Bailey Important Tables
Table: Cardiovascular and Metabolic Characteristics of Shock
| Characteristic | Hypovolaemic | Cardiogenic | Obstructive | Distributive |
|---|---|---|---|---|
| Cardiac output | Low | Low | Low | High |
| Systemic vascular resistance | High | High | High | Low |
| Venous pressure | Low | High | High | Low |
| Mixed venous saturation | Low | Low | Low | High |
| Base deficit | High | High | High | High |
Key Points for Revision:
- Cardiac output is high in distributive shock, but low in all other types.
- Systemic vascular resistance is low in distributive shock but high in all others.
- Venous pressure is low in hypovolaemic and distributive shock, but high in cardiogenic and obstructive shock.
- Mixed venous saturation is high in distributive shock and low in others.
- Base deficit is high in all types of shock.
Table: Monitors for Organ/Systemic Perfusion
| Category | Clinical | Investigational |
|---|---|---|
| Systemic perfusion | Base deficit, Lactate, Mixed venous oxygen saturation | |
| Organ perfusion | ||
| 1) Muscle | – | Near-infrared spectroscopy, Tissue oxygen electrode |
| 2) Gut | – | Sublingual capnometry, Gut mucosal pH, Laser Doppler flowmetry |
| 3) Kidney | Urine output | – |
| 4) Brain | Conscious level | Near-infrared spectroscopy, Tissue oxygen electrode |
Key Points for Revision:
- Systemic perfusion is assessed using investigational tools like:
- Base deficit
- Lactate
- Mixed venous oxygen saturation
- Muscle perfusion is monitored using:
- Near-infrared spectroscopy
- Tissue oxygen electrode
- Gut perfusion includes investigational methods such as:
- Sublingual capnometry
- Gut mucosal pH
- Laser Doppler flowmetry
- Kidney perfusion is evaluated clinically by urine output.
- Brain perfusion is monitored clinically by conscious level and investigationally by Near-infrared spectroscopy and Tissue oxygen electrode.
Master Table: CDC Surgical Wound Classification
| Category | Criteria | Additional Details | Infection Rate (%) | Infection Rate with Ab Prophylaxis |
|---|---|---|---|---|
| Clean (Class I) | - Uninfected operative wounds | - No inflammation present - Respiratory, alimentary, genital, urinary tracts not entered - Primarily closed wound - Closed drainage, if necessary - Elective procedure | 1-3% | 1-3% |
| Clean-Contaminated (Class II) | - Operative wounds with controlled entry into respiratory, alimentary, genital, or urinary tracts - No unusual contamination | - Involves biliary tract, appendix, vagina, oropharynx - Minor break in aseptic technique - Mechanical drain used - No major infection or contamination | 5-8% | 3% |
| Contaminated (Class III) | - Open, fresh accidental wounds - Major breaks in sterile technique (e.g., open cardiac massage) - Gross spillage from the gastrointestinal tract | - Uncontrolled spillage from viscus - Inflammation present - Incisions where acute non-purulent inflammation is encountered - Unclean wound or breach of aseptic technique | **20-25% |
[13-20%] | 6% | | Dirty-Infected (Class IV) | - Old traumatic wounds with devitalized tissue - Existing infection or perforated viscera | - Pus in operative wound - Severe inflammation - Untreated, uncontrolled spillage from the viscus - Organisms causing infection were present before surgery | 30-40%** | 7% |
Key Points for Revision:
- Class I: Clean:
- No inflammation or contamination.
- Primarily closed, with no entry into hollow viscera or other tracts.
- Typically involves elective procedures.
- Class II: Clean-Contaminated:
- Controlled entry into respiratory, alimentary, or genital tracts.
- No unusual contamination; includes operations like biliary tract or appendix surgeries.
- Minor aseptic breaks or mechanical drains may be used.
- Class III: Contaminated:
- Open accidental wounds or operations with major sterile technique breaks.
- Gross spillage from the gastrointestinal tract, with acute but non-purulent inflammation present.
- Class IV: Dirty-Infected:
- Old traumatic wounds with devitalized tissue and pus.
- Severe infection or inflammation present, with spillage from perforated viscera before surgery.
Surgical Safety Checklist
1. Before Induction of Anaesthesia (with at least nurse and anaesthetist)
- Has the patient confirmed his/her identity, site, procedure, and consent?
- ☑ Yes
- Is the site marked?
- ☑ Yes / ☐ Not applicable
- Is the anaesthesia machine and medication check complete?
- ☑ Yes
- Is the pulse oximeter on the patient and functioning?
- ☑ Yes
- Does the patient have a:
- Known allergy?
- ☐ No / ☑ Yes
- Difficult airway or aspiration risk?
- ☐ No / ☑ Yes, and equipment/assistance available
- Risk of >500ml blood loss (7ml/kg in children)?
- ☐ No / ☑ Yes, and two IVs/central access and fluids planned
- Known allergy?
2. Before Skin Incision (with nurse, anaesthetist, and surgeon)
- Confirm all team members have introduced themselves by name and role.
- ☑ Yes
- Confirm the patient's name, procedure, and where the incision will be made.
- ☑ Yes
- Has antibiotic prophylaxis been given within the last 60 minutes?
- ☐ Yes / ☐ Not applicable
- Anticipated Critical Events:
- To Surgeon:
- What are the critical or non-routine steps?
- How long will the case take?
- What is the anticipated blood loss?
- To Anaesthetist:
- Are there any patient-specific concerns?
- To Nursing Team:
- Has sterility (including indicator results) been confirmed?
- Are there equipment issues or any concerns?
- To Surgeon:
- Is essential imaging displayed?
- ☐ Yes / ☐ Not applicable
3. Before Patient Leaves Operating Room (with nurse, anaesthetist, and surgeon)
- Nurse Verbally Confirms:
- The name of the procedure
- Completion of instrument, sponge, and needle counts
- Specimen labelling (read specimen labels aloud, including patient name)
- Whether there are any equipment problems to be addressed
- To Surgeon, Anaesthetist, and Nurse:
- What are the key concerns for recovery and management of this patient?
