BSSEE cheat sheet

Wound classification: clean (Class I), clean-contaminated (II), contaminated (III), dirty/infected (IV); infection risk rises with class and drives antibiotic prophylaxis choice.

Surgical antibiotic prophylaxis: single preoperative dose within 60 minutes of incision (120 minutes for vancomycin/fluoroquinolones); redose at 2 half-lives or >1500 mL blood loss; discontinue within 24 hours.

ASA physical status I-VI stratifies perioperative risk; emergency modifier E. ASA III or higher plus major surgery predicts increased 30-day morbidity.

Revised Cardiac Risk Index (RCRI) components: ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine >2 mg/dL, high-risk surgery; 2 or more points warrants further cardiac evaluation.

Normal adult maintenance fluids: 4-2-1 rule, 4 mL/kg/hr for first 10 kg, 2 for next 10 kg, 1 for each kg thereafter.

Postoperative fever timing mnemonic: wind (atelectasis, POD 1-2), water (UTI, POD 3-5), wound (POD 5-7), walk (DVT), wonder drugs (POD 7+).

Surgical consent requires capacity, disclosure of material risks, alternatives, and no coercion; emergency exception applies when life-threatening and patient cannot consent.

Enhanced recovery (ERAS) elements: preoperative counseling, carbohydrate loading, opioid-sparing multimodal analgesia, early feeding and ambulation, goal-directed fluids.

Appendicitis: Alvarado score (migration, anorexia, nausea, tenderness, rebound, fever, leukocytosis); CT is first-line in adults, ultrasound in children and pregnancy.

Small bowel obstruction: initial management is NPO, nasogastric decompression, IV fluids, and serial exams; operate for strangulation signs (fever, tachycardia, peritoneal signs, closed loop).

Large bowel obstruction: diverticular stricture and malignancy most common; volvulus shows 'coffee bean' sign (sigmoid) or 'cecal bascule'; sigmoid volvulus often decompresses with flexible sigmoidoscopy.

Crohn disease favors skip lesions, transmural inflammation, fistulae, and perianal disease; ulcerative colitis is continuous, mucosal, and starts at the rectum.

Right hemicolectomy removes terminal ileum, cecum, ascending colon, and hepatic flexure with ileocolic anastomosis; left colectomy for descending/sigmoid disease.

Peptic ulcer perforation: free air on upright film or CT; treatment is omental (Graham) patch repair with peritoneal lavage; test and treat H. pylori.

Acute mesenteric ischemia: pain out of proportion to exam; CT angiography is diagnostic; superior mesenteric artery embolus often spares proximal jejunum.

Lower GI bleeding: diverticulosis is the most common cause; hemodynamically unstable or brisk bleeding warrants urgent colonoscopy or CT angiography and embolization.

Acute cholecystitis: right upper quadrant pain, Murphy sign, leukocytosis; ultrasound shows wall thickening >3 mm, pericholecystic fluid; early laparoscopic cholecystectomy within 72 hours is preferred.

Choledocholithiasis: elevated bilirubin and alkaline phosphatase with dilated common bile duct; MRCP or ERCP for diagnosis and clearance; ascending cholangitis (Charcot triad: fever, jaundice, RUQ pain) requires urgent ERCP drainage.

Calot triangle borders: cystic duct, common hepatic duct, and inferior liver edge; critical view of safety before clipping prevents bile duct injury.

Acute pancreatitis diagnosis requires 2 of 3: characteristic pain, lipase >3 times upper limit, or imaging findings; severity scored by BISAP, APACHE II, or revised Atlanta criteria.

Pancreatic head adenocarcinoma: painless jaundice with double duct sign; Whipple (pancreaticoduodenectomy) is standard; superior mesenteric artery margin determines resectability.

Liver segments follow Couinaud classification based on portal and hepatic vein anatomy; segments I-IX; segment I is caudate, segments V-VIII right lobe.

Hepatocellular carcinoma surveillance uses ultrasound with or without AFP every 6 months in cirrhotic patients; diagnosis by LI-RADS imaging or biopsy.

Postoperative pancreatic fistula defined by drain amylase >3 times serum upper limit on POD 3 or later; most common complication after pancreaticoduodenectomy.

Breast cancer staging: TNM; sentinel lymph node biopsy is standard for clinically node-negative axilla; axillary dissection for node-positive disease after neoadjuvant therapy or clinically evident nodes.

Breast triple assessment: clinical exam, imaging (mammography plus ultrasound), and tissue diagnosis (core needle biopsy).

Thyroid nodule workup: TSH, ultrasound (TIRADS), and fine-needle aspiration based on size and ultrasound features; Bethesda categories guide management.

Recurrent laryngeal nerve injury causes hoarseness; external branch of superior laryngeal nerve injury causes loss of high pitch; hypocalcemia from parathyroid devascularization after total thyroidectomy.

Primary hyperparathyroidism: elevated calcium with inappropriately normal or high PTH; sestamibi and ultrasound for localization; focused parathyroidectomy when single adenoma.

