RACS GSSE cheat sheet

ATLS primary survey order: catastrophic haemorrhage control, Airway with cervical spine protection, Breathing and ventilation, Circulation with haemorrhage control, Disability (GCS/pupils), Exposure with prevention of hypothermia.

Shock index = heart rate / systolic blood pressure; a value above 0.9 in trauma suggests occult hypoperfusion and need for blood products rather than crystalloid.

Permissive hypotension targets systolic BP ~80-90 mmHg in penetrating trauma without head injury; avoid in traumatic brain injury where cerebral perfusion pressure must be maintained.

Massive transfusion protocol ratios approximate 1:1:1 (packed red cells : fresh frozen plasma : platelets); give tranexamic acid 1 g within 3 hours of trauma, then 1 g over 8 hours.

Surgical site infection prevention: parenteral antibiotic within 60 minutes of incision (120 minutes for vancomycin/fluoroquinolones), re-dose at two half-lives or after 1500 mL blood loss, maintain normothermia and normoglycaemia.

Anastomotic leak typically presents day 5-8 postoperatively with tachycardia, fever, ileus, rising CRP and lactate; CT with water-soluble contrast is first-line imaging.

Wound classification: clean, clean-contaminated, contaminated, dirty; only clean-contaminated and above require therapeutic or extended prophylaxis.

Enhanced recovery principles: carbohydrate loading up to 2 hours preoperatively, avoidance of routine nasogastric tubes and drains, multimodal opioid-sparing analgesia, early feeding and mobilisation.

Sepsis-3: sepsis = life-threatening organ dysfunction from dysregulated host response to infection; qSOFA uses respiratory rate ≥22, altered mentation, systolic BP ≤100 mmHg.

Acute appendicitis: Alvarado score components are migratory pain, anorexia, nausea/vomiting, right iliac fossa tenderness, rebound tenderness, fever, and leukocytosis; score ≥7 supports operative management.

Acute cholecystitis: Tokyo Guidelines grade I-III; early laparoscopic cholecystectomy within 72 hours of presentation is preferred in fit patients; percutaneous cholecystostomy for high-risk grade III.

Pancreatitis: Atlanta classification; severity by modified Glasgow or APACHE II; fluid resuscitation with balanced crystalloid at 5-10 mL/kg/h; no routine prophylactic antibiotics; ERCP within 24-72 hours for cholangitis or persistent obstruction.

Bowel obstruction: supine and erect abdominal films plus CT with contrast; CT identifies transition point, strangulation (reduced wall enhancement, pneumatosis) and closed-loop obstruction requiring urgent laparotomy.

Lower GI bleeding: colonoscopy after rapid purge if stable; CT angiography for brisk bleeding (>0.5 mL/min); interventional embolisation or surgery for refractory haemodynamic instability.

Thyroid surgery: recurrent laryngeal nerve at risk at the ligament of Berry; superior thyroid artery ligated close to the gland to protect the external branch of the superior laryngeal nerve; postoperative haematoma is an airway emergency requiring bedside opening.

Hyperparathyroidism: primary shows high calcium with inappropriately normal or high PTH; sestamibi and ultrasound localise; intraoperative PTH drop >50% at 10 minutes predicts cure.

Breast cancer: triple assessment is clinical examination, imaging (mammography plus ultrasound) and core biopsy; sentinel node biopsy using dual dye and radiolabelled colloid for clinically node-negative axilla.

Colorectal cancer: right-sided tumours present with iron-deficiency anaemia and mass; left-sided with obstruction and altered bowel habit; staging by CT chest/abdomen/pelvis plus MRI rectum for local staging.