Surgery Quiz Surgical Shock & Haemorrhage 1 / 10 In the context of Damage Control Resuscitation (DCR), what is the intended effect of implementing “permissive hypotension”? To increase the cardiac output and stabilize end-organ perfusion. To reduce blood loss and minimize dilutional coagulopathy induced by fluids To avoid additional tissue damage and bleeding during surgery To rapidly restore the patient's blood pressure to normotensive levels. Explanation: Permissive hypotension is a strategy within DCR that is applied while the patient is still actively bleeding. It involves allowing the patient to maintain a lower-than-normal blood pressure. The rationale is that this reduces blood loss from bleeding sites. Additionally, it reduces the dilutional coagulopathy and hypothermia that would otherwise be induced by the vigorous administration of fluids aimed at normalizing perfusion. 2 / 10 Which definition accurately describes Secondary haemorrhage? Haemorrhage occurring immediately as a result of an injury or surgery. Delayed haemorrhage within 24 hours, often due to clot dislodgement. Bleeding due to sloughing of the vessel wall, typically 7–14 days after injury. General bleeding from raw surfaces caused by underlying coagulopathy. Explanation: Haemorrhage is classified by timing: Primary haemorrhage occurs immediately following injury. Reactionary haemorrhage is delayed, occurring within 24 hours, usually due to clot dislodgement or technical failure. Secondary haemorrhage is defined as bleeding due to the sloughing of a vessel wall, and it typically occurs 7–14 days after the initial injury. It is often precipitated by local factors such as infection or pressure necrosis. 3 / 10 Acute traumatic coagulopathy (ATC) is characterized by which specific abnormalities? Hypotension, hypothermia, and acidosis Systemic hyperfibrinolysis, low fibrinogen levels, and platelet dysfunction Loss of coagulation factors due to dilution only High fibrinogen levels, low fibrinolysis, and increased platelet function Acute traumatic coagulopathy (ATC) develops rapidly due to the combination of tissue trauma and hypovolaemic shock. ATC is specifically characterized by systemic hyperfibrinolysis. Furthermore, ATC involves low fibrinogen levels and platelet dysfunction. ATC evolves into trauma-induced coagulopathy (TIC) with further derangements induced by subsequent resuscitation measures. 4 / 10 Which clinical sign is noted as typically being present in distributive (septic) shock, contrasting with hypovolaemic shock? Warm peripheries and brisk capillary refill Tachycardia Hypotension Decreased urinary output Explanation: Most patients in hypovolaemic shock typically present with cool, pale peripheries and prolonged capillary refill times. However, in distributive shock, such as septic shock, the peripheries will be warm and the capillary refill will be brisk. This difference exists despite the presence of profound shock. 5 / 10 In compensated shock, how does the body preserve flow to the lungs, brain, and kidneys? By increasing glomerular filtration rate By stimulating the release of vasopressin (ADH) only By reducing flow to nonessential organs like the skin and GI tract By inducing a compensatory respiratory acidosis Explanation: As shock progresses, the body initiates cardiovascular and endocrine compensatory responses. These responses prioritize reducing blood flow to nonessential organs, such as the skin, muscle, and gastrointestinal tract. This shunting mechanism is necessary to preserve preload and maintain adequate flow to vital organs like the lungs, brain, and kidneys. However, even in compensated shock, the underperfused nonessential organs sustain ischaemic damage and switch to anaerobic respiration. 6 / 10 Which condition is listed as a cause of obstructive shock? Myocardial infarction Massive pulmonary embolus High spinal cord injury Diabetes insipidus Explanation: Obstructive shock occurs when there is a reduction in preload due to mechanical obstruction of cardiac filling. Common causes include cardiac tamponade, tension pneumothorax, air embolus, and a massive pulmonary embolus. In all these cases, the obstruction reduces the filling of the left and/or right sides of the heart, leading to low cardiac output. 7 / 10 Which classification system is noted as the most common and clinically applicable for categorizing shock states? Based on physiological level of compensation Based on the presence of systemic metabolic acidosis Based on the estimated percentage of blood loss Based on the initiating mechanism Explanation: While there are numerous ways to classify shock, the most common and clinically applicable system is one based on the initiating mechanism. This classification system groups shock into five main categories: haemorrhagic/hypovolaemic shock, cardiogenic shock, obstructive shock, distributive shock, and endocrine shock. It is noted that different shock states based on this classification may coexist within the same patient. 8 / 10 In the microvascular changes associated with progressing tissue ischaemia, what primary mechanism leads to tissue edema? Activation of the renin–angiotensin–aldosterone axis Cytokine release causing systemic vasoconstriction Damaged endothelium becoming "leaky" Failure of sodium/potassium pumps in cell membranes Explanation: As tissue ischaemia progresses, activation of the immune and coagulation systems leads to injury of the capillary endothelial cells. The damaged endothelium subsequently loses its integrity and becomes “leaky”. This loss of integrity creates spaces between endothelial cells, allowing fluid to leak out of the vessels. The ensuing fluid leak causes tissue oedema, which further exacerbates cellular hypoxia. 9 / 10 As perfusion to tissues is reduced in shock, cells switch to anaerobic metabolism, resulting in the systemic accumulation of which substance? Lactate CO2 Glucose Intracellular potassium Explanation: Shock is a systemic state of low tissue perfusion, meaning there is insufficient delivery of oxygen and glucose for normal cellular respiration. When oxygen delivery is insufficient, cells switch from aerobic to anaerobic metabolism. The product of anaerobic respiration is lactic acid, not carbon dioxide. The accumulation of this lactic acid in the blood ultimately produces a systemic metabolic acidosis. 10 / 10 What is cited as the most common cause of death among surgical patients? Infection ARDS Shock AKI Explanation: Shock is definitively stated as the most common cause of death of surgical patients. Death may occur rapidly because of a profound state of shock or may occur later due to the consequences of organ ischaemia and reperfusion injury. Because of this significant mortality risk, it is essential that every surgeon understands the pathophysiology, diagnosis, and management priorities related to shock and haemorrhage. kindly log in Your score isThe average score is 61% 0% Restart quiz Metabolic Response to Injury 1 / 12 1) To minimize the risk of surgical site infection, within how many minutes prior to incision must prophylactic antibiotics be administered according to the ERAS protocol? 1) Within 120 minutes 2) Within 60 minutes. 3) Within 30 minutes 4) Immediately after skin incision. Timing of Prophylactic Antibiotics Infection prophylaxis is a critical pre-operative step. The timing of the intervention must be precise to ensure adequate tissue concentration during the incision. Prophylactic antibiotics must be administered within 60 minutes prior to the surgical incision. Adherence to this timing is essential for minimizing skin and wound infections 2 / 12 2) One of the key postoperative elements of the ERAS protocol is the early removal of urinary catheters and surgical drains. If possible, when should the urinary catheter be removed following surgery? 1) Remove after Day 2 or 3. 2) Remove in less than 24 hours. 3) Remove only after tolerating solid food. 4) Removal is based on discharge criteria. Avoidance of Routine Postoperative Devices ERAS protocols aim to remove potential hindrances to early mobilization and recovery, including tubes and catheters. Specifically, urinary catheters should be removed in less than 24 hours post-surgery if possible. Early removal reduces discomfort and aids in getting the patient out of bed quickly, promoting independent mobility 3 / 12 3) Cornerstone of ERAS Intraoperative Analgesia Which regional technique is highlighted as a cornerstone of ERAS perioperative care for optimal pain relief, stress reduction, and promotion of early gastrointestinal motility? 1) Transversus Abdominis Plane (TAP) blocks 2) Peripheral Nerve Blocks. 3) Intrathecal Morphine. 4) Thoracic Epidural Analgesia (TEA). Cornerstone of ERAS Intraoperative Analgesia Optimal pain management is essential to minimize the massive inflammatory cascade associated with surgery. Thoracic Epidural Analgesia (TEA) is highlighted as a cornerstone because it provides excellent pain relief, minimizes the release of stress hormones, and promotes earlier gastrointestinal motility. This technique is key to the overall goal of achieving early functional recovery 4 / 12 4) Under the ERAS protocol, how long before anesthesia are patients permitted to consume clear fluids? 1) Up to 12 hours before anesthesia. 2) Up to 2 hours before anesthesia. 3) NPO after midnight (Traditional approach) 4) Up to 6 hours before anesthesia. The ERAS Fasting Rule for Clear Fluids The traditional rule of "NPO after midnight" is challenged by ERAS. Shortened fasting is safe and is associated with reduced preoperative thirst, hunger, and anxiety. Under ERAS protocols, patients are permitted to consume clear fluids (including carbohydrate drinks) up to 2 hours before anesthesia. Solid food must be stopped 6 hours before 5 / 12 5) A 60-year-old patient receives massive fluid resuscitation for septic shock. By Day 3, the patient has gained 8 kg since admission. What is the most likely explanation for the paradoxical weight gain despite massive tissue breakdown? 1) Expansion of the extracellular water space due to hormone release and IV fluid administration. 2) Increased synthesis of new proteins in visceral organs exceeding muscle loss. 3) The breakdown of cardiac muscle protein, which releases large volumes of intracellular water 4) Suppression of the inflammatory response leading to water conservation Despite massive tissue breakdown (catabolism) during critical illness, patients often experience paradoxical weight gain. This gain is due to the expansion of the extracellular water space (6–10 L). This fluid accumulation results from aggressive IV resuscitation and the conservation of salt/water driven by hormones such as Aldosterone and AVP, leading to peripheral and visceral edema 6 / 12 6) A patient scheduled for elective surgery following an Enhanced Recovery After Surgery (ERAS) protocol is given a clear carbohydrate drink 2 hours before surgery. What is the primary metabolic benefit of this intervention? 1) It significantly increases the pre-operative core body temperature (normothermia) 2) It decreases post-operative insulin resistance. 3) It acts as a powerful anti-inflammatory agent, reducing IL-6 secretion. 4) It directly blocks afferent pain input to the hypothalamus. Enhanced Recovery After Surgery (ERAS) protocols aim to minimize the metabolic stress response. The traditional practice of keeping patients NPO overnight compounds the stress response. A key intervention is allowing clear fluids and administering a carbohydrate drink 2 hours prior to surgery, because this intervention significantly decreases post-operative insulin resistance 7 / 12 7) Which interleukin (IL) is recognized as the "acute-phase switch" cytokine whose peak concentration 12–24 hours post-injury reflects the degree of tissue damage? 1) Interleukin-1 (IL-1) 2) Tumour Necrosis Factor -alpha 3) Interleukin-10 (IL-10) 4) Interleukin-6 (IL-6) Cytokines mediate the inflammatory arm of the stress response. IL-6 is the most important cytokine associated with surgery. Peak circulating values are found 12–24 hours after surgery, and its magnitude reflects the degree of tissue damage. IL-6 is known as the acute-phase switch because it drives the hepatic synthesis of acute phase proteins like CRP. 8 / 12 8) Which group of hormones is typically suppressed during the acute (Ebb and Flow) phases of the metabolic stress response? 1) Cortisol, Glucagon, Catecholamines 2) ACTH, GH, Prolactin 3) Insulin, Testosterone, Oestrogen 4) . Aldosterone, AVP, Renin During the stress response, the secretion of anabolic hormones is suppressed, including Insulin, Testosterone, and Oestrogen. Conversely, catabolic hormones such as Glucocorticoids (Cortisol), Catecholamines, and Glucagon are released or secreted in increased amounts. 9 / 12 9) What is the primary cellular mechanism responsible for the rapid catabolic wasting of skeletal muscle during critical illness? 1) Lysosomal acid hydrolase activation 2) Calcium-dependent Calpain pathway activation. 3) ATP-dependent Ubiquitin-Proteasome pathway activation. 4) Increased mitochondrial biogenesis. The rapid wasting of skeletal muscle is caused by an increase in muscle protein degradation coupled with a decrease in synthesis. The main mechanism responsible for skeletal muscle wasting is the ATP-dependent ubiquitin-proteasome pathway. In this pathway, myofibril protein binds to ubiquitin (an ATP-dependent process) and is then degraded by the 26S proteasome. 10 / 12 10) A 55-year-old diabetic patient undergoes major abdominal surgery. Despite preoperative glycemic control, his blood glucose levels remain persistently elevated (250-300 mg/dL) for the first 3 postoperative days, requiring increased insulin doses. His HbA1c was 7.2% preoperatively. What is the most appropriate management strategy for this surgical stress-induced hyperglycemia? 1) Continue preoperative insulin regimen unchanged 2) Implement intensive insulin therapy targeting glucose levels of 80-110 mg/dL 3) Target glucose levels of 140-180 mg/dL with sliding scale insulin 4) Withhold insulin until oral intake resumes Current evidence-based guidelines recommend targeting glucose levels of 140-180 mg/dL in critically ill and postoperative patients. Intensive insulin therapy targeting very tight control (80-110 mg/dL) has been associated with increased risk of hypoglycemia and mortality. The stress response to surgery causes insulin resistance and hyperglycemia, which gradually improves as the stress response subsides. Moderate glycemic control balances the benefits of glucose management while minimizing hypoglycemic risks during the vulnerable postoperative period. 11 / 12 11) A 30-year-old female patient sustains 40% total body surface area burns. Within 24-48 hours post-injury, she develops increased metabolic rate, elevated body temperature, and significantly increased caloric requirements. Her resting energy expenditure is measured to be 150% above normal. Which phase of metabolic response to injury does this represent? 1) Ebb phase 2) Flow phase (catabolic phase) 3) Anabolic phase 4) Recovery phase This represents the flow phase (catabolic phase) of metabolic response to injury, which typically occurs 24-48 hours after the initial insult. This phase is characterized by hypermetabolism, hyperthermia, increased oxygen consumption, and elevated energy expenditure. The metabolic rate can increase by 50-100% or more in severe burns. This phase is mediated by inflammatory mediators, stress hormones, and sympathetic activation, leading to increased catabolism and energy demands for healing and immune function. 12 / 12 12) Which of the following is not included in the criteria for SIRS? 1) Heart Rate 2) TLC 3) Respiratory Rate 4) CRP SIRS is defined by at least two of the following: abnormal body temperature, heart rate (HR) >90 bpm, respiratory rate (RR) >20 breaths/min or PaCO2 <32 mmHg, and white blood cell count (WBC) abnormality (↑ >12000 or ↓<4000), or >10% immature forms (bands). C-reactive protein (CRP) is an inflammatory marker but is not part of the SIRS criteria. kindly log in Your score isThe average score is 79% 0% Restart quiz Wound Healing kindly log in 1 / 12 What is the characteristic cellular event of the early inflammatory phase (days 1–2) of wound healing? Peak presence of lymphocytes (T and B cells). Proliferation and migration of fibroblasts Influx of polymorphonuclear leukocytes, particularly neutrophils Replacement of Type III collagen by Type I collagen Correct Option: C Explanation: The early inflammatory phase, occurring in the first 1 to 2 days, is characterized by an influx of inflammatory cells, primarily led by polymorphonuclear leukocytes (PMNs), particularly neutrophils. These neutrophils are important for minimizing bacterial contamination of the wound. Neutrophils are the most predominant cells in the wound at day 2, while monocytes/macrophages peak slightly later around day 3. 2 / 12 The release of vasoactive amines, such as serotonin and histamine, primarily contributes to which mechanistic change during the inflammatory phase? Increased tensile strength of the wound. Increased vascular permeability and vasodilatation Phagocytosis of necrotic debris by neutrophils Direct stimulation of Type I collagen synthesis. Correct Option: B Explanation: Vasoactive amines, such as histamine and serotonin, are released by platelets and the local injured tissue. These amines, which are also contained in platelet dense bodies, cause vasodilatation and increased vascular permeability. This increase in permeability aids the infiltration of inflammatory cells from the intravascular space into the extracellular compartment. This intense vasodilatation and increased vascular permeability contribute to the clinical findings of inflammation, such as rubor (redness), tumor (swelling), calor (heat), and dolor (pain). 3 / 12 Platelet alpha granules release various proteins essential for subsequent wound healing. Which combination of factors is specifically contained within these alpha granules? Thrombin and Plasminogen Activator. Histamine and Serotonin TGF- beta, PDGF, and fibrinogen Interleukin-8 (IL-8) and Interleukin-1 (IL-1) Correct Option: C Explanation: Platelet adhesion causes activation and the release of granules, specifically alpha granules, which contain hundreds of proteins. These proteins include essential cytokines and growth factors such as transforming growth factor beta (TGF-$\beta$), platelet-derived growth factor (PDGF), fibroblast growth factor, epidermal growth factor, and vascular endothelial growth factor (VEGF). Alpha granules also contain fibronectin, fibrinogen, thrombospondin, and von Willebrand factor. These growth factors are vital for processes like extracellular matrix deposition, chemotaxis, epithelialisation, and the formation of new blood vessels (angiogenesis). 4 / 12 Scenario: An 8-month-old scar, having achieved maximum potential strength, is examined. This maturation process involved collagen alignment and cross-linking. What specific molecular replacement characterized the collagen composition during the remodeling phase? Type I collagen replaced by type II collagen Type III collagen replaced by Type I collagen Type II collagen replaced by type I collagen Type III collagen replaced by type II collagen Correct Option: B Explanation: The remodeling phase is characterized by collagen maturation. During this process, Type III collagen, which is prevalent during the proliferative phase, is gradually replaced by stronger Type I collagen. This maturation continues until the normal skin ratio of 4:1 Type I to Type III is re-established, leading to increased tensile strength. 5 / 12  Scenario: A full-thickness skin wound is healing by secondary intention. Over several weeks, the observable size of the defect noticeably shrinks as the wound edges are pulled inward. This mechanical reduction in wound size is caused by which contractile cell type? Endothelial cells T cells Myofibroblasts Osteoblasts Correct Option: C Explanation: In the later part of the proliferative phase, some fibroblasts differentiate into myofibroblasts, which are specifically identified as contractile cells. These cells play an essential role in contraction to bring the edges of the wound together, thereby reducing the size of the wound defect. 6 / 12 Scenario: A physician examines a wound bed roughly two weeks post-injury and notes the presence of robust, pink, granular tissue. If a biopsy were taken, the predominant activity of the cells in this granulation tissue would be the synthesis of which essential components of the Extracellular Matrix (ECM)? Lysosomal enzymes and free oxygen radicals Factor VIII and thromboxane A2 Collagen and ground substance (GAGs/proteoglycans) Elastase and MMP-9 Correct Option: C Explanation: The wound tissue formed in the early part of the proliferative phase is called granulation tissue, which has a pink and granular appearance. This phase is dominated by fibroblast activity. The primary function of these fibroblasts is to synthesize collagen and the ground substance components, which include glycosaminoglycans (GAGs) and proteoglycans. 7 / 12 . What percentage of uninjured skin strength does the maximal tensile strength of the wound represent 12 weeks post-injury? Approximately 20% Approximately 40% Approximately 80% Approximately 95% Correct Option: C Explanation: Maximal tensile strength occurs 12 weeks post injury and represents approximately 80% of the uninjured skin strength. 8 / 12 Which cell differentiates from monocytes and is considered truly crucial to wound healing ? Dendritic cells Myofibroblasts Macrophages Keratinocytes Correct Option: C Explanation: The macrophage is the one cell that is truly crucial to wound healing by orchestrating the release of cytokines and stimulating subsequent processes. 9 / 12 Which vasoactive amine released by platelets and injured tissue increases vascular permeability? Factor X Serotonin Fibrin D Factor V Correct Option: B Explanation: Platelets and injured tissue release vasoactive amines, such as histamine and serotonin, which increase vascular permeability. 10 / 12 Which phase of wound healing is often described as the immediate phase occurring before inflammation? Proliferation Remodellig Haemostasis Fibroplasia Correct Option: C Explanation: Haemostasis is the additional stage often described as the immediate phase occurring before inflammation. 11 / 12 Which growth factor predominantly drives angiogenesis during the proliferative phase? VEGF TGF-beta PDGF FGF VEGF is the principal mediator of angiogenesis, especially under hypoxic conditions. It stimulates endothelial cell migration, proliferation, and capillary bud formation. PDGF, FGF, and TGF-β support fibroblast recruitment and matrix synthesis. Adequate neovascularization supplies oxygen and nutrients for granulation tissue. Impaired angiogenesis delays epithelialization and collagen deposition. 12 / 12 Which feature best characterizes healthy granulation tissue? Pale, avascular, firm Beefy red, moist, bleeds easily Dry, keratinized surface Necrotic, sloughing, foul odor Healthy granulation tissue is beefy red, moist, and bleeds easily due to rich capillary networks. It is composed of proliferating endothelial cells, fibroblasts, and Type III collagen. It serves as a temporary scaffold for epithelialization and contraction. Pale or necrotic tissue suggests ischemia or infection. Excessively friable tissue may indicate infection or over-granulation. 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