anal defecation and exhaustion (usually 3 to 4 days)
Semi-liquid diet for 5 to 6 days
Eat regular food for 7 to 9 days
Postoperative position
"The waist is numb and flat, the neck and chest are high, the abdomen is low, and both sides are curled up."
Postoperative suture removal time
Head, face and neck surgery: 4 to 5 days
Lower abdominal and perineal surgery: 6 to 7 days
Chest, upper abdominal, back, buttock surgery
7~9 days
Extremity surgery: 10~12 days
Tension-reducing sutures: 14 days
Incision classification
Category I
Clean (sterile) incision
eg. Subtotal thyroidectomy
Category II
possible contamination gap
parts
Stomach/small intestine
time
<6~8h wound debridement and suturing
eg. Major gastric resection
Class III
contaminated incision
parts
Large intestine/appendix
time
>8h wound debridement and suturing
eg. Radical resection of colon cancer, appendiceal perforation, appendectomy, intestinal obstruction and necrosis
Healing grade
Class A healing
No adverse reactions
Class B healing
No suppuration
Redness, swelling, induration, hematoma, effusion, etc.
Class C healing
suppuration
Postoperative complications and prevention and treatment
postoperative bleeding
Incomplete intraoperative bleeding
Wound bleeding is not completely controlled
Original spasm small A (stump) diastole
Coagulation disorders, etc.
Fever (most common)
Non-infectious fever (absorptive heat)
Early, average 1.4 days after surgery
infectious fever
late, an average of 2.7 days after surgery
surgical infection
Classification
According to pathogenic bacteria/nature
Non-specific (general/purulent) infection
Boils, carbuncles, acute mastitis - Staphylococcus aureus
Erysipelas – Streptococcus
Acute appendicitis - Escherichia coli
specific infection
"Sister Feng is so bad and greedy."
Tuberculosis, tetanus, gas gangrene, anthrax, candidiasis
Characteristics of pus caused by bacterial infection
Staphylococcus aureus: pus is thick, yellow, not smelly, and small in amount
Hemolytic Streptococcus: pus is thin, light red, and abundant
Escherichia coli Anaerobic bacteria: thick, foul-smelling pus
Pseudomonas aeruginosa (Pseudomonas aeruginosa): more common in infections after large burns, sweet and fishy odor
Proteus: Fecal odor, three low symptoms
Bacteroidetes: foul odor
According to disease course
Acute: <3w
Subacute: 3w~2m
Chronic: >2m
V.S. Leukemia does not look at time but at cell classification
According to the conditions of infection
Conditional (opportunistic) infections
Superinfection (alternation of flora)
nosocomial infection
Superficial tissue bacterial infection
Boils and carbuncles
Purulent inflammation caused by Staphylococcus aureus infection
boil
Involves a single hair follicle
Symptoms: Mild systemic reaction
Good hair: head, face, neck and back
Anti-infection ability ↓ (eg. diabetics)
Appearance: small induration (redness, swelling, heat and pain (yellow-white pus plug))
treat
Physics, Chinese medicine, physiotherapy
When there is a pus spot or a fluctuating sensation on the boil, you can apply iodophor or use a needle tip to remove the pus plug (squeezing is contraindicated)
carbuncle
Involves multiple hair follicles
Symptoms: severe systemic reaction
Favorable hair: thicker skin on the back of the neck
Appearance: Small patches of hard swelling
treat
When there is only redness and swelling in the early stage, 50% magnesium sulfate wet compress can be used
Antibiotic treatment (penicillin), incision and drainage if necessary
Incision is contraindicated for lip abscesses (leaving scars)
Make a " " or " " shaped incision under intravenous anesthesia. The incision line should reach the healthy tissue at the edge of the lesion (that is, the incision line should exceed the skin at the edge of the lesion). The depth must reach the base of the carbuncle (deep fascia layer). For purulent but devitalized tissue, the abscess cavity is filled with physiological saline, iodophor, and Vaseline gauze, and is wrapped with a dry gauze bandage.
The incision after carbuncle incision and drainage is never sutured
eg. Middle-aged and elderly people often have a history of diabetes. A small patch of skin on the back of the neck is hard, swollen, hot and painful. The wound may be honeycomb-shaped. Chill and fever.
