Comprehensive Medical Practice Guide EXTENDED Edition
For education and simulation training only. This handbook summarizes high yield principles and common
procedural steps. It is NOT a substitute for formal training, credentialing, local protocols, or
specialist consultation. Always follow ATLS/ACLS/PALS, institutional policies, and consult relevant
experts. Doses and techniques vary; verify locally before use.
Table of Contents (High Level)
1) Trauma & Resuscitation 2) Airway/Anesthesia 3) Critical Care 4) Cardiothoracic 5) Vascular 6)
General Surgery 7) Orthopedics 8) Neurosurgery 9) ENT/Airway 10) OB/GYN 11) Urology 12)
Plastics/Burns 13) Emergency Procedures 14) Imaging & FAST 15) Post Op & ERAS 16)
Pediatrics/Geriatrics 17) Complications & Crisis 18) Checklists 19) Drug Quick Cards 20) Appendices
(Labs, Formulas, Notes)
Trauma XABCDE Overview
X: eXsanguination control first (tourniquet, hemostatic gauze, direct pressure). A: Airway with C spine
protection. B: Breathing (ventilation, chest injuries). C: Circulation (hemorrhage, access, permissive
hypotension in uncontrolled bleeding except TBI). D: Disability (GCS, pupils, glucose). E:
Exposure/Environment (fully expose; prevent hypothermia). Parallel: monitoring, IV/IO access, labs,
imaging as stable.
Shock Recognition & Initial Actions
Hypovolemic (bleeding), Obstructive (tamponade, tension pneumo, PE), Cardiogenic, Distributive (sepsis,
anaphylaxis). Act fast: control bleeding, oxygen, two large bore IVs/IO, labs (CBC, type&cross, lactate),
activate MTP when indicated, ultrasound for source, avoid excess crystalloids if hemorrhaging.
Rapid Sequence Intubation (RSI) Summary
Indications: failure to protect airway, failure to oxygenate/ventilate, anticipated deterioration.
Pre oxygenate, choose induction and paralytic per protocol, apply cricoid only if indicated, confirm with
waveform capnography. Backup plans: bougie, supraglottic airway, surgical airway.
Surgical Airway (Cricothyrotomy) Educational Steps
Landmark cricothyroid membrane; prep; vertical skin incision; horizontal membrane incision; dilate;
insert trach/ET tube; confirm position. Complications: bleeding, false passage, posterior wall injury.
Use only in 'can't intubate, can't oxygenate' scenarios.
Sepsis Bundle First Hour
Recognize sepsis; obtain cultures; start broad spectrum antibiotics early; source control; fluid bolus if
hypotension; vasopressors for MAP 65 if needed; lactate measurement and trend; reassess perfusion;
consider ICU.
Ventilation Quick Notes (ARDS)
Lung protective strategy: Vt 6 mL/kg IBW, plateau <30 cmH2O, adequate PEEP, permissive hypercapnia as
tolerated, prone positioning for severe hypoxemia, conservative fluids, consider neuromuscular blockade
early in refractory hypoxemia.
CABG Concept & Key Steps (Educational)
Goal: bypass obstructed coronary arteries with grafts (LIMA/RIMA or saphenous vein). Key steps: median
sternotomy; harvest conduits; cardiopulmonary bypass and cardioplegia (on pump) or off pump
stabilization; anastomose grafts (distal then proximal); wean from bypass; hemostasis; drains; close.
Post op: rhythm monitoring, graft patency concerns, bleeding control, early mobilization.
Valve Surgery Overview
Mitral repair/replacement, aortic valve replacement (SAVR/TAVR). Indications: severe symptomatic
stenosis/regurgitation, LV dysfunction. Intra op: cardioplegic arrest, valve exposure,
repair/replacement, de airing, TEE confirmation. Post op: anticoagulation depending on valve type, rhythm
and afterload management.
Emergency Thoracotomy Indications & Sequence
Indications (trauma): penetrating chest trauma with witnessed arrest, tamponade, massive hemothorax,
aortic/heart injury. Sequence: anterolateral thoracotomy; open pericardium longitudinally; relieve
tamponade; internal cardiac massage; control hilar/vascular bleeding; cross clamp aorta if indicated;
rapid transport to OR for definitive repair.