Here is a simplified table with key points from the three categories in the box:
Surgical Safety Checklist: Key Points
| Category | Keywords |
|---|---|
| Sign In | - Confirm identity, site, procedure, consent - Pulse oximeter functioning - Airway & aspiration risk evaluated - Risk of >500 ml blood loss |
| Time Out | - Team introductions - Confirm identity, site, procedure - Critical events review (e.g., blood loss) - Antibiotics within 60 min - Essential imaging displayed |
| Sign Out | - Procedure name - Instrument & needle counts complete - Specimen labelling - Equipment issues addressed - Key concerns for recovery |
This table captures the main actions for each phase. Let me know if you need further adjustments!
Key Points for Revision:
- Confirm patient's identity, site, procedure, and consent before anaesthesia.
- Ensure all team members introduce themselves by name and role before skin incision.
- Verify antibiotic prophylaxis given within 60 minutes before incision.
- Discuss critical events and anticipated blood loss with the surgeon, anaesthetist, and nursing team.
- Confirm key checks before the patient leaves the operating room: procedure name, instrument counts, specimen labelling, and equipment issues.
Pressure Injury Staging
| Stage | Description |
|---|---|
| 1 | Non-blanchable erythema of intact skin |
| 2 | Partial-thickness skin loss with exposed dermis |
| 3 | Full-thickness skin loss |
| 4 | Full-thickness skin and tissue loss |
| Unstageable Full-thickness Injury | Obscured full-thickness skin and tissue loss |
| Deep Tissue Pressure Injury | Persistent non-blanchable, deep red, maroon, or purple discoloration |
Key Points for Revision:
- Stage 1: Non-blanchable erythema (skin intact).
- Stage 2: Partial-thickness skin loss (dermis exposed).
- Stage 3: Full-thickness skin loss.
- Stage 4: Full-thickness skin and tissue loss.
- Unstageable: Obscured full-thickness skin loss.
- Deep Tissue Pressure Injury: Deep red/maroon or purple discoloration, non-blanchable.
Definitions of SIRS and Sepsis
| Condition | Description |
|---|---|
| SIRS | Presence of two out of three of the following: - Hyperthermia (>38°C) or hypothermia (<36°C) - Tachycardia (>90/min) or tachypnoea (>20/min) - White cell count >12 × 10⁹/l or <4 × 10⁹/l |
| Sepsis | SIRS with a documented source of infection |
| Severe Sepsis or Sepsis Syndrome | Sepsis with evidence of organ failure in respiratory, cardiovascular (septic shock), renal, hepatic, coagulation, or central nervous system |
Last Minute Revision Table: Sepsis Management
| Key Initiative | Description |
|---|---|
| Surviving Sepsis Campaign (SSC) | Launched in 2002 by ESICM and SCCM to develop guidelines and reduce sepsis mortality. Continually updates guidelines and tools for sepsis management. |
| Sepsis Bundle (Resuscitation Bundle) | Evidence-based tasks completed within 6 hours for patients with severe sepsis, septic shock, and/or lactate >4 mmol/L. |
| Sepsis Six | Developed by UK Sepsis Trust to reduce mortality. Focuses on giving and taking specific interventions within 1 hour of sepsis diagnosis. |
| Give Three | 1. IV fluid challenge 2. IV antibiotics 3. Oxygen and monitor urine output |
| Take Three | 4. Blood cultures 5. Full blood count 6. Lactate |
Note:
- Surviving Sepsis Campaign focuses on reducing sepsis mortality through international guidelines and updated protocols.
- Sepsis Bundle emphasizes completing critical interventions within 6 hours for severe sepsis patients.
- Sepsis Six is an effective, practical approach within the first hour, aiming to stabilize and treat sepsis patients promptly.
Comparison of Cutting and Coagulation Using Diathermy
| Aspect | Cutting | Coagulation |
|---|---|---|
| Voltage | Lower voltage | Higher voltage |
| Current Flow | Continuous current (100% on) | Interrupted current (6% on, 94% off) |
| Energy Dispersion | Energy concentrated over a small area | Energy dispersed over a large area |
| Tissue Heating | Rapid heating causing vaporization of tissue | Modulated current causing tissue to cool slightly and dehydrate, leading to coagulation |
| Lateral Spread | Minimal lateral spread | Extensive lateral spread |
| Contact with Tissue | Most efficient when tip is held just above tissue | Works best when held just above tissue with minimal or no contact |
| Uses | - Clean cut tissue - Dissect and divide tissue | - Haemostasis - Coagulation |
Key Points for Revision:
- Cutting uses lower voltage, continuous current, and vaporizes tissue with minimal spread.
- Coagulation uses higher voltage, interrupted current, and dehydrates tissue for haemostasis, with more lateral spread.
- Cutting requires close proximity without direct contact for best results.
- Coagulation is used primarily for haemostasis and tissue coagulation.
The risk of a thromboembolic event varies according to the underlying medical condition.
High Risk Conditions
| Condition | Risk |
|---|---|
| Atrial fibrillation with valvular heart disease | High |
| Mechanical mitral valve | High |
| Mechanical valve with previous thromboembolic event | High |
Low Risk Conditions
| Condition | Risk |
|---|---|
| Deep vein thrombosis (DVT) | Low |
| Uncomplicated atrial fibrillation | Low |
| Bioprosthetic valve | Low |
| Mechanical aortic valve | Low |
Endoscopy with Anticoagulant/Antiplatelet Management – Detailed Flowchart
1. Low-Risk Procedure:
- Diagnostic procedures with/without biopsy
- Biliary or pancreatic stenting
- Device-assisted enteroscopy without polypectomy
- Oesophageal, enteral or colonic stenting
- EUS without sampling or interventional therapy
Management:
- If on Warfarin:
- Check INR 1 week before endoscopy.
- If INR is within the therapeutic range: Continue usual daily dose.