Dangerous triangular furuncle on face
The triangle area from both sides of the mouth to the root of the nose
Improper treatment (when squeezing) → medial canthus V, facial V → intracranial cavernous V sinus → purulent cavernous V sinusitis
Progressive swelling of the face, chills, high fever, headache, vomiting, coma and even death
Acute cellulitis (suppurative inflammation)
Pathogenic bacteria
Hemolytic Streptococcus (major)
Secrete hyaluronidase → Decompose extracellular matrix → Inflammation is not easily localized (diffuse), unclearly separated from normal tissue, and spreads rapidly → Extensive subcutaneous tissue inflammation, exudation, and edema within a short period of time, leading to systemic inflammatory response syndrome (SIRS) , endotoxemia (negative blood culture)
Staphylococcus aureus
Secretion of plasma coagulase (fibrinogen → fibrin) → the lesions are more localized → loose connective tissue is involved → the lesions are diffuse, unclear boundaries, and easy to spread
Escherichia coli
Anaerobic bacteria, etc.
Temporary appearance
Gasogenic subcutaneous cellulitis
Does not invade muscle layer
Mainly anaerobic bacteria → gas production → subcutaneous crepitus may be present
gas gangrene
Invasion into the myometrium
treat
antibacterial drugs
Penicillin or cephalosporin Metronidazole (anaerobes)
local treatment
Early stage (no abscess formed)
50% magnesium sulfate wet compress traditional Chinese medicine
Late stage (abscess formation (fluctuating feeling)
Incision and drainage should be performed promptly
special type
Floor of mouth, submandibular cellulitis
Temporary appearance
More common in children
Can quickly spread to the throat → laryngeal edema and compress the trachea
The skin under the jaw is slightly red and warm, but the swelling is obvious, accompanied by high fever, shortness of breath, difficulty swallowing, inability to eat, and swelling of the floor of the mouth.
Infection often spreads to the submandibular or deep neck, and can involve the connective tissue under the submandibular or behind the platysma muscle, and even the mediastinum, causing difficulty in swallowing, breathing, and even suffocation.
treat
Incision and decompression should be performed as soon as possible to prevent laryngeal edema and tracheal compression (inhalation injuries should also be incised as soon as possible)
Erysipelas (non-suppurative inflammation)
"alone"
Easy to cure, but easy to relapse
Pathogenic bacteria
beta-hemolytic streptococci
→Lymphatic network→Acute non-suppurative inflammation
Predisposed areas
Skin lesions of lower limbs ← toes/tinea pedis
Facial ← Mouth Ulcer/Sinusitis
Temporary appearance
local
Flaky skin rash with slightly raised (lymphatic network), bright red color, clear border, fever - recurring → lymphatic obstruction → elephantiasis
"Dan"
V.S. Filariasis
No suppuration or necrosis
whole body
The onset is sudden, the systemic inflammatory response is obvious, and there are chills, fever, headache, etc. at the beginning - severe → sepsis
"poison"
prevention
Pay attention to skin cleanliness and treat small wounds promptly (predisposing factors)
Doctors should wash their hands and disinfect before and after contacting patients/changing dressings
Actively treat tinea pedis, oral ulcers, sinusitis, etc. (predisposing factors)
treat
Rest in bed and elevate the affected limb
Topically apply 50% magnesium sulfate wet compress
Systemic antibiotics: penicillin/cephalosporin preferred
No need for incision and drainage
V.S. tuberculosis cold abscess should never be incised and drained in the early stage (sinus tract that does not heal for a long time)
Tubular lymphangitis (non-suppurative inflammation)
Pathogenic bacteria
beta-hemolytic streptococci
Staphylococcus aureus
Temporary appearance
Lesions are more common in the limbs, more commonly in the lower limbs
The superficial lesions appear like "red lines" on the epidermis and are tender to touch. When they expand, the red lines extend toward the proximal end - "red silk boils"
Lymphangitis deep under the skin does not show red lines, but may have strips of tenderness.
treat
Treatment of primary infection (main)
Local 50% magnesium sulfate wet compress
Systemic antibiotics: penicillin
Pus needs incision and drainage
Acute purulent bacterial infection of hands
What hand infections have in common
The main pathogenic bacteria are Staphylococcus aureus
Make a longitudinal incision and elevate the affected hand
It is strictly forbidden to cut the swollen back of the hand
Paronychia and purulent dactylitis
Paronychia
Finger trauma (hangnail/nail cutting too deep) → Redness, swelling, heat and pain in the nail groove (next to it) - spreading → nail root
→Contralateral inferior nail groove
→Semi-circular abscess
purulent dactylitis
Injury to the distal part of the finger (fish stab injury) → redness, swelling, heat and pain at the distal part of the finger
treat
Paronychia
Not yet pus
Traditional Chinese Medicine Physical Therapy Oral Antibiotics
Has turned into pus
Incision and drainage (longitudinal incision along the nail groove)
purulent dactylitis
Initial episode: Suspension of the forearm, placing the affected hand flat, antibiotics and traditional Chinese medicine
If the affected finger is severely painful and swollen, accompanied by systemic symptoms, timely incision and drainage should be performed to prevent phalangeal necrosis (tissue pressure ↑ (the most common complication) and osteomyelitis
Once pulsating tenderness occurs, incision and decompression should be performed as soon as possible even if there is no fluctuation.