Ruptured AAA Open vs EVAR (Recap)
Open: midline laparotomy, proximal/distal control, graft interposition, meticulous hemostasis, consider
temporary closure if edema. EVAR: femoral access, wire/catheter to aorta, deploy endograft across
aneurysm, confirm seal, less invasive if anatomy allows. Post op: BP control, renal protection, bleeding
surveillance.
Carotid Endarterectomy Key Steps
Indication: symptomatic high grade stenosis or selected asymptomatic high grade. Steps: cervical
incision along SCM; expose carotid bifurcation; heparinize; clamp sequence; arteriotomy; plaque removal;
patch angioplasty; unclamp; hemostasis; drain; close. Complications: stroke, cranial nerve injury,
hematoma/airway compromise.
Fem Pop Bypass Outline
Indication: peripheral arterial disease with limb threatening ischemia. Steps: expose common femoral and
popliteal; tunnel graft; systemic heparin; perform proximal and distal anastomoses; confirm pulses/flow;
close. Post op: antiplatelet therapy, wound care, surveillance for graft patency.
Embolectomy with Fogarty Snapshot
Acute limb ischemia: anticoagulate; incision over artery; arteriotomy; introduce Fogarty catheter;
inflate balloon; extract clot; restore flow; repair arteriotomy; fasciotomy if reperfusion compartment
syndrome risk.
Laparoscopic Appendectomy Steps
Ports placement; identify and skeletonize appendix; divide mesoappendix (clip/energy device); ligate base
with endoloops/stapler; remove specimen; irrigate; close ports. Complications: stump leak, abscess,
bleeding.
Laparoscopic Cholecystectomy Critical View of Safety
Obtain critical view: only cystic duct and artery entering gallbladder; dissect Calot's triangle; clip
and divide cystic duct/artery; separate gallbladder from liver bed; retrieve in bag. Beware aberrant
anatomy; convert to open if unclear. Complications: bile duct injury, bleeding.
Damage Control Laparotomy Trauma
Indications: profound shock, coagulopathy, hypothermia, acidosis. Goals: control hemorrhage (packing,
vascular clamps, stapled bowel resection without anastomosis), control contamination, temporary abdominal
closure (VAC), ICU resuscitation, planned re look.
Small Bowel Resection & Anastomosis Outline
Indications: ischemia, obstruction, trauma. Steps: identify affected segment; vascular control; resect;
create tension free, well perfused anastomosis (stapled or hand sewn); mesenteric defect closure; leak
test as indicated.
Inguinal Hernia Repair (Lichtenstein) Key Points
Open anterior approach; identify ilioinguinal nerve; reduce sac; place polypropylene mesh with adequate
overlap; secure without excessive tension; close layers. Complications: chronic groin pain, recurrence,
infection.
Hip Fracture Hemiarthroplasty Snapshot
Indication: displaced femoral neck fracture in elderly. Steps: posterolateral or anterolateral approach;
femoral head removal; canal preparation; trial components; implant stem and head; reduce; repair capsule;
close; DVT prophylaxis and early mobilization.
Tibial Shaft Fracture Intramedullary Nailing
Entry point (patellar tendon split or parapatellar); guidewire; reaming; nail insertion; proximal/distal
locking; confirm alignment; close. Complications: malalignment, infection, knee pain.
Distal Radius ORIF Essentials
Volar approach; protect median nerve; reduce fracture; place volar locking plate; confirm screws length;
ROM test; close; splint. Complications: tendon irritation/rupture, malunion.
Compartment Syndrome Fasciotomy
Indication: pain out of proportion, tense compartments, sensory changes, rising pressures. Leg:
two incision four compartment fasciotomy; leave wounds open with VAC; staged closure/skin graft later.
Complications: infection, nerve injury.
Epidural Hematoma Craniotomy (Recap)
Biconvex CT; rapid deterioration. Steps: incision; bone flap; evacuate clot; control middle meningeal
artery; hemostasis; replace flap or decompressive if needed; drain; close. ICU monitoring post op.
Acute Subdural Hematoma Outline
Criteria for surgery: thickness >10 mm or midline shift >5 mm, or neuro deterioration. Steps: craniotomy;
dural opening; evacuate clot; hemostasis; duraplasty if needed; ICP control. Beware recurrent bleeding
and brain swelling.