- If INR is above the therapeutic range but <5: Reduce daily dose until INR returns to therapeutic range.
- If on DOAC (Dabigatran, Rivaroxaban, Apixaban, Edoxaban):
- Omit DOAC on the morning of the procedure.
2. High-Risk Procedure:
- Polypectomy
- ERCP with sphincterotomy
- EMR/ESD (endoscopic mucosal resection/submucosal dissection)
- Dilatation of strictures
- Therapy of varices
- PEG (Percutaneous Endoscopic Gastrostomy)
- EUS-guided sampling with/without interventional therapy
- Oesophageal or gastric radiofrequency ablation
Management:
- Warfarin:
- Stop warfarin 5 days before the procedure.
- Check INR prior to procedure to ensure INR <1.5.
- Restart warfarin the evening of the procedure with the usual daily dose.
- Check INR 1 week later to ensure adequate anticoagulation.
- If patient has a high risk of VTE: Start LMWH 2 days after stopping warfarin and stop LMWH 1 day before the procedure. Restart LMWH after the procedure until INR is adequate.
- DOAC (Dabigatran, Rivaroxaban, Apixaban, Edoxaban):
- Stop DOAC 3 days before endoscopy.
- For Dabigatran with CrCl (eGFR) 30–50 mL/min: Take last dose 5 days before the procedure.
- Restart DOAC 2-3 days after the procedure (depending on patient’s condition and risk factors).
- Clopidogrel, Prasugrel, Ticagrelor:
- Stop 7 days before endoscopy.
- Continue aspirin if already prescribed.
- Restart Clopidogrel, Prasugrel, or Ticagrelor 1-2 days after procedure.
3. Low-Risk Condition:
- Xenograft heart valve
- AF without high-risk factors (CHADS₂ score <4)
- More than 3 months after VTE
Management:
- Continue usual anticoagulation.
4. High-Risk Condition:
- Prosthetic metal valve in mitral or aortic position
- Prosthetic heart valve and AF
- AF with mitral stenosis
- AF with previous stroke/TIA and 3 or more of the following:
- Congestive cardiac failure
- Hypertension
- Age >75 years
- Diabetes mellitus
- AF and stroke/TIA within 3 months
- Less than 3 months after VTE
Management:
- Stop warfarin 5 days before endoscopy.
- Discuss anticoagulant management with a haematologist or interventional cardiologist.
5. Stents in Coronary Arteries:
- High-Risk Condition: Coronary artery stents.
Management:
- Discuss strategy with consultant interventional cardiologist:
- Consider temporary cessation of P2Y12 receptor antagonist if:
- 6–12 months after insertion of drug-eluting coronary stent.
- >1 month after insertion of bare metal coronary stent.
- Continue aspirin.
- Consider temporary cessation of P2Y12 receptor antagonist if:
Additional Notes:
- For patients with rapidly deteriorating renal function, consult with a haematologist for DOAC management.
- Consider delaying endoscopy if INR or anticoagulant management is not optimal.
Risk Factors for Post-ERCP Pancreatitis
| Definite | Possible |
|---|---|
| - Suspected SOD (Sphincter of Oddi Dysfunction) | - Female sex |
| - Young age | - Low volume of ERCPs performed |
| - Normal bilirubin | - Absent CBD (Common Bile Duct) stone |
| - Prior ERCP-related pancreatitis | |
| - Difficult cannulation | |
| - Pancreatic duct contrast injection | |
| - Pancreatic sphincterotomy | |
| - Balloon dilatation of biliary sphincter |
Key Points for Revision:
- Definite risk factors include Suspected SOD, young age, and prior ERCP-related pancreatitis.
- Possible risk factors include female sex, low volume of ERCPs performed, and absence of CBD stone.
Table 1: Mallampati Classification (Airway Assessment)
| Grade | Description |
|---|---|
| Grade 1 | Faucial pillars, soft palate, and uvula fully visible |
| Grade 2 | Faucial pillars, soft palate, and part of uvula visible |
| Grade 3 | Soft palate only visible |
| Grade 4 | Hard palate only visible |
Table 2: Physical Measurements for Airway Assessment
| Measurement | Ideal Value |
|---|---|
| Mouth opening | >3 cm |
| Thyromental distance | >6.5 cm |
| Thyrosternal distance | >12.5 cm |
| Ability to protrude jaw | Present |
| Ability to extend head | Present |
Key Points for Revision:
- Mallampati Classification helps predict the difficulty of intubation.
- Thyromental and thyrosternal distances are key predictors of difficult airway.
- Jaw protrusion and head extension abilities help assess ease of airway access.
Combined Table: Drug Management Before Surgery
| Drug | When to Stop |
|---|---|
| Statins | Continue |
| Warfarin | 5 days |
| Apixaban | 2-3 days |
| OHAs (Oral Hypoglycemic Agents) | Omit morning dose |
| Hormone Replacement | 4 weeks |
| Clopidogrel | 10 days |
| Anti-Parkinsonism Drugs | Continue |
| Beta Blockers | Continue |
| ACE Inhibitors and ARBs | Stop for 24 hours |
| Dabigatran | 2-3 days |
| Regular Inhalers | Till start of anesthesia |
| Estrogen-containing Pills | 4 weeks |
| Aspirin | 7 days |
| Anti-convulsants | Continue |
| Lithium | 24 hours |
Risk Factors for Thrombosis
| Risk Factor | Details |
|---|---|
| Age | >60 years |
| Obesity | BMI >30 kg/m² |
| Trauma or Surgery | Especially of the abdomen, pelvis, and lower limbs |
| Total Anaesthesia Time | >90 minutes |
| Reduced Mobility | For more than 3 days |
| Pregnancy/Puerperium | Increased risk due to physiological changes |
| Varicose Veins with Phlebitis | Increased risk of thrombus formation |
| Drugs | Oestrogen contraceptives, Hormone Replacement Therapy (HRT), Smoking |
| Active Cancer or Treatment | Increased risk due to malignancy and medical comorbidities |
| Family/Personal History of Thrombosis | Includes deficiencies in Antithrombin III, Protein S, or Protein C |
Key Points for Revision:
- Major risk factors include age >60, obesity (BMI >30), surgery, and reduced mobility.
