Surgery: Trauma, Shock, Sepsis and the Acute Abdomen
Surgery: what is tested
Surgery tests preoperative assessment, shock and fluid resuscitation, wound healing, sepsis, trauma and the acute abdomen, including burns and hernia. The exam often presents a patient who needs a prioritised first action.
Core rules
- Trauma follows ABCDE: airway with cervical spine control, breathing, circulation, disability and exposure. Life-threatening problems are treated as they are found.
- Shock is classified by blood loss and perfusion. Tachycardia, cool peripheries and narrow pulse pressure suggest hypovolaemic shock; initial adult resuscitation uses warmed crystalloid, but blood products are needed for major haemorrhage.
- Wound healing proceeds through haemostasis, inflammation, proliferation and remodelling. Factors impairing healing include diabetes, steroids, malnutrition, infection and ischaemia.
- Acute abdomen: assess pain migration, peritonism, bowel sounds, hernia orifices and pregnancy status. Sepsis needs cultures, antibiotics and source control.
- Burns: estimate total body surface area, give crystalloid by the Parkland formula, keep the patient warm and provide analgesia and tetanus cover.
Worked example. A 70 kg man has 30% total body surface area burns and arrives 2 hours after injury. Reasoning: Parkland formula gives 4 mL x 70 kg x 30% = 8,400 mL in 24 hours. Half, 4,200 mL, is given in the first 8 hours from the time of the burn, so 4,200 / 8 = 525 mL/h for the first 6 remaining hours of that period. The clock starts at injury, not at arrival; urine output guides adjustment.
Traps that cost marks
- Starting the Parkland clock at hospital arrival.
- Forgetting airway risk in facial or inhalational burns.
- Using the same urine output target for adults and children.
- Missing a strangulated hernia because analgesia masked the pain.