Pheochromocytoma: episodic hypertension, headache, sweating, palpitations; elevated plasma metanephrines; alpha blockade (phenoxybenzamine) before beta blockade to avoid hypertensive crisis.

Adrenal incidentaloma: assess for hormonal function (cortisol, aldosterone, metanephrines) and imaging characteristics; size >4 cm or suspicious features warrant resection.

Breast conservation therapy requires negative margins (no tumor on ink) plus whole-breast radiation; mastectomy with or without reconstruction for multicentric disease or patient preference.

ATLS primary survey: airway with cervical spine protection, breathing, circulation with hemorrhage control, disability, exposure; treat as you find.

Hemorrhagic shock classes: I (<15% loss), II (15-30%), III (30-40%), IV (>40%); class III shows hypotension and tachycardia; class IV requires massive transfusion.

Massive transfusion protocol: balanced 1:1:1 ratio of packed red cells, plasma, and platelets; give tranexamic acid within 3 hours of injury.

FAST exam detects free fluid in pericardial, perihepatic, perisplenic, and pelvic windows; positive FAST with hemodynamic instability mandates laparotomy.

REBOA is an adjunct for non-compressible torso hemorrhage; zone I for abdominal, zone III for pelvic; contraindicated in cardiac arrest from non-hemorrhagic cause.

Abdominal compartment syndrome: bladder pressure >20 mmHg with new organ dysfunction; decompressive laparotomy is definitive.

Damage control laparotomy: control hemorrhage and contamination, temporary closure, ICU resuscitation, planned re-exploration within 24-48 hours.

Pelvic fracture with hemodynamic instability: binder at greater trochanters, angiographic embolization or preperitoneal packing; avoid repeated pelvic exams.

Peripheral arterial disease: ankle-brachial index <0.90 is diagnostic; claudication managed with supervised exercise, statin, antiplatelet, and smoking cessation.

Acute limb ischemia: 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia); Rutherford classification guides heparin, catheter-directed thrombolysis, or embolectomy.

Abdominal aortic aneurysm repair indicated at diameter >5.5 cm in men or >5.0 cm in women, or rapid growth >1 cm/year, or symptomatic.

Carotid endarterectomy benefits symptomatic stenosis 70-99% (NASCET) and selected 50-69%; best within 2 weeks of transient ischemic attack or minor stroke.

Varicose veins: great saphenous vein reflux on duplex; treatment options include endovenous ablation, sclerotherapy, and stripping.

Aortic dissection Stanford type A involves ascending aorta and requires emergency surgery; type B managed medically unless complicated.

Graft infection: Staphylococcus aureus and coagulase-negative staphylococci common; explantation with extra-anatomic bypass or in situ reconstruction.

Compartment syndrome after revascularization: monitor for pain with passive stretch, paresthesia, and elevated compartment pressure >30 mmHg; fasciotomy is definitive.

Chest tube management: place in triangle of safety; suction for persistent pneumothorax; remove when no air leak and drainage <200 mL/day with lung expanded.

Tension pneumothorax: hypotension, distended neck veins, absent breath sounds, tracheal deviation; immediate needle decompression then tube thoracostomy.

Lung cancer staging: CT chest plus PET-CT; mediastinal staging by EBUS-TBNA or mediastinoscopy; early-stage NSCLC treated with lobectomy and lymph node sampling.

Esophageal cancer: adenocarcinoma distal (Barrett), squamous cell proximal; staging with EUS and PET-CT; esophagectomy with gastric conduit for localized disease.

Flail chest: three or more consecutive ribs fractured in two or more places; management is analgesia, pulmonary hygiene, and positive pressure ventilation if respiratory failure.

Empyema stages: exudative, fibrinopurulent, organizing; treatment is antibiotics plus drainage; VATS decortication for organizing stage.

Thymoma: anterior mediastinal mass with myasthenia gravis in 30-40%; complete thymectomy is treatment; staging by Masaoka-Koga.

Postoperative atrial fibrillation after thoracic surgery: treat with rate control and anticoagulation if persistent; common after pneumonectomy and esophagectomy.

Brain death criteria: unresponsive coma, absent brainstem reflexes, apnea test with PaCO2 rise; confirmatory testing per institutional protocol.

Kidney transplant evaluation: HLA matching, panel-reactive antibody, crossmatch; living donor grafts have superior survival versus deceased donor.

Immunosuppression induction with basiliximab or antithymocyte globulin; maintenance with calcineurin inhibitor (tacrolimus), antimetabolite (mycophenolate), and steroid.

Acute rejection: cellular (T-cell mediated) versus antibody-mediated; biopsy with C4d staining; treatment with pulse steroids, thymoglobulin, or plasmapheresis.

Calcineurin inhibitor toxicity: nephrotoxicity, hypertension, tremor, gingival hyperplasia (cyclosporine), new-onset diabetes (tacrolimus).

Liver transplant: MELD-Na score for allocation; indications include decompensated cirrhosis, hepatocellular carcinoma within Milan criteria, and fulminant hepatic failure.

Post-transplant lymphoproliferative disorder: associated with Epstein-Barr virus and high-intensity immunosuppression; reduce immunosuppression and treat with rituximab.

Cytomegalovirus prophylaxis with valganciclovir for high-risk (donor positive, recipient negative) recipients for 3-6 months.

TNM staging: T describes primary tumor size and invasion, N regional nodes, M distant metastases; stage grouping determines prognosis and treatment.

Sentinel lymph node biopsy uses blue dye and radiolabeled colloid; identifies first draining node; standard for melanoma and breast cancer staging.

Melanoma: Breslow thickness determines prognosis; wide local excision margins 1 cm for ≤1 mm, 2 cm for >2 mm; sentinel node biopsy for thickness >0.8 mm or ulcerated.

Colorectal cancer: right-sided tumors present with anemia and obstruction; left-sided with change in bowel habit; adjuvant chemotherapy for stage III disease.

Neoadjuvant therapy: used for locally advanced rectal cancer (chemoradiation), esophageal cancer, and borderline resectable pancreatic cancer.

Soft tissue sarcoma: grade, size, depth, and margins predict outcome; limb-sparing surgery with radiation preferred over amputation when feasible.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for selected peritoneal carcinomatosis from appendiceal and colorectal primaries; cytoreduction completeness predicts survival.

Tumor lysis syndrome: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; prevention with hydration and allopurinol or rasburicase.

Sepsis-3 definition: life-threatening organ dysfunction from dysregulated host response; SOFA increase ≥2; septic shock requires vasopressors to maintain MAP ≥65 with lactate >2 mmol/L despite fluids.

Surviving Sepsis bundle: blood cultures before antibiotics, broad-spectrum antibiotics within 1 hour, 30 mL/kg crystalloid for hypotension or lactate ≥4, vasopressors for MAP <65.

ARDS Berlin criteria: acute onset within 1 week, bilateral opacities, not explained by heart failure, PaO2/FiO2 ≤300 on PEEP ≥5; lung-protective ventilation with tidal volume 6 mL/kg predicted body weight.

Acute kidney injury KDIGO staging: creatinine rise ≥0.3 mg/dL in 48 hours or urine output <0.5 mL/kg/hr for 6 hours; stage 3 requires dialysis.

Ventilator-associated pneumonia: new infiltrate after 48 hours of ventilation; diagnose with quantitative cultures; treat with broad coverage then de-escalate.

Nutrition in critical illness: enteral feeding within 24-48 hours when hemodynamically stable; trophic feeding acceptable initially; parenteral nutrition if enteral contraindicated.

Delirium prevention: identify and treat pain, agitation, and delirium (PADIS); avoid benzodiazepines; early mobility and sleep hygiene.

Massive transfusion complications: hypocalcemia from citrate, hypothermia, hyperkalemia, dilutional coagulopathy; monitor ionized calcium and temperature.

Informed consent elements: diagnosis, nature and purpose of procedure, risks and benefits, alternatives including no treatment, and consequences of refusal.

Capacity assessment: patient can understand information, appreciate consequences, reason, and communicate choice; capacity is decision-specific and time-specific.

Surrogate decision-making hierarchy: patient's prior expressed wishes, then substituted judgment, then best interests; advance directives guide care.

Confidentiality exceptions: patient consent, legal reporting requirements (communicable disease, gunshot wounds), imminent harm to self or others, and court order.

Medical error disclosure: full, prompt disclosure of harmful errors to patient and family; apology and explanation; system reporting for learning.

Never events: wrong-site surgery, retained foreign body, wrong patient procedure; require root cause analysis and reporting.

Conflict of interest: disclose financial relationships with industry; recuse from decisions affecting personal gain; institutional review of gifts.

Team communication tools: SBAR (situation, background, assessment, recommendation) and closed-loop communication improve handoffs and reduce errors.

TNM staging: T describes primary tumor size and invasion, N regional nodes, M distant metastases; stage grouping determines prognosis and treatment.

Sentinel lymph node biopsy uses blue dye and radiolabeled colloid; identifies first draining node; standard for melanoma and breast cancer staging.

Melanoma: Breslow thickness determines prognosis; wide local excision margins 1 cm for ≤1 mm, 2 cm for >2 mm; sentinel node biopsy for thickness >0.8 mm or ulcerated.

Colorectal cancer: right-sided tumors present with anemia and obstruction; left-sided with change in bowel habit; adjuvant chemotherapy for stage III disease.

Neoadjuvant therapy: used for locally advanced rectal cancer (chemoradiation), esophageal cancer, and borderline resectable pancreatic cancer.

Soft tissue sarcoma: grade, size, depth, and margins predict outcome; limb-sparing surgery with radiation preferred over amputation when feasible.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for selected peritoneal carcinomatosis from appendiceal and colorectal primaries; cytoreduction completeness predicts survival.

Tumor lysis syndrome: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; prevention with hydration and allopurinol or rasburicase.