Exhaustive Medical and Surgical Study Guide: Clinical Procedures, Pathophysiology, and Trauma Management

SURGICAL NOMENCLATURE AND OPERATIVE TERMINOLOGY

The naming of a surgical operation is a comprehensive process that includes the type of procedure, the specific organ involved, the extension or scope, the technical approach, topographical variants, and the intended purpose. The suffix -tomie denotes the sectioning, opening, or incision of an organ or anatomical region. Examples include laparo or celio regarding the abdominal cavity, toraco for the thorax, gastro for the stomach, duodeno, colo, sterno, and lombo for the lumbar region. A complex example is toraco-freno-laparo-tomie, which involves the thorax, diaphragm, and abdomen simultaneously. Common abdominal incisions include the supraumbilical or xipho-umbilical median incision, the subumbilical or pubo-umbilical median incision, the xipho-pubic median incision (encompassing both supra and subumbilical regions), and subcostal or bisubcostal incisions. When sectioning an organ can occur at different levels, such as in vagotomy, it is classified as trunkal, selective, or supraselective.

The suffix -rafie refers to the suturing of organs or structures. This includes celiorafie or laparorafie, which is the closure of the abdomen following a celiotomy; neurorafie, the suturing of a nerve severed during trauma (which can be epineural or perineural); and tenorafie, the suturing of a tendon. The suffix -stomie describes operations that create a communication between a hollow organ and the exterior or between two hollow organs, known as anastomoses. Examples include gastrostomy, jejunostomy, tracheostomy, and colostomy (which may be lateral or terminal), as well as ileostomy and cholecystostomy. Internal anastomoses include gastro-jejunostomy (gastro-jejunal anastomosis) and gastro-duodenostomy, with configurations classified as end-to-end (termino-terminal), end-to-side (termino-lateral), side-to-end (latero-terminal), or side-to-side (latero-lateral). Of note, a total gastrectomy results in the union of the esophageal stump and the duodenal stump.

-Ectomie signifies the removal of an organ, such as in cholecystectomy, appendicectomy, thyroidectomy (which may be right/left lobectomy or subtotal), and hemihepatectomy or segmentectomy. In oncological surgery involving resection, the R-classification is used: an R0 resection has no residual tumor, R1 indicates microscopic residual tumor, and R2 indicates macroscopic residual tumor. Cancer surgical treatment is categorized as radical (aiming for cure) or palliative (aiming to prolong survival, prevent or treat complications, or alleviate symptoms). In the lymphatic territory, this involves removing the primary tumor organ and/or lymph nodes. Specific examples include radical mastectomy (original, involving muscle removal) or modified radical mastectomy (removing lymph nodes). For the kidneys, a simple nephrectomy is used for benign diseases, while a radical nephrectomy for cancer includes the kidney, perirenal fat, and fascia. A distinction is made between resection (removing an intermediate segment followed by anastomosis) and amputation (removing a terminal segment), both of which are possible in rectal surgery.

RECONSTRUCTIVE TECHNIQUES AND FUNCTIONAL PROCEDURES

The suffix -plastie refers to the reconstruction or modification of organs. Examples include esophagoplasty after an esophagectomy, mammaplasty (used after mastectomy or for augmentation/reduction), and pyloroplasty, which is performed to keep the pylorus open after a trunkal vagotomy. The suffix -pexie involves the fixation of an organ in a specific position, such as rectopexy for rectal prolapse or colpohysteropexy for genital prolapse, where the uterus and vagina are fixed to the sacrum using a polypropylene mesh. -Plicatura involves the folding of an organ or a portion of it. In Gastroesophageal Reflux Disease (GERD), fundoplication is used, while in recurrent intestinal occlusion due to adherent bands, enteroplication is used to direct the adhesive process.

Transplantation involves several categories based on the source of the graft. Alexis Carrel is recognized as the founder of vascular and transplant surgery. Autotransplant involves tissues from the same individual, such as a skin graft. Alotransplant involves organs from the same species and can be orthotopic or heterotopic. Isotransplant occurs between identical twins, while Xenotransplant involves organs or tissues transferred from animals to humans.