- Oestrogen-containing drugs and smoking are significant drug-related risk factors.
- Varicose veins, prolonged anaesthesia, and personal/family history of thrombosis are also notable contributors.
Table 1: Patient Factors Predisposing to High Risk of Morbidity and Mortality
| Risk Factor | Details |
|---|---|
| Severe cardiorespiratory illness | Acute myocardial infarction, COPD, or stroke |
| Late-stage vascular disease | Involves the aorta |
| Age >70 years | Limited physiological reserve in one or more vital organs |
| Extensive surgery | Surgery for carcinoma |
| Acute abdominal catastrophe | Associated with haemodynamic instability (e.g., peritonitis) |
| Massive blood loss | >8 units of blood |
| Septicemia | Positive blood culture or septic focus |
| Respiratory failure | PaO₂ <8 kPa or FiO₂ >0.4, mechanical ventilation >48 hours |
| Acute renal failure | Urea >20 mmol/L or creatinine >260 mmol/L |
Table 2: Surgery-Specific Estimates of Risk
| Risk Level | Surgeries |
|---|---|
| High Risk (Cardiac >5%) | Open aortic, Major vascular, Peripheral vascular, Urgent body cavity |
| Intermediate Risk (1-5%) | Elective abdominal, Carotid, Endovascular, Aneurysm, Head and neck, Major neurosurgery, Arthroplasty |
| Low Risk (Cardiac <1%) | Breast, Dental, Thyroid, Ophthalmic, Gynaecological, Minor orthopaedic, Minor urology |
Surgical Risk Scores Classified by Outcome Measures
| Scores Predicting Mortality | Scores Predicting Morbidity |
|---|---|
| Scores Not Requiring Operative Information | |
| ASA (American Society of Anesthesiologists) | ASA |
| APACHE-II | APACHE-II |
| Hardman Index | Revised Cardiac Risk Index (RCRI) |
| Glasgow Aneurysm Score | Veltkamp Score |
| Surgical Outcome Risk Tool (SORT) | VA Respiratory Failure Score |
| Boey Score | VA Pneumonia Prediction Index |
| Hacettepe Score | ACS NSQIP Surgical Risk Score |
| Physiological POSSUM | |
| ACS NSQIP Surgical Risk Score | |
| Scores Requiring Operative Information | |
| Mannheim Peritonitis Index | POSSUM |
| NELA Score (National Emergency Laparotomy Audit) | P-POSSUM |
| Reiss Index | |
| Fitness Score | |
| POSSUM (Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity) | |
| P-POSSUM (Portsmouth POSSUM) | |
| Cleveland Colorectal Model | |
| Surgical Risk Scale |
Key Points for Revision:
- Mortality Predictors: ASA, APACHE-II, Glasgow Aneurysm Score, and ACS NSQIP are key tools that don't require intraoperative information.
- Morbidity Predictors: Revised Cardiac Risk Index, VA Respiratory Failure Score, and POSSUM variants (POSSUM and P-POSSUM) are commonly used.
Operative Mortality by ASA Grade
| ASA Grade | Description | 30-day Mortality (%) |
|---|---|---|
| I | Healthy | 0.1% |
| II | Mild systemic disease, no functional limitation | 0.7% |
| III | Severe systemic disease, definite functional limitation | 3.5% |
| IV | Severe systemic disease, constant threat to life | 18.3% |
| V | Moribund patient, unlikely to survive 24 hours with/without surgery | 93.3% |
| E | Emergency operation | – |
Key Points for Revision:
- ASA Grade I indicates a healthy individual with 0.1% mortality.
- ASA Grade V represents a moribund patient with 93.3% mortality.
- Increasing grades indicate higher severity of systemic disease and correspondingly higher mortality rates.
Revised Cardiac Risk Index of Lee
| Risk Factors | Number of Factors =Risk of Major Cardiac Complications (%) |
|---|---|
| History of ischaemic heart disease | 0= 0.4% |
| History of compensated or prior heart failure | 1 = 0.9% |
| History of cerebrovascular disease | 2 = 7.0% |
| Diabetes mellitus | 3 = 11.0% |
| Renal insufficiency (creatinine >177 μmol/L) | |
| High-risk surgery |
Clavien-Dindo Classification of Postoperative Complications
| Grade | Definition |
|---|---|
| I | Any deviation from the normal postoperative course without need for pharmacological or surgical intervention. Wound infections opened at the bedside included. |
| II | Requiring pharmacological treatment beyond acceptable regimens. Includes blood transfusions and total parenteral nutrition. |
| III | Requiring surgical, endoscopic, or radiological intervention. |
| IIIa | Intervention not under general anaesthesia. |
| IIIb | Intervention under general anaesthesia. |
| IV | Life-threatening complication requiring ICU management (e.g., CNS complications, excluding TIAs). |
| IVa | Single-organ dysfunction (including dialysis). |
| IVb | Multiorgan dysfunction. |
| V | Death of a patient. |
Key Points for Revision:
- Grade I: Minor deviation, no invasive intervention.
- Grade II: Includes pharmacological interventions like blood transfusions.
- Grade III: Requires surgical or endoscopic interventions, with IIIa not requiring general anaesthesia.
- Grade IV: ICU management required, with single or multiorgan dysfunction.
- Grade V: Death of the patient.