V.S.
Compartment syndrome, ACS, AOSC
acute hematogenous osteomyelitis
Cervical spondylotic myelopathy, tension pneumothorax, postoperative thyroid hematoma
Incision and drainage
Do not use nerve block anesthesia near the lesion to prevent the spread of infection
Make a longitudinal incision on the side of the distal finger
The distal end does not exceed 1/2 of the nail groove
The proximal end does not extend beyond the knuckle crease
Avoid fish-mouth incisions
Avoid large scars that may limit finger function
For larger abscesses, mouth drainage is required
Acute bacterial infection of palmar space
After forming an abscess, it enters the tendon sheath, synovial bursa, and space.
Thenar space infection → cannot palm
Infection of the space in the palm → limited movement of the 3rd, 4th, and 5th fingers
systemic infection
Overview
sepsis
Refers to a systemic inflammatory response caused by pathogenic bacteria, leading to life-threatening organ dysfunction
bacteremia
Those with positive blood cultures are a type of sepsis
Harmful factors of systemic infection on the body
Pathogens and metabolites
endotoxin
Exotoxins
inflammatory mediators
Common pathogenic bacteria
G-bacteria
Contemporary infections with G-bacilli exceed G-cocci
Common: Escherichia coli, Pseudomonas aeruginosa, Proteus, Klebsiella, Enterobacter
Main causative factor: endotoxin
G-bacteria sepsis is generally more serious and may occur with three low phenomena (low body temperature, low WBC, and low BP), and septic shock is more common.
G cocci
Staphylococcus aureus is multidrug-resistant and often causes metastatic abscesses (easily spreads through hematogenous dissemination).
Staphylococcus epidermidis easily adheres to medical plastic products such as intravenous catheters (PICCs), which can avoid the body's defenses and antibiotic effects
It is difficult to find the primary focus of enterococcal sepsis, and the drug resistance is strong, which may come from the intestines
non-spore-forming anaerobic bacteria
Common Bacteroides, Clostridium, etc.
Multiple simultaneous aerobic bacterial infections
Pus may have a foul odor
Fungi
Conditional infection
Difficult to detect in blood culture
Granulomas or necrosis may form, leading to vascular embolism
Temporary appearance
G cocci sepsis
Common pathogenic bacteria
Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus
toxin
Exotoxins
Common
rash
Metastatic abscess (common with Staphylococcus aureus)
Complicated myocarditis
Delirium and coma
Rare
Three lows
Chills
Cold limbs
Oligouria and anuria
hot type
Jiliu Fever/Zhang Chi Fever
septic shock
late, short
G-bacteria sepsis
Common pathogenic bacteria
Escherichia coli, Pseudomonas aeruginosa, Proteus, Klebsiella
toxin
endotoxin
Rare
rash
Metastatic abscess (common with Staphylococcus aureus)
Complicated myocarditis
Delirium and coma
Common
Three lows
Chills
Cold limbs
Oligouria and anuria
hot type
intermittent heat
septic shock
Early, long
fungal sepsis
Similar to G-bacteria sepsis
Candida albicans (conditional pathogenic), more common after long-term use of antibiotics
Sudden chills, high fever, rapid disease progression
Accompanied by apathy, shock and coma
Peripheral blood WBC↑↑ often reaches 25×10^9/L (leukemia-like reaction)
V.S.NAP↑
A small number of patients have gastrointestinal bleeding (stress ulcers)
Very easy to misdiagnose, treatment with amphotericin B
Spore-forming anaerobic infection
Trauma-related specific infections
tetanus
Pathogenic bacteria: Clostridium tetani
G Anaerobic bacteria, Bacillus
Found in soil, human and animal feces, and rust
Cannot invade normal skin and mucous membranes, can only invade through wounds
Spores→deep narrow hypoxic wound→proliferating body—production→exotoxins→
Hemolytic toxin
convulsant toxin
Imaging vesicle placement, Gly release during return inhibition ↓→α motor N element/anterior horn of spinal cord involvement→skeletal muscle tonic contraction, paroxysmal spasm
Into the blood→toxemia
Bacteria do not enter the blood
Temporary appearance
Spasm toxin (exotoxin) →
Sympathetic N ( )→BP↑, HR↑, T↑, sweating
Tonic contractions and paroxysmal spasms of striated muscles (skeletal muscles)
Typical sequence of symptom stages
①Masticatory muscles (masseter) → difficulty opening mouth (trismus)
First to be affected
②Facial expression muscles→wry smile face
③Neck, back, abdomen, and limb muscles → opisthotonus
Decerebrate rigidity, opisthotonus too
④Intercostal muscles, diaphragm→difficulty in ventilation (apnea)
leading cause of death
Clinical seizure characteristics
Paroxysmal: each attack lasts from seconds to minutes
Sound, light, vibration, and touch can all induce
Muscles cannot fully relax between attacks
The patient is always conscious and generally does not have high fever
Prevention and treatment
Prevention (most important)
avoid trauma
Treat wounds correctly
Early and thorough debridement
The most critical preventive measures
Improve local circulation and eliminate anaerobic environment
Rinse with 3% hydrogen peroxide (the preferred rinse solution)
—H2O2 enzyme →H2O O2↑
Eliminate anaerobic environment
Immunotherapy
active immunity (antigen→antibody)
Antigen (tetanus toxoid)—stimulates → the body produces antibodies
Basic immunity: diphtheria-tetanus pertussis vaccine
Intensive injection: 0.5ml of toxoid is injected subcutaneously every 5 to 7 years on the basis of basic immunity.
passive immunity (Antibody)
Antibodies (TAT, TIG) → direct application in human body
Tetanus Antitoxin (TAT)
If you did not receive active immunization before the injury, inject TAT as soon as possible
Active immunity throughout the pre-injury process: using toxoid
Human Tetanus Immune Globulin (TIG)
Currently the best, with a long action time of 4~5w
10 times more efficient than TAT
treat
Remove sources of toxins, treat wounds, and provide adequate drainage (early debridement)
Administer immune preparations (TIG, TATA): neutralize free toxins
Control and relieve spasms, prevent suffocation, keep the respiratory tract open, and prevent complications
The most critical treatment
Antibiotics: Penicillin, Metronidazole (most effective)
After admission, stay in an isolation ward to avoid sound and light stimulation and interference.
gas gangrene
Pathogenic bacteria: Clostridium perfringens
G Anaerobic bacteria, Bacillus
Invasion from wounds, survival in hypoxic environment
Severe myonecrosis, myositis (characteristic)
Often mixed infections
secondary peritonitis, too
Spores—hypoxia→invade the wound→decompose G and Pr→H2S↑
→Stink
→Tissue swelling, tension ↑↑, subcutaneous emphysema, crepitus
Exotoxins
alpha toxin
Hemolytic toxin
enzyme
lecithinase
Pancreatitis, too
→RBC (hemolysis) →jaundice
→MyoC→Myonecrosis
Hyaluronidase
→Inflammation easily spreads through tissue gaps
Temporary appearance
Affected limb is heavy
Severe swelling-like pain, general analgesics are ineffective
The degree of pain and swelling of the patient is not proportional to the degree of trauma
V.S.
Viral myocarditis: T and P are not parallel
Intestinal stroke: symptoms don’t match up
Acute pancreatitis: Serum amylase is not parallel to the condition
Hepatocellular carcinoma: ALT separated from AFP
"Balloon-like" swelling and marble-like markings (pale-dark red-purple-black) around the wound
“cooked beef”-like myonecrosis in the wound
Air between tissues (crepitus)
Foul-smelling bloody exudate from the wound
alpha toxin
RBC membrane destruction - intravascular hemolysis
anemia
jaundice
Hemoglobinuria (soy sauce color)
Vascular endothelium c——vascular permeability↑
Severe toxemia, rapid onset of toxic shock
Prevention and treatment
prevention
Early and thorough debridement and drainage
The most critical preventive measures
High-dose antibiotics: penicillin, metronidazole
treat
Surgical treatment (debridement)
Complete removal of necrotic tissue and fasciotomy for decompression
The most critical treatment measures
Open the wound, flush it with hydrogen peroxide, and drain it thoroughly
Amputate limbs if necessary to save lives
antibiotic
Penicillin (preferred), metronidazole
Aminoglycosides are ineffective (against G-bacteria)
hyperbaric oxygen therapy
V.S. Spinal cord injury, cervical spondylotic myelopathy, CO poisoning, thromboangiitis obliterans
supportive care
Early incision and drainage
General law
Fluctuating sensation - incision and drainage
special
Tetanus prevention, gas gangrene
Early and thorough debridement, incision and drainage (the key to preventing attacks)
Acute cellulitis, boils, carbuncles, acute mastitis...
Early stage (pre-pus): topical antibiotics
Late stage (pus has formed): incision and drainage
submandibular cellulitis
Early incision and drainage (to prevent suffocation)
Paronychia, purulent dactylitis, purulent tenosynovitis
If swelling and pain are obvious, perform incision and drainage
erysipelas
No need for incision and drainage (no suppuration)
cold abscess
Anti-tuberculosis treatment Lesion debridement (early incision and drainage is not suitable (to prevent the formation of permanent sinus tracts)
Only incision and drainage should be performed if the symptoms of systemic poisoning are obvious.
Water, electrolyte, acid-base balance imbalance
dehydration
Temporary appearance
Sunken eye sockets, clammy extremities, low blood pressure, etc.
The most important treatment measures: Treat the primary disease
Normal osmotic pressure: 280~310mmol/L
Commonly used clinical isotonic solutions
0.9%NaCl solution (NS)
Mass fraction: 0.9g/100ml → Number of ions: 9g/58.5×2×1000=307mmol/L
5% glucose
1.87% sodium lactate
1.4%NaHCO3
Ringer's solution
Isotonic dehydration (most common)
Acute (short-term) dehydration
acute intestinal obstruction
Acute massive vomiting and diarrhea
Extensive burns
Water and sodium are lost in equal proportions
Serum sodium is normal (135~150mmol/L)
Blood volume ↓ (hematoconcentration) → blood pressure ↓ (hematocrit ↑)
No thirst in early stage (can be present in shock)
Features
Mainly extracellular fluid decreases (intracellular fluid also decreases)
Interstitial fluid and plasma are lost in equal proportions (hemoconcentration)
Treatment: Rehydration
Preferred balanced salt solution - Ringer's solution (sodium lactate (same ion concentration as plasma)
V.S. Not suitable for diabetes, prone to lactic acidosis
Second choice normal saline (NS) - 0.85% NaCl (0.9% NaCl) solution
→[Cl-]154mmol/L>Plasma (103mmol/L)
Large amounts of NS infusion can lead to hyperchloremic acidosis
hypotonic dehydration
Long-term, recurring chronic dehydration
gastrointestinal decompression
long term vomiting
Loss of large amounts of digestive juices
Just add water
Sodium loss > water loss
Serum sodium <135mmol/L
No thirst in early stage (can be present in shock)
Features
Mainly reduced extracellular fluid (slightly increased intracellular fluid (compared to isotonic))
The proportion of tissue fluid loss is greater than that of plasma
Treatment: Rehydration (preferred)
Preferred hypertonic solution (eg.5%NaCl solution/5%GNS)
5%GNS=5%G NS: 1 part solution, 2 parts solute → hypertonic
0.9%NaCl≈1gNaCl/100ml
Amount of sodium supplement = [normal blood sodium value - measured blood sodium value] × body weight (kg) × 0.5
1gNaCl=1/58.5×100=17mmolNa
eg. Female patient, weight 60kg, serum sodium 130mmol/L Amount of sodium supplement=(142-130)×60×0.5=360mmolNa 360mmolNa /17=21g NaCl
Rehydration method
Make up half of it on the same day (eg.10.5gNaCl)
Normal physiological requirement 4.5gNaCl
15gNaCl≈1500ml5%GNS
hypertonic dehydration
Esophageal cancer (difficulty eating and drinking)
Profuse sweating, extensive burns (excessive water loss)
Hyperosmolar hyperglycemic syndrome - large amounts of fluids, NS is preferred
Water loss > Sodium loss
Serum sodium＞150mmol/L/plasma osmotic pressure＞310mmol/L
→ADH↑
→thirst
→Urine specific gravity↑ (concentrated urine)
Features
Mainly reduced intracellular fluid
A small amount of tissue fluid and plasma are lost in equal proportions
Treatment: Rehydration
Hypotonic (0.45%)NaCl/5%G is preferred
potassium disorder
Normal blood potassium value: 3.5~5.5mmol/L
Hypokalemia
Cause
Chronic undereating
Long-term and recurring vomiting
Excess potassium excretion