CLINICAL ANAMNESIS AND SYSTEMATIC PHYSICAL EXAMINATION

A diagnosis is the result of integrating information from the anamnesis, the objective physical examination, and extra-clinical investigations. The objective examination highlights morphological or functional changes produced by disease through direct investigation of the patient to obtain "signs." This occurs in stages: general examination, system/apparatus examination, and local examination. The general examination includes monitoring vital signs, consciousness, nutritional status, facies, skin (teguments), mucous membranes, appendages (fanere), and lymph nodes. The systematic examination covers the muscular, osteo-articular, nervous, respiratory, cardiovascular (CV), digestive, and excretory systems. The local examination focuses on the specific region carrying the lesion intended for surgical treatment. The combination of anamnesis and objective examination leads to the clinical diagnosis, which may be a diagnosis of a specific disease (e.g., esophageal hernia) or a syndrome (e.g., esophageal syndrome comprising neoplasm, achalasia, esophagitis, or diverticulum), which is an association of signs and symptoms characteristic of various diseases. A positive diagnosis is reached when extra-clinical tests are added, serving as the criterion for treatment.

The anamnesis includes general data, the reason for presentation (patient symptoms, unclear symptoms, specific characteristics), medical history (AHC - family history, APF - physiological history, APP - pathological history), and lifestyle. Environmental factors are significant, such as endemic goiter, gastric cancer prevalence in Transylvania, and how rural or urban environments dictate activity, nutrition, and hygiene. Profession may expose patients to carcinogens, contact with animals (hydatid cyst), or physical effort leading to hernias or prolonged standing leading to varicose veins. Specific habits such as alcoholism are linked to liver cirrhosis and upper gastrointestinal bleeding (HDS), while smoking is linked to bronchopulmonary and pancreatic cancers, as well as atherosclerosis (ACOMI). Nutrition plays a role; smoked foods are linked to gastric cancer, Western diets to colorectal cancer, and irregular meals to peptic ulcer disease (UGD).

Physiological history (APF) for women includes menarche, duration and regularity of cycles, and pregnancy count. Monthly ovulation is a risk factor for ovarian cancer, while pregnancy is protective. Rupture of the perineum during childbirth can lead to genital prolapse, and breastfeeding is protective against breast cancer. Menopause history should include any metrorrhagia or fibroid involution. Pathological history (APP) includes prior surgeries, which may be the cause of current issues like eventrations, intestinal occlusions, or postoperative complications such as thrombitis or suppuration. Medication history is vital; antiaggregant treatments must be stopped days before surgery, and oral anticoagulants are replaced with low-molecular-weight heparins. Antidiabetics are swapped for insulin, and antihypertensives may be changed to parenteral administration. In rectal cancer patients treated with radiotherapy, surgery is delayed at least $8$ weeks to allow for "downstaging."

LOCAL OBJECTIVE EXAMINATION OF INFECTIONS AND GLANDS

Specific skin and soft tissue lesions are differentiated by their characteristics. An abscess is a well-delimited purulent collection resulting from tissue damage by microbial agents; it presents as a fluctuant, painful swelling with erythema and heat. A phlegmon is a diffuse bacterial infection with inflammation of the subcutaneous or deep soft tissues; it lacks clear boundaries and includes general symptoms like fever, asthenia, chills, and headache. A furuncle is a circumscribed infection starting in the hair follicle, presenting as a small, red, pruritic nodule that eventually fistulizes to evacuate pus. A carbuncle is a conglomerate of furuncles forming an extensive area of subcutaneous infection. Hidrosadenitis is a bacterial infection of the axillary sudoriparous or apocrine glands. Hidradenitis suppurativa occurs when these nodules fistulize, leading to chronic suppuration, fibrosis, and scar formation. Erysipelas is a streptococcal skin infection characterized by a raised, red, warm, and well-delimited placard, often on the limbs or face, accompanied by fever and chills. Gas gangrene is a severe anaerobic infection characterized by necrosis, hard tissue edema, hemorrhagic bullae, foul-smelling secretions, and systemic shock. Fournier gangrene is a similar severe anaerobic infection specifically affecting the genitals and perineum. Finally, an echimoză (bruise) is a violaceous patch from capillary blood extravasation, while a hematoma is a larger collection of blood from bigger vessels.