Table 1: KDIGO Guidelines for Acute Kidney Injury (AKI)
| Stage | Criteria |
|---|---|
| Stage 1 | - Increased sCr × 1.5–1.9 times of baseline within 7 days, or sCr increase ≥0.3 mg/dL within 48 hours |
| - Urine output <0.5 mL/kg/h for 6–12 hours | |
| Stage 2 | - Increased sCr × 2–2.9 times of baseline |
| - Urine output <0.5 mL/kg/h for ≥12 hours | |
| Stage 3 | - Increased sCr × 3 times of baseline or sCr ≥4 mg/dL |
| - Initiation of RRT (Renal Replacement Therapy) | |
| - GFR decrease to <35 mL/min/1.73 m² in patients <18 years old | |
| - Urine output <0.3 mL/kg/h for ≥24 hours or anuria for ≥12 hours |
Table 2: NICE Guidelines for Acute Kidney Injury (AKI)
Criteria
- Rise in serum creatinine of
26 µmol/L
or greater within 48 hours
- ≥50% rise in serum creatinine within the past 7 days
- Fall in urine output to <0.5 mL/kg/h for more than 6 hours in adults and >8 hours in children and young people
- ≥25% fall in estimated GFR in children and young people within the past 7 days
Note for Revision:
- KDIGO Guidelines focus on staging AKI based on changes in serum creatinine (sCr) and urine output, with Stage 3 being the most severe, potentially requiring renal replacement therapy (RRT).
- NICE Guidelines emphasize the rise in serum creatinine (≥26 µmol/L) within 48 hours and urine output changes for more than 6 hours as diagnostic criteria for AKI.
Table 1: Two-Level DVT Wells Score
| Clinical Features | Points |
|---|---|
| Active cancer (treatment ongoing, within 6 months, or palliative) | 1 |
| Paralysis, paresis, or recent plaster immobilisation of lower extremities | 1 |
| Recently bedridden >3 days, or major surgery within 12 weeks | 1 |
| Localised tenderness along the deep venous system | 1 |
| Entire leg swollen | 1 |
| Calf swelling >3 cm compared to asymptomatic side | 1 |
| Pitting oedema confined to the symptomatic leg | 1 |
| Collateral superficial veins (non-varicose) | 1 |
| Previously documented DVT | 1 |
| Alternative diagnosis at least as likely as DVT | -2 |
Clinical Probability Simplified Score:
- DVT Likely: 2 points or more
- DVT Unlikely: 1 point or less
Table 2: Two-Level PE Wells Score
| Clinical Features | Points |
|---|---|
| Clinical signs and symptoms of DVT | 3 |
| Alternative diagnosis less likely than PE | 3 |
| Heart rate >100 beats per minute | 1.5 |
| Immobilisation >3 days or surgery within previous 4 weeks | 1.5 |
| Previous DVT/PE | 1.5 |
| Haemoptysis | 1 |
| Malignancy (on treatment or within 6 months, or palliative) | 1 |
Clinical Probability Simplified Score:
- PE Likely: More than 4 points
- PE Unlikely: 4 points or less
Note for Revision:
- The DVT Wells Score assesses the likelihood of deep vein thrombosis based on clinical features, with a score of 2 or more indicating a high likelihood.
- The PE Wells Score evaluates the likelihood of pulmonary embolism, with more than 4 points indicating a high probability of PE.
Table: Composition of Plasma vs Intravenous Fluid Replacements
| Component (mmol/L) | Plasma | 0.9% Saline | Hartmann's Solution | 5% Dextrose |
|---|---|---|---|---|
| Sodium | 135–145 | 154 | 131 | 0 |
| Chloride | 95–105 | 154 | 111 | 0 |
| Potassium | 3.5–5.3 | 0 | 5 | 0 |
| Bicarbonate | 24–32 | 0 | 29 | 0 |
| Calcium | 2.2–2.6 | 0 | 2 | 0 |
| Magnesium | 0.8–1.2 | 0 | 0 | 0 |
| Glucose | 3.5–5.5 | 0 | 0 | 227.8 (50 g) |
| Lactate | 0.5–1.0 | 0 | 29 | 0 |
| pH | 7.35–7.45 | 4.5–7.0 | 5.0–7.0 | 3.5–5.5 |
| Osmolality (mOsmol/L) | 275–295 | 308 | 273 | 278 |
Key Points for Revision:
- 0.9% Saline has high sodium and chloride but no potassium, bicarbonate, or calcium.
- Hartmann's Solution contains potassium, bicarbonate, and calcium, making it more balanced for electrolyte replacement compared to 0.9% saline.
- 5% Dextrose contains glucose (50g), but no electrolytes.
Table: Recommended Monitoring Schedule for Feeding Regimens
| Frequency | Observations/Tests |
|---|---|
| Daily | - Observations: Pulse, blood pressure, temperature, body weight - Fluid balance (urine, intestinal losses) - Quantity/type of food consumed Plasma levels: Sodium, potassium, urea, creatinine - Blood glucose - Magnesium, phosphate (if refeeding risk) - Liver function tests, C-reactive protein |
| Weekly to Fortnightly | Plasma levels: Full blood count - Calcium, zinc, copper - Plasma proteins (albumin) - Thiamine - Triglycerides - Vitamin B12, Folic acid |
| 3–6 Monthly | Plasma levels: Ferritin - Selenium, manganese - 25-hydroxyvitamin D |
Key Points for Revision:
- Daily monitoring includes vital signs, fluid balance, and key electrolytes.
- Weekly to fortnightly tests include micronutrients like calcium, zinc, copper, and vitamins.
- 3–6 monthly tests focus on trace elements like ferritin, selenium, and vitamin D.
Criteria for DCS and ETC
| Criteria for DCS | Criteria for ETC |
|---|---|
| Hypothermia: <34°C | Stable haemodynamics |
| Acidosis: pH <7.2 | No need for vasoactive/inotropic stimulation |
| Serum Lactate: >5 mmol/L | No hypoxaemia, no hypercapnia |
| Coagulopathy | Serum Lactate: <2 mmol/L |
| Blood Pressure: <70 mmHg | Normal coagulation |
| Transfusion: Approaching 15 units | Normothermia |
| Injury Severity Score: >36 | Urinary output >1 mL/kg/h |
Key Points for Revision:
- DCS is indicated when there is severe derangement such as hypothermia (<34°C), acidosis (pH <7.2), or coagulopathy.