Apply large amounts of potassium-depleting diuretics: furosemide, indapamide
Diarrhea caused by acute gastroenteritis
Temporary appearance
skeletal muscle
Fatigue (earliest onset): first the limbs, then the trunk, and finally the respiratory muscles
V.S.Tetanus
Tendon reflex (knee reflex)↓
Smooth muscle (gastrointestinal): intestinal paralysis
Myocardium: Arrhythmia, U wave appears
Alkali substitution, paradoxical aciduria (Na-K competes with Na-H)
treat
Treatment of primary disease (most important)
Potassium supplement
KCl solution is diluted and intravenously dripped
Supplement potassium 40~80mmol (3~6gKCl) every day
1gKCl=13.4mmolK
Potassium supplement concentration: should not exceed 40mmol/L (3gKCl/L)
Potassium supplementation rate: ≤20mmol/h (1.5gKCl/h)
Potassium supplementation in urine
hyperkalemia
Cause
Use potassium-sparing diuretics: spironolactone
Inject a large amount of stock blood (RBC destroys K release)
Crush syndrome (dissolution and destruction of skeletal muscle)
Temporary appearance
heart
Mild hyperkalemia
Excitability↑
Resting potential and threshold potential distance↓
Significantly high potassium
Cardiac arrest (most dangerous)
Na channel inactivation
ECT: Arrhythmia, high peak T wave
Acid substitution, abnormal alkaline urine
treat
Immediately stop taking all potassium-containing drugs and foods
Heart protection: 10% calcium gluconate diluted and intravenously injected
Potassium lowering measures
Move into the cell
Correct acid migration and promote migration: 5% NaHCO3 solution
Metabolic shift: Insulin G
Potassium-depleting diuretic: furosemide
Oral potassium-lowering resin
Acid-base imbalance
Normal pH 7.35~7.45, HCO3-/H2CO3=20:1
Acid substitution (most common)
Blood HCO3-＜22mmol/L
Cause
DKA
Temporary appearance
Mild: no obvious symptoms
Severe
Breathe deeply and quickly (kussmaul breathing)
H ↑Stimulate peripheral respiratory center
Rotten apple flavor (keto flavor)
treat
Treatment of the cause (primary)
No need to supplement alkali in early stage
Alkali supplementation → oxygen dissociation curve shifts to the left → tissue hypoxia
When plasma HCO3-＜10mmol/L, fluids and alkaline drugs should be infused immediately
substitute alkali
Blood HCO3->27mmol/L
Cause
Hypokalemia
Pyloric obstruction
Transfuse large amounts of stored blood
Secondary: hyperkalemia (RBC destruction) → acidosis (compensatory, mild)
Mainly: sodium citrate (anticoagulant)—intrahepatic metabolism→HCO3-↑→alkali substitution
2,3-DPG↓→Oxygen dissociation curve shifts to the left
Temporary appearance
Generally there are no obvious symptoms, sometimes breathing becomes shallow and slow (reduces CO2 discharge, maintaining 20:1)
treat
Treatment of the cause (primary)
Pyloric obstruction, excessive gastric juice loss leading to hypokalemia and hypochloral alkalosis
NS/5%GNS KCl
eg.500mlNS 1.5gKCl
Severe alkalosis (blood HCO3-45~50mmol/L, pH>7.65)
Dilute HCl solution
Acid breath
PaCO2>45mmHg (normal 35~45mmHg)
Cause
Pulmonary ventilation↓
AECOPD
severe asthma
Scoliosis
treat
Treatment of the cause (primary)
Improve ventilation
Ventilator, airway dilation, respiratory stimulants
Respiratory alkali
PaCO2<35mmHg (normal 35~45mmHg)
Cause
Pulmonary ventilation↑↑
Improper use of ventilator
Hysteria
hyperventilation
Temporary appearance
Alkalosis → Hypocalcemia → Neuromuscular excitability ↑ → Numbness at the corners of the mouth, twitching of the limbs, and pins and needles
Asepsis, blood transfusion, shock, anesthesia, see memory skills
Narcotics
The ester ester is decomposed by choline, and the remaining amides are less allergic
Puka is safe and not anesthetic, but Dinka is highly toxic.
Lido is all-purpose for spinal anesthesia and childbirth analgesia.