External Ventricular Drain (EVD) Summary
Indications: hydrocephalus, elevated ICP. Steps: landmark Kocher's point; sterile prep; burr hole;
cannulate ventricle; confirm CSF flow; connect to closed drainage with set height; secure. Complications:
infection, hemorrhage, malposition.
Decompressive Craniectomy Snapshot
For refractory intracranial hypertension. Steps: large hemicraniectomy; dural expansion; ICP monitoring;
delayed cranioplasty. Watch for sinking flap, hygroma, infection.
Epistaxis Endoscopic Management
After first aid, localize bleeding (Little's area common). Cauterize with silver nitrate or
electrocautery. If posterior source or refractory, consider posterior packing or endoscopic
sphenopalatine artery ligation. Avoid bilateral septal cautery to prevent perforation.
Tracheostomy Key Steps & Complications
Position with neck extension; horizontal incision; dissect strap muscles; control thyroid isthmus; window
in tracheal rings 2 4; insert tube; secure. Early complications: bleeding, pneumothorax, tube
displacement. Late: stenosis, TE fistula.
Tonsillectomy Peri Op Notes
Indications: recurrent tonsillitis, OSA. Techniques: cold steel, electrocautery, coblation. Risks:
post tonsillectomy hemorrhage (primary/secondary), pain control, hydration. Counsel regarding return to
ED for bleeding.
Cesarean Section Steps (Lower Segment)
Pfannenstiel incision; enter peritoneum; bladder flap; low transverse uterine incision; deliver fetus;
clamp/cut cord; deliver placenta; uterine repair in 2 layers; ensure hemostasis; close layers. Watch for
atony uterotonics.
Ectopic Pregnancy Laparoscopic Salpingectomy
Indication: ruptured or unsuitable for salpingostomy. Steps: ports; identify ectopic; control mesosalpinx
vessels; resect tube segment; retrieve; hemostasis; close. Post op: Rhogam if indicated.
Postpartum Hemorrhage Surgical Options
Uterine balloon tamponade; compression sutures (B Lynch); stepwise uterine/iliac artery ligation;
hysterectomy if refractory. Always resuscitate concurrently and use tranexamic acid early per protocol.
Testicular Torsion Detorsion & Orchiopexy
Emergent scrotal exploration; detorse (usually medial to lateral 'open book'); assess viability; fix both
testes to scrotal wall (bilateral orchiopexy). Time is testis aim <6 hours.
Obstructing Stone with Sepsis Decompression
Never delay drainage. Options: ureteral stent (retrograde) or percutaneous nephrostomy. Start broad
antibiotics. Definitive stone treatment after sepsis resolves.
TURP Snapshot
For symptomatic BPH refractory to meds. Steps: endoscopic resection of prostate tissue under continuous
irrigation; control bleeding; 3 way catheter with continuous bladder irrigation post op. Risks: bleeding,
TUR syndrome, retrograde ejaculation.
Escharotomy Lines & Indications
Indication: circumferential full thickness burns with vascular/ventilatory compromise. Lines along
mid medial/lateral limbs and anterior axillary lines on chest; cut through eschar to subcutaneous fat
until release. Protect nerves/vessels. Manage pain and bleeding.
Split Thickness Skin Graft Steps (Recap)
Harvest with dermatome; mesh as needed; secure to prepared wound bed; bolster dressing; immobilize;
elevate; watch for hematoma/infection; initiate scar management later (silicone, compression).
Flexor Tendon Repair Principles
Zone specific approach; atraumatic handling; core suture (e.g., 4 strand) + epitendinous suture; early
protected mobilization with therapy; prevent adhesions and rupture. Complications: stiffness, re rupture.
Pericardiocentesis Summary
Indication: tamponade with hemodynamic compromise. Subxiphoid approach commonly used; aspirate while
monitoring ECG/echo; be ready for pericardial window if unsuccessful. Complications: coronary or cardiac
injury, arrhythmia.
Needle Thoracostomy & Tube Thoracostomy Recap
Preferred site for needle: 5th intercostal space anterior/mid axillary line with catheter length adequate
for chest wall. Convert to chest tube promptly. Tube insertion in safe triangle, direct
posterior/inferior, connect to underwater seal.