- ETC is appropriate in patients with stable haemodynamics, normal coagulation, and serum lactate <2 mmol/L.
Table 1: Head Injury Severity – Clinical Classification
| Injury Severity | GCS (Glasgow Coma Scale) |
|---|---|
| Minor head injury | GCS 15 with no loss of consciousness (LOC) |
| Mild head injury | GCS 14 or 15 with LOC |
| Moderate head injury | GCS 9–13 |
| Severe head injury | GCS 3–8 |
Table 2: NICE Guidelines for CT Imaging in Head Injury
| Timeframe | Indications for CT Imaging |
|---|---|
| Within 1 hour | - GCS <13 at any point - GCS <15 at 2 hours - Focal neurological deficit - Suspected open or depressed skull fracture - Post-traumatic seizure - More than 1 episode of vomiting |
| Within 8 hours | - Age >65 - Coagulopathy (e.g., aspirin, warfarin) - Dangerous mechanism of injury - Retrograde amnesia >30 minutes |
Table 3: Key Parameters to Maintain in Head-Injured Patients (Neurointensive Care)
| Parameter | Target Value |
|---|---|
| PaCO₂ | 4.5–5.0 kPa |
| PaO₂ | >11 kPa |
| MAP (Mean Arterial Pressure) | 80–90 mmHg |
| ICP (Intracranial Pressure) | <20 mmHg |
| CPP (Cerebral Perfusion Pressure) | >60 mmHg |
| [Na⁺] (Plasma Sodium) | >140 mmol/L |
| [K⁺] (Plasma Potassium) | >4 mmol/L |
Key Points for Revision:
- Head injury severity is classified by GCS with a score <8 indicating severe injury.
- NICE CT guidelines recommend immediate imaging for patients with GCS <13 and other signs like skull fractures or seizures.
- Neurointensive care parameters focus on maintaining optimal oxygenation, pressure, and electrolyte levels.
Table 1: Glasgow Outcome Scale
| Outcome | Score |
|---|---|
| Good Recovery | 5 |
| Moderate Disability | 4 |
| Severe Disability | 3 |
| Persistent Vegetative State | 2 |
| Dead | 1 |
Table 2: NICE Criteria for CT Scan in Children with Head Injury
Indication for CT Imaging
Suspicion of
NAI (Non-Accidental Injury)
First seizure
GCS <14 or <15 in under-ones
GCS <15 two hours post-injury
Signs of skull fracture
Focal neurological deficit
Bruise, swelling, laceration >5 cm in under-ones
More than one of the following:
- Loss of consciousness >5 minutes
- Abnormal drowsiness
- Four or more episodes of vomiting
- Dangerous mechanism
- Amnesia >5 minutes
Table 3: NICE Guidelines for CT in Adults with Head Injury
| Indications for CT within 1 hour | Indications for CT within 8 hours |
|---|---|
| GCS <13 at any point | Age >65 |
| GCS <15 at 2 hours | Coagulopathy (e.g., aspirin, warfarin use) |
| Focal neurological deficit | Dangerous mechanism of injury |
| Suspected skull fracture | Retrograde amnesia >30 minutes |
| Post-traumatic seizure | |
| More than one episode of vomiting |
Key Points for Revision:
- The Glasgow Outcome Scale measures recovery from brain injury, with 5 being a good recovery and 1 being death.
- The NICE criteria for children include GCS <15 and signs of skull fractures for immediate CT imaging.
- In adults, indications for a CT scan within 1 hour include GCS <13, while age >65 or anticoagulant use requires a scan within 8 hours.
Table 1: Causes of Burns and Their Likely Depth
| Cause of Burn | Probable Depth |
|---|---|
| Scald | Superficial but deep dermal in the absence of first aid |
| Fat Burns | Deep dermal to full thickness |
| Flame Burns | Mixed deep dermal and full thickness |
| Alkali Burns (including cement) | Often deep dermal or full thickness |
| Acid Burns | Superficial (weak concentrations), deep dermal (strong concentrations) |
| Electrical Contact Burns | Full thickness |
Table 2: Criteria for Acute Admission to a Burns Unit
- Suspected airway or inhalational injury
- Any burn likely to require fluid resuscitation
- Any burn likely to require surgery
- Burns to hands, face, feet, or perineum
- Patients at extremes of age
- Suspicion of non-accidental injury
- High-tension electrical burns or hydrofluoric acid burns
Table 3: Key Features of Escharotomy Placement
| Location | Escharotomy Placement |
|---|---|
| Upper Limb | Midaxial, anterior to elbow to avoid ulnar nerve |
| Hand | Midline in digits, best done in theatre |
| Lower Limb | Midaxial, posterior to ankle to avoid saphenous vein, anterior to fibula to avoid peroneal nerve |
| Chest | Down chest lateral to nipples, across level of xiphisternum |
| General Rules | Extend wound, diathermy vessels, apply haemostatic dressing, elevate limb postoperatively |
Key Points for Revision:
- Burn causes vary in depth from superficial (scald) to full thickness (electrical).
- Admission criteria focus on airway injuries, extremities, and severe burns requiring surgery.
- Escharotomy placement involves careful incision placement to avoid nerves and blood vessels.
Milan System for Reporting Salivary Gland Cytology
| Diagnostic Criteria | Risk of Malignancy | Usual Management |
|---|---|---|
| I Non-diagnostic | 25% | Clinical and radiological correlation/repeat FNAC |
| II Non-neoplastic | 10% | Clinical follow-up and radiological correlation |
| III AUS (Atypia of Undetermined Significance) | 20% | Repeat FNAC or surgery |
| IVA Neoplasm, Benign | <5% | Conservative surgery or clinical follow-up |
| IVB SUMP (Salivary Gland Neoplasm of Uncertain Malignant Potential) | 35% | Conservative surgery |
| V Suspicious for Malignancy | 60% | Surgery (extent depends on type and grade of malignancy) |
| VI Malignant | >90% | Surgery (extent depends on type and grade of malignancy) |
Key Points for Revision:
- Non-diagnostic cases (Category I) have a 25% risk of malignancy and require repeat FNAC.
- Benign neoplasms (Category IVA) have a low risk (<5%), whereas SUMP neoplasms (Category IVB) have a higher risk (35%).
- Malignant cases (Category VI) carry the highest risk (>90%), and surgery is the standard management.
Table 1: Classification of Fine-Needle Aspiration Cytology (FNAC) Reports
| Category | Description |
|---|---|
| Thy1 | Non-diagnostic |
| Thy1c | Non-diagnostic cystic |
| Thy2 | Non-neoplastic |
| Thy3 | Follicular |
| Thy4 | Suspicious of malignancy |
| Thy5 | Malignant |
Table 2: Breast Imaging Reporting and Data System (BI-RADS) Final Assessment
| Category | Definition |
|---|---|
| 0 | Incomplete assessment; additional imaging needed |
| 1 | Negative; recommend annual screening |
| 2 | Benign finding; recommend annual screening |
| 3 | Probably benign (<2% malignant); short-interval follow-up |
| 4 | Suspicious abnormality (2%–95% malignant); biopsy recommended |
| 5 | Highly suggestive of malignancy (>95% malignant); appropriate action needed |
| 6 | Known biopsy-proven malignancy |
Table 3: 2017 Bethesda System for Reporting Thyroid Cytopathology
| Diagnostic Category (Bethesda Number) | Risk of Malignancy if NIFTP ≠ Cancer | Usual Management |
|---|---|---|
| I Nondiagnostic | 5%–10% | Repeat FNA with ultrasound guidance |
| II Benign | 0%–3% | Clinical and sonographic follow-up |
| III AUS/FLUS | ~10%–30% | Repeat FNA, molecular testing, or lobectomy |
| IV FN/SFN | 25%–40% | Molecular testing or lobectomy |
| V Suspicious for Malignancy | 50%–75% | Near-total thyroidectomy or lobectomy |
| VI Malignant | 97%–99% | Near-total thyroidectomy or lobectomy |
Key Points for Revision:
- FNAC categories range from non-diagnostic (Thy1) to malignant (Thy5).
- BI-RADS helps classify breast lesions based on their likelihood of malignancy, with Category 4 and 5 requiring biopsy.
- The Bethesda system assesses thyroid cytology, with Category VI being the most suspicious for malignancy.
Table 1: Sonographic Patterns, Estimated Risk of Malignancy, and FNA Guidance Thyroid Nodule
| Sonographic Pattern | Sonographic Features | Risk of Malignancy | FNA Size Cutoff |
|---|---|---|---|
| High Suspicion | Solid hypoechoic nodule with irregular margins, microcalcifications, or taller-than-wide shape | >70%–90% | ≥1 cm |
| Intermediate Suspicion | Hypoechoic solid nodule with smooth margins, no microcalcifications or ETE | 10%–20% | ≥1 cm |
| Low Suspicion | Isoechoic or hyperechoic nodule with irregular shape, no microcalcifications | 5%–10% | ≥1.5 cm |
| Very Low Suspicion | Spongiform or partially cystic nodule | <3% | ≥2 cm or observation |
| Benign | Purely cystic nodules (no solid component) | <1% | No biopsy; only for symptoms |
Table 2: TI-RADS (Thyroid Imaging Reporting and Data System)
| TR Level | Description | FNA/Follow-Up Criteria |
|---|---|---|
| TR1 = 0 | Benign | No FNA |
| TR2 = 2 | Not Suspicious | No FNA |
| TR3 =3 | Mildly Suspicious | FNA if ≥2.5 cm, follow-up if ≥1.5 cm |
| TR4 = 4-6 | Moderately Suspicious | FNA if ≥1 cm, follow-up if ≥1 cm |
| TR5 = ≥7 | Highly Suspicious | FNA if ≥1 cm, follow-up if ≥0.5 cm |
Key Points for Revision:
- High suspicion nodules have a higher malignancy risk (>70%) and require FNA at ≥1 cm.
- TR5 (Highly Suspicious) nodules in TI-RADS should be biopsied if ≥1 cm, and followed up if ≥0.5 cm.
Combined AJCC TNM Staging Table (8th Edition) For Oral Cavity Cancer
T Category (Primary Tumor)
| T Category | Criteria |
|---|---|
| TX | Primary tumor cannot be assessed |
| Tis | Carcinoma in situ |
| T1 | Tumor ≤2 cm, DOI (Depth of Invasion) ≤5 mm |
| T2 | Tumor ≤2 cm, DOI >5 mm and ≤10 mm OR tumor >2 cm but ≤4 cm, DOI ≤10 mm |
| T3 | Tumor >4 cm OR any tumor >10 mm DOI |
| T4 | Moderately or very advanced local disease |
| T4a | Moderately advanced: Tumor invades through cortical bone, maxilla, or adjacent structures |
| Moderately advanced local disease: (lip) tumour | |
| invades through cortical bone or involves the | |
| inferior alveolar nerve, floor of mouth or skin of | |
| face (i.e. chin or nose); (oral cavity) tumour invades | |
| adjacent structures only (e.g. through cortical bone | |
| of the mandible or maxilla, or involves the maxillary | |
| sinus or skin of the face); **note that superficial | |
| erosion of bone/tooth socket (alone) by a gingival | |
| primary is not sufficient to classify a tumour as T4** | |
| T4b | Very advanced: Tumor invades masticator space, pterygoid plates, skull base, or encases the internal carotid artery |
N Category (Regional Lymph Nodes)
| N Category | Criteria |
|---|---|
| NX | Regional lymph nodes cannot be assessed |
| N0 | No regional lymph node metastasis |
| N1 | Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension, ENE-negative |
| N2 | Metastasis in a single ipsilateral lymph node, 3–6 cm, OR multiple ipsilateral lymph nodes ≤6 cm, ENE-negative |
| N2a | Metastasis in a single ipsilateral/contralateral node ≤3 cm, ENE-positive or ≤6 cm, ENE-negative |
| N2b | Multiple ipsilateral nodes, none >6 cm, ENE-negative |
| N2c | Metastasis in bilateral/contralateral nodes, none >6 cm, ENE-negative |
| N3 | Metastasis in a node >6 cm, ENE-negative, or metastasis in ipsilateral/contralateral nodes with ENE-positive |
| N3a | Metastasis in a lymph node >6 cm, ENE-negative |
| N3b | Metastasis in a single ipsilateral lymph node >3 cm with ENE-positive or bilateral/contralateral lymph nodes with ENE-positive |
Key Definitions:
- DOI: Depth of Invasion, not to be confused with tumor thickness.
- ENE: Extranodal extension of tumor from lymph node into surrounding tissues.
Table 1: Causes of Hypercalcemia
| Cause | Details |
|---|---|
| Endocrine | Primary hyperparathyroidism, Thyrotoxicosis, Phaeochromocytoma |
| Renal Failure | Secondary hyperparathyroidism, Tertiary hyperparathyroidism |
| Malignant Disease | Skeletal metastatic disease, Multiple myeloma, Solid tumors (lung, renal, squamous cell carcinoma) |
| Nutritional | Excessive vitamin D ingestion, Vitamin A intoxication, Milk-alkali syndrome, Aluminium intoxication |
| Granulomatous Disease | Sarcoidosis, Tuberculosis |
| Inherited | Hypercalciuric hypercalcemia |
| Immobilization | Prolonged bed rest |
| Paget's Disease | Associated with bone turnover |
| Drug-Related | Lithium |
Table 2: Consensus Guidelines for Surgical Management of Asymptomatic Primary Hyperparathyroidism
| Criteria | Details |
|---|---|
| Serum Calcium | 0.25 mmol/L (1.0 mg/dL) above the upper limit of normal |
| Skeletal | BMD by DEXA; T score < -2.5 at lumbar spine, total hip, femoral neck; vertebral fracture |
| Renal | Creatinine clearance <60 mL/min, |
| 24-hour urinary calcium >10 mmol/dL (>400 mg/day), | |
| risk of stones | |
| Age | <50 years |
Table 3: Indications for Surgical Intervention in Secondary Hyperparathyroidism
| Essential Components | Clinical Findings |
|---|---|
| PTH >500 pg/mL | Severe osteitis fibrosa, Progressive ectopic calcification, Calciphylaxis, Bone mineral reduction |
| Hyperphosphatemia | |
| (serum PO4 >6 mg/dL) or hypercalcaemia | |
| (serum Ca >2.5 mmol/L or 10 mg/dL) which is refractory to | |
| medical management | Symptoms like bone/joint pain, pruritus, anemia, cardiac failure |
| Enlarged gland >300–500 mm³ or long axis >1 cm | Symptoms resistant to medical management |
Table 4: Indications for Surgical Intervention in Tertiary Hyperparathyroidism
Criteria
Subacute severe hypercalcemia >3 mmol/L
Impaired graft function
Nodular hyperplasia of the parathyroid gland(s)
Progressive symptoms >2 years after transplantation: Worsening bone disease, Renal stones/nephrocalcinosis, Soft-tissue calcifications
Key Points for Revision:
- Primary hyperparathyroidism is associated with elevated serum calcium and BMD decline.
- Secondary hyperparathyroidism may involve high PTH and symptoms of calcification or bone loss.
- Tertiary hyperparathyroidism occurs with prolonged hypercalcemia post-transplant, with progressive bone or kidney complications.
Criteria for Genetic Testing in Hereditary PHPT
- Testing should be considered for patients with PHPT and a creatinine clearance ratio >0.02, who meet one of the following criteria:
Criteria 1:
- Presenting before the age of 35 years
Criteria 2:
- Presenting before the age of 45 years with one of the following:
- Proven multigland involvement
- Hyperplasia on histology
- Ossifying fibroma(s) of the maxilla or mandible
- At least one first-degree relative with unexplained hyperparathyroidism
Testing Criterion for FHH:
- Familial Hypocalciuric Hypercalcemia (FHH): Creatinine clearance ratio <0.02
Summary of Recommendations for Perioperative Medical Management
Coronary Revascularization Before Noncardiac Surgery
• Revascularization before noncardiac surgery is recommended based on existing clinical guidelines.
• Coronary revascularization is not recommended to exclusively reduce preoperative cardiac events.
Timing of Elective Noncardiac Surgery in Patients with Previous PCI
• Noncardiac surgery should be delayed:
• 14 days after balloon angioplasty.
• 30 days after BMS (Bare Metal Stent) implantation.
• 365 days after DES (Drug-Eluting Stent) implantation.
• Elective noncardiac surgery after DES implantation may be considered after 180 days.
• Noncardiac surgery should not be performed in patients requiring DAPT within 30 days of BMS implantation.
Perioperative Beta Blocker Therapy
• Continue beta blockers in patients already on them.
• For patients with intermediate or high-risk preoperative tests, it may be reasonable to begin beta blockers.
• Initiating beta-blockers just before surgery is not generally recommended unless necessary.
Perioperative Statin Therapy
• Continue statins in patients currently taking them.
• Perioperative initiation of statins is reasonable for vascular surgery patients.
α2-Agonists
• α2-Agonists are not recommended for preventing cardiac events.
ACE Inhibitors
• Continuation of ACE inhibitors or ARBs is reasonable perioperatively.
• Restart these medications postoperatively as soon as clinically feasible.
Antiplatelet Agents
• Continue DAPT in patients undergoing urgent noncardiac surgery during the first 4 to 6 weeks after BMS or DES implantation, unless bleeding risk is high.
• Continuation of aspirin is reasonable for non-emergency noncardiac surgery in patients without prior coronary stenting.
• Continuation of aspirin is not beneficial for patients undergoing elective surgery who have not had previous coronary stenting.
Perioperative Management of Patients with CIEDs
• Patients with ICDs should be on continuous cardiac monitoring during the entire period of device inactivation.
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