Breast examination divides the breast into $5$ quadrants. Inspection is performed with the patient standing or lying down with arms in various positions (by the side, vertical, or at the nape). Palpation uses the palmar surface of the fingers, moving systematically from external to internal quadrants, then the mamelon. If a mass is found, its size, mobility, and boundaries must be recorded. The Tillaux maneuver involves the patient performing arm adduction against resistance to contract the pectoral muscle, allowing the examiner to assess tumor mobility. Axillary and supraclavicular lymph nodes must be palpated. Mastitis affects breastfeeding women but must be differentiated from inflammatory (carcinomatous) mastitis, a highly aggressive cancer characterized by "orange peel" (peau d'orange) skin and lymphatic invasion.

PHYSICAL EVALUATION OF HERNIAS, SCROTAL PATHOLOGIES, AND ULCERS

Hernia inspection is best performed with the patient standing to observe the size, position relative to the inguinal plica, expansion upon coughing, and peristaltic movements. Palpation assesses consistency (elastic for digestive contents, pasty for omentum/epiploon) and femoral pulse. The two pathognomonic signs of a hernia are reducibility and impulse on coughing. Percussion helps identify content; dullness (matitate) suggests omentum, while tympany (timpanism) suggests the digestive tract. Auscultation can reveal hydro-aerial sounds, confirming a segment of the digestive tube. An eventrație is a soft pseudotumoral mass located at a post-operative scar, which is often hypertrophic.

Scrotal pathologies include the varicocele, more frequent on the left side, described as feeling like a "packet of worms" or "bird intestines" during palpation in a standing position. A hidrocel is a fluid collection in the hemiscrotum where the epididymis becomes impossible to palpate; it is differentiated from a solid tumor by transillumination (cold light), which passes through the fluid but not a solid mass. Varicose veins in the lower limbs are soft and compressible, assessed using the Trendelenburg and Perthens tests. Peripheral arteriopathy presents with shiny skin and brown spots. Cutaneous ulcers are classified by localization (TBC on the neck, carcinomas on the face) and margins (undermined in TBC, punched-out in pressure sores, exuberant/burjonate in cancer).

HEMATOLOGICAL AND BIOCHEMICAL LABORATORY EXPLORATIONS

A full hemogram includes the count of erythrocytes, hemoglobin, hematocrit, indices, leukocytes, and platelets. Erythrocytes may show hereditary anemias (hemolytic, sickle cell/falciform, pyruvate kinase deficiency, or hereditary spherocytosis) or acquired anemias (deficiency of iron, $B_{12}$, folic acid, $B_6$, or bone marrow aplasia from chemotherapy). Specific indices like VEM (mean corpuscular volume) and HEM (mean corpuscular hemoglobin) classify anemias as macrocytic (alcoholic, liver disease), normocytic, or microcytic. CHEM (mean corpuscular hemoglobin concentration) is decreased in iron deficiency and increased in spherocytosis.

Leukocytosis (increased WBC) occurs in infections, cancers, and tissue necrosis. Acute bacterial infections typically follow a neutrophil phase, a monocytic reactive phase, and a lymphocytic-eosinophilic recovery phase. Leukopenia (decreased WBC) is seen in viral infections, hypersplenism, or bone marrow depression. Specific variations include neutrophilia (bacterial infection, burns, IMA), eosinophilia (allergic or parasitic diseases), and lymphocytosis (viral or chronic infections like TBC and syphilis). Platelets (trombocite) can show transient physiological thrombocytosis (effort, birth) or secondary thrombocytosis (inflammation, post-op). Thrombocytopenia (low platelets) is caused by destruction (cirrhosis, hypersplenism, CID) or low production (cytostatics).

Coagulation is evaluated through the Quick prothrombin time (evaluates the extrinsic pathway, normal ratio approx. $1$), INR for patients on anticoagulants, APTT (evaluates the intrinsic pathway), and thrombin time (increased when fibrinogen is low). Bleeding time (tests platelet function) has a normal value of less than $9\text{ min}$, and coagulation time is normally $2-3\text{ min}$. Biochemical tests include glycemia (essential for screening and monitoring surgical stress), urea and creatinine (renal function indicators), and the Glomerular Filtration Rate (RFG), calculated based on creatinine, age, sex, and race. Tissue destruction markers include ASAT and ALAT (liver), lipase/amylase (pancreas), and troponin (myocardium).

Bilirubin metabolism involves the degradation of hemoglobin into heme. Unconjugated (insoluble) bilirubin circulates bound to albumin, is captured by the liver, and becomes conjugated (soluble) with gluconic acid. Intestinal flora deconjugate it into urobilinogen (UBG) and stercobilin. Hemolytic anemias increase unconjugated bilirubin, while hepatic diseases increase both. Post-hepatic (obstructive/surgical) jaundice increases conjugated (direct) bilirubin. Other markers include alkaline phosphatase and gamma-GT for cholestasis. Serum proteins, especially albumin, indicate nutritional status; hypoalbuminemia leads to increased surgical complications. C-reactive protein (PCR) and procalcitonin indicate inflammation, while D-dimers suggest thrombosis or pulmonary embolism.

DIAGNOSTIC IMAGING AND ENDOSCOPY

Urinalysis evaluates pH (alkaline in infections), density (concentration capacity), and the presence of proteins, glucose, ketones, nitrites, or biliary pigments. The urinary sediment may show RBCs, WBCs, casts (cilindrii), or crystals. An EKG is used for pre-operative evaluation to detect arrhythmias, ischemia, or electrolyte imbalances (K). Ultrasound (Ecografie) uses transducers to generate and receive high-frequency sound waves. Transonic structures (fluid) appear black, while echogenic structures appear white or gray. Contrast ultrasound uses sulfur hexafluoride gas in phospholipid microvesicles. An echogenic image with a shadow cone inside the gallbladder suggests biliary lithiasis. Eco Doppler utilizes the Doppler effect to evaluate vascular flow.

X-rays (Radiografia) show radiotransparent (black, such as air) or radio-opaque (white, such as bone) structures. For specialized organ viewing, barium sulfate is used for transit (esophagus, stomach, duodenum) or irigography (colon), where colon cancer may appear as an "apple core" (cotor de măr). CT scans provide anatomical detail and are enhanced by intravenous contrast, though this carries nephrotoxic and allergenic risks. Scintigraphy involves the capture of radioactive isotopes in tissues, while PET-CT uses radioactively marked glucose to identify malignant tissues with high metabolism. MRI (RMN) provides high detail but is contraindicated in patients with metallic stents, pacemakers, or prosthetic heart valves.

Endoscopies allow for internal inspection of cavities, biopsies, and therapeutic maneuvers. EDS covers the esophagus, stomach, and duodenum, while EDI (colonoscopy) examines the colon and terminal ileum. Patients undergo preparation such as fasting or osmotic laxatives for EDI.

PATHOPHYSIOLOGY AND PHASES OF SURGICAL SHOCK

Shock is a syndrome characterized by a marked decrease in tissue perfusion, leading to hypoxia, cellular death, and organ dysfunction. It is distinct from ischemia, which is localized. Colaps is a rapid life-threatening drop in blood pressure, while coma maintains vital functions but loses consciousness. Microcirculation involves arterioles (resistance sector) and post-capillary venules (capacitance sector). Pre-capillary sphincters have Alpha receptors (vasoconstriction), while arteriolovenous shunts have Beta receptors (vasodilatation). Catecholamines stimulate constriction, while histamine, lactic acid, and prostaglandins stimulate relaxation. Pre-capillary sphincters are more sensitive to acidosis than post-capillary ones; as acidosis increases, pre-capillary sphincters relax first, leading to blood pooling.

Causes of shock include decreased volume (hemorrhage, vomiting, diarrhea). In peritonitis or intestinal occlusion, the affected area becomes a "dead space" where water and electrolytes are sequestered (the Randall third space), leading to hypovolemia. Cardiogenic shock results from pump failure (IMA, arrhythmias, tamponade). Distributive shock involves fluid sequestration throughout the body. Hemorrhagic shock triggers a sympathetic reaction releasing cortisol and catecholamines. Early reversible shock involves centralization of circulation, where the heart and brain are preferentially perfused while the skin and viscera are "squeezed." Late reversible shock involves acidosis opening the pre-capillary sphincters while post-capillary ones remain closed, leading to fluid shifts into the interstitium.

Refractory reversible shock leads to decreased peripheral resistance and severe hypotension. Reperfusion can flush toxic metabolites, causing multiple organ failure (MOF). Blood "sludge" and stasis lead to CID (disseminated intravascular coagulation). Irreversible shock results in anuria, respiratory failure requiring mechanical ventilation, and eventually cardiac arrest. Specific organ consequences include "shock lung" (altered ventilation-perfusion ratio), "shock kidney" (acute tubular necrosis with oliguria and high creatinine), and mucosal necrosis in the stomach (stress ulcers). The acid-base balance shifts toward metabolic acidosis, although hyperventilation can temporarily cause respiratory alkalosis. Electrolyte imbalances include hyponatremia and hyperkalemia.

Treatment of shock focuses on correcting the cause (hemostasis, surgery), correcting hypovolemia with saline or macromolecular solutions, and supporting blood pressure with vasopressors like adrenaline or dopamine. Furosemide may be used to force diuresis but only after volemia is restored.

FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

The human body is approximately $60.00\%$ water. This is divided into the intracellular compartment ($45.00\%$) and the extracellular compartment ($15.00\%$). The extracellular space is further divided into intravascular ($5.00\%$) and extravascular/interstitial ($10.00\%$). Major positive ions include $Na$, $K$, $Ca$, and $Mg$, while negative ions include $Cl$, $HCO_3$, $PO_4$, and $SO_4$. Deshidratarea (dehydration) is classified by weight loss: mild (< 3.00\%^), medium (< 6.00\%^), grave (< 9.00\%^), and critical (> 9.00\%^). Symptoms range from fatigue and concentrated urine to the "facies hipocratic" (sunken eyes, hollow cheeks), hypovolemic shock, and coma.

Hiperhidratarea (hyperhydration) results in edema and can be caused by renal retention (hyperaldosteronism, ADH) or iatrogenic administration. Hiposodemia (low sodium) causes cerebral edema and confusion; it is treated with hypertonic saline. Hipersodemia (high sodium) is often caused by excessive insensible water loss (fever, tracheostomy). Hipopotasemia (low potassium) is common in surgical patients with digestive leaks/fistulas, while Hiperpotasemia is dangerous for cardiac rhythm and occurs in renal failure or massive tissue destruction (trauma, burns).

Metabolic acidosis results from bicarbonate loss (diarrhea) or acid accumulation (lactic acid, DZ ketosis). Respiratory acidosis results from alveolar hypoventilation (anesthesia, narcotics), while respiratory alkalosis results from hyperventilation. Treatment solutions include: Ser fiziologic ($0.90\%\,NaCl$), which is isotonic but high in chloride; soluții glucozate ($5.00\%$ is isotonic, $10.00\%$ requires insulin); and Ringer's solution. Dextran is used to retain water in the intravascular space but interferes with blood grouping tests. Fluids are administered in the order of: deficit correction, replacement of apparent losses, and physiological needs.

SOFT TISSUE TRAUMA AND MUSCULAR DISORDERS

Trauma can be mechanical, thermal, electrical, or chemical. A contuzie is a closed trauma with intact skin, while a plagă is an open trauma. Penetrating wounds open a fascia or serosa. Impregnarea occurs when microparticles (dirt, dust) are embedded in the skin. A flictenă is a fluid accumulation between epidermis and dermis; a vesicle is < $10.00\,mm$, while a bulla is > $10.00\,mm$. Necroza cutanată from pressure leads to an escară de decubit (pressure sore). Prevention involves redistributing pressure every few hours and using alternating pressure mattresses. An echimoză (bruise) changes color over $3$ weeks from red-brown to blue-violet to yellow-green due to hemoglobin degradation.

Hematomul (hematoma) is a blood collection that can reach volumes of $1000-3000\,ml$, potentially causing infection or fibrous remodeling. A subungual hematoma (under the nail) is extremely painful and may indicate a distal phalanx fracture. Liposcleroza posttraumatică involves fat necrosis and saponification, resulting in hard nodules. Seromul traumatic (Morel-Lavallee) is a sero-lymphatic accumulation between the deep hypodermis and fascia, often requiring compression or drainage. Hernia musculară is the protrusion of muscle through a ruptured fascia, visible only when the muscle is relaxed. Stupoarea musculară is a temporary loss of contraction ability.

Ruptura musculară (muscle rupture) can be total or partial; total ruptures show a gap between retracted ends and require surgically suturing (miorafie). Atriția musculară involves the crushing of muscle tissue and is often associated with bone/nerve damage. Sindromul de compartiment (e.g., anterior tibial) is a surgical emergency where edema in an inextensible space compresses vessels and nerves, leading to ischemia; it is treated by fasciotomie longitudinală. Sindromul de strivire (crush syndrome) is life-threatening; treatment requires iv fluids before decompression to prevent systemic poisoning from released metabolites. Sindromul Volkmann is an irreversible ischemic contraction of the forearm muscles, often caused by a cast that is too tight.

WOUND MANAGEMENT AND HEALING PHASES

Wounds are classified as recent if they occurred less than $6$ hours ago ($12$ hours for the head/neck/hand). Healing involves three phases: Inflamatorie (first $3$ days, involving neutrophils and macrophages), Proliferativă (day $3$ to $6$ weeks, involving fibroblasts, collagen production, and angiogenesis), and Remodelare (up to $12$ months, where collagen consolidates and the scar pales).

Vindecarea primară (primary intention) involves surgical closure with sutures or staples, providing minimal scarring. Vindecarea secundară (secondary intention) involves leaving the wound open for heavy contamination or suppuration, using dressings or negative pressure therapy. Vindecarea terțiară (delayed primary closure) involves treating an infected wound for about $5$ days before suturing it. Complications include infection, Clostridium (gas gangrene), tetanus, and rabies. Wound toilet involves antiseptics: alcohol/betadine for skin, and hydrogen peroxide/cloramine for the wound itself. Suture removal times are: $5$ days (face/neck), $7-8$ days (limbs/abdomen), and $8-10$ days (posterior thorax). In the case of venomous snake bites (Vipera), treatment involves immobilization, superficial incision to help drain venom, and anti-viperin serum.

POLYTRAUMA, ABDOMINAL AND THORACIC INJURIES

Politraumatismul involves two or more traumatic lesions, at least one of which is life-threatening. Evaluation follows the ABCDE protocol, often assisted by the H.E.L.P. M.E. schema (Hyperextension, elivering oral cavity, Luxation of mandible, Pensarea nasului, Masaj cardiac, Extern). Thoracic traumas include volet costal (flail chest), where a portion of the chest wall moves paradoxically (inward during inspiration). Pneumotorace sufocant (tension pneumothorax) is a one-way valve effect increasing pleural pressure, requiring immediate needle decompression in the second intercostal space. Tamponada cardiacă is the accumulation of blood in the pericardium, preventing heart filling, and is treated by sternotomy and evacuation.

Abdominal contusions can cause Morell-Lavallee seromas, muscle ruptures, or epigastric artery ruptures. Organs such as the liver, spleen, and kidneys can suffer hematom subcapsular (rupture of parenchyma with intact capsule) or total rupture leading to internal hemorrhage. A rapid FAST ultrasound is used to identify intra-abdominal fluid (> $400\,ml$). Laparotomia de control lezional (damage control surgery) is used for unstable patients to quickly stop bleeding and contamination before stabilization. Sindromul de compartiment abdominal occurs from massive fluid resuscitation and is treated by decompression (laparostomie).

CRANIO-CEREBRAL TRAUMA (TCC)

Traumatic brain injury (TBI) mechanisms include acceleration, deceleration, and counter-blow (contralovitură). Evaluation uses the Glasgow Coma Scale (eyes, verbal, motor). Paralytic investigations include CT (most important), MRI, and monitoring intracranial pressure (PIC). A plagă cranio-cerebrală involves the scalp, skull fracture, and dural/cerebral lesion. Comoția (concussion) is a functional lesion with brief loss of consciousness and retrograde amnesia. Contuzia cerebrală involves microhemorrhages in brain substance and is categorized as minor, medium, or grave.

Skull base fractures are indicated by rinoliquoree (CSF from the nose) or otoliquoree (CSF from the ear), as well as periorbital ecchymosis ("raccoon eyes"). Intracranial hematomas can be extradural (between bone and dura, usually arterial), subdural, or intracerebral. Treatment includes anti-edema measures (Mannitol, corticosteroids) and surgical evacuation of hematomas. TBI is rarely a cause of shock; if a TBI patient is in shock, thoracic or abdominal bleeding must be suspected.

HEMORRHAGE, HEMOSTASIS, AND TRANSFUSION

Hemorrhage is classified by volume: small (< $500\,ml$), medium ($500-1500\,ml$), grave ($1500-2500\,ml$), very grave (> $2500\,ml$), and cataclysmic (massive in a very short time). Arterial blood is bright red and pulsatile; venous blood is dark and continuous. Hemostasis can be spontaneous (coagulation cascade), temporary (manual compression, tourniquet/garou, meșaj), or definitive (ligature, clips, cauterization, vascular sealing up to $7\,mm$).

Blood products include masa eritrocitară (packed RBCs, $330\,ml$, hematocrit $0.57$), masa trombocitară (platelets, last $5$ days), and plasma proaspătă congelată (FFP, $200\,ml$, contains all coagulation factors). Albumina is used for acute hypoalbuminemia and has near-zero viral risk due to heat treatment. Transfuzia autologa involves pre-depositing the patient's own blood. Complications include immediate hemolysis (ABO/Rh incompatibility), febrile non-hemolytic reactions (anti-leukocyte antibodies), and infectious transmission (HCV, HIV, syphilis).

VASCULAR PATHOLOGY AND ARTERIAL OCCLUSION

Arterial trauma causes hemorrhage, thrombosis, and ischemia. Complications include fistulă arteriovenoasă or pseudo-anevrism. Aneurysms are permanent arterial dilations (> 50.00\%^ normal diameter). Ocluzia arterială periferică is most commonly caused by atherosclerosis. Claudicația intermitentă is muscular cramp-like pain appearing on effort and disappearing at rest. Ischemia critică involves rest pain for > $2$ weeks and trophic lesions; the ankle-brachial index (IGB) is < $0.40$. Acute arterial ischemia (embolism or thrombosis) is a medical emergency with the "5 P's": Pain, Pulselessness, Pallor, Paresthesia, Paralysis. Treatment involves heparin, vasodilators, or embolectomy/bypass within $6$ hours to prevent gangrene.

Venous pathology involves the superficial system ($10.00-20.00\%$ of flow) and the deep system ($80.00-90.00\%$ of flow). Varicose veins (Varice) are caused by valvular incompetence and reflux. In advanced stages, this leads to celulită scleroasă, dermatită pigmentară (iron deposits from RBC breakdown), and venous ulcers. Tromboflebita profundă (DVT) combined with pulmonary embolism (TEP) results in boala trombembolica. DVT signs include the Homans sign (pain on calf compression). Pulmonary embolism presents with chest pain, tachycardia, and hemoptysis; it is diagnosed via ventilation-perfusion scintigraphy.

ABDOMINAL WALL DEFECTS AND SURGICAL COMPLICATIONS

Hernias occur through anatomical weak points. They have a sac herniar (with a narrow neck/col) and conținut herniar (usually viscera). Strangularea is the most dangerous complication, presenting like intestinal occlusion. Eventrația (incisional hernia) occurs at old surgical scars due to poor healing, obesity, or wound infection. Eviscerația is the postoperative exteriorization of viscera through a dehiscence; complete evisceration requires emergency surgery.

Postoperative complications include hemoragia (from surgical technique errors), șoc postoperator, and hipotermia. Pneumonia de aspirație occurs from the inhalation of gastric contents during waking from anesthesia. Post-operative fever is classified by the "6 W's":

1. Wind (respiratory infection, atelectasis).
2. Water (urinary tract infection, often catheter-related).
3. Wound (surgical site infection).
4. Walking (thrombosis, DVT/PE).
5. Wonder drugs (medication-induced).
6. What did we do (iatrogenic causes/catheter sepsis).

THYROID AND MAMMARY PATHOLOGY

The thyroid gland produces T4 (thyroxine) and T3 (triiodothyronine), controlled by TSH from the pituitary. Iodine is fixed on thyroglobulin. Calcitonina from C-cells lowers blood calcium. Hiperroidism (e.g., Basedow-Graves) presents with exophthalmos, goiter, and tachycardia. Hipotiroidