Surgery: Acute Abdomen, Trauma, and Perioperative Care
What this domain tests
This domain covers acute abdominal pain, trauma, wound care, hernias, urological obstruction, orthopaedic emergencies, and perioperative risk. Questions often ask for the next investigation or the first operative decision in an unstable patient.
Core rules
- Trauma follows ABCDE: catastrophic haemorrhage, airway, breathing, circulation, disability, exposure. Tension pneumothorax is a clinical diagnosis treated before imaging.
- Acute abdomen: resuscitate, examine, investigate selectively, and operate when peritonitis, perforation, ischaemia, or obstruction with compromise is present.
- Appendicitis is a clinical diagnosis supported by imaging in equivocal cases; do not delay surgery for a normal white cell count.
- In penetrating abdominal trauma, hypotension or evisceration mandates laparotomy rather than CT.
- Perioperative assessment focuses on functional capacity, cardiorespiratory reserve, and correction of dehydration, anaemia, and electrolytes.
Worked example
A 30-year-old motorcyclist is hypotensive, with absent left breath sounds, distended neck veins, and tracheal deviation to the right. The diagnosis is left tension pneumothorax. Do immediate needle decompression in the second intercostal space mid-clavicular line or fifth intercostal space anterior axillary line, then insert a chest drain. Do not send the patient for chest X-ray first; imaging delays treatment in a haemodynamically unstable patient.
Traps
Ordering CT in an unstable trauma patient; attributing absent bowel sounds to obstruction alone; missing posterior hip dislocation after dashboard injury; giving opioids before assessing abdominal signs in a stable patient; forgetting tetanus prophylaxis and wound exploration in bite injuries.
Exam strategy
Ask whether the patient is stable. Stable patients can be investigated; unstable patients need immediate resuscitation or operation.