Massive Transfusion Protocol (MTP) Essentials
Trigger based on physiology and predicted blood loss. Provide balanced PRBC:FFP:Platelets; add calcium;
consider tranexamic acid early; warm products; monitor coags and ionized calcium; reassess frequently.
FAST/eFAST Windows & Uses
RUQ (Morison), LUQ (splenorenal), Pelvic (pouch of Douglas), Subxiphoid (pericardial). eFAST adds
anterior chest for pneumothorax/hemothorax. Repeat serially; negative FAST does not rule out injury if
unstable consider OR/CT per status.
Enhanced Recovery After Surgery (ERAS) Core Elements
Pre op counseling; carbohydrate loading; multimodal analgesia; opioid sparing; early feeding and
mobilization; PONV prophylaxis; normothermia; goal directed fluids; drain minimization when feasible.
Post Op Orders & Monitoring Template
Vitals, neuro/vascular checks, pain plan, fluids, diet, DVT prophylaxis, antibiotics duration, labs
timing, wound/drain care, mobilization, imaging as needed, when to call team (red flag thresholds).
Pediatrics Key Differences
Airway narrower and anterior; higher O2 consumption; weight based dosing; consider congenital anatomy
variants; Broselow tape for sizing; beware non accidental trauma; fluid resuscitation more cautious;
maintenance fluids tailored to age.
Geriatrics Surgical Considerations
Frailty assessment, delirium prevention, careful medication review (polypharmacy), lower physiologic
reserve, DVT/PE and infection risk, early mobilization and nutrition, goals of care discussions.
Anaphylaxis Immediate Management
Stop trigger; call for help; IM epinephrine lateral thigh; airway/oxygen; fluids; antihistamines and
steroids as adjuncts; observe for biphasic reaction; prescribe auto injector and education on discharge.
Transfusion Reactions Quick Guide
Stop transfusion; maintain IV line with saline; check patient ID and unit; send blood and patient
samples; manage per reaction type (acute hemolytic, febrile non hemolytic, TRALI, TACO); supportive care
and notify blood bank.
Intra Op Hemorrhage Control Strategy
Compress, expose, suction, vascular control proximal/distal, hemostatic agents, sutures/clips/staples,
temporary shunts when needed, call for help and resources, consider damage control tactics and MTP.
WHO Surgical Safety Checklist Highlights
Sign in: patient, site/side, allergies, airway risk, antibiotics given. Time out: team introductions,
critical steps, blood availability, imaging. Sign out: counts correct, specimens labeled, equipment
issues, recovery plan.
Procedure Specific Time Outs Tips
Mark site with patient awake when possible; confirm implants/sizes; clarify anticipated blood loss and
backup plans; ensure necessary imaging and instruments are present.
ACLS Core Drugs Quick Card (Illustrative)
Cardiac arrest: Epinephrine 1 mg IV q3 5 min; Amiodarone 300 mg bolus then 150 mg. Bradycardia: Atropine
1 mg IV q3 5 min (max 3 mg); then TCP or epinephrine/dopamine infusion. Tachyarrhythmias: Adenosine for
stable narrow regular; synchronized cardioversion if unstable.
Analgesia/Sedation Basics Snapshot
Multimodal: acetaminophen, NSAIDs if appropriate, regional blocks, opioids for severe pain with
monitoring, ketamine adjunct for select patients. Sedation in ICU: target RASS, daily sedation
vacations, consider dexmedetomidine/propofol; monitor for delirium.
Appendix Normal Labs & Formulas (Selected)
Hb (g/dL): W 12 15.5, M 13.5 17.5; Platelets 150 400k; INR ~1. Creatinine per lab norms; Lactate <2
mmol/L (context dependent). Formulas: Parkland (burns), Anion gap = Na (Cl + HCO3), Corrected Ca =
measured Ca + 0.8*(4 albumin).
Appendix Documentation Templates
Operative Note: Diagnosis, Procedure, Surgeon/Assistants, Anesthesia, Findings, Steps, Implants, EBL,
Specimens, Drains, Complications, Disposition, Post op plan. Consent Elements: indication, benefits,
risks, alternatives, recovery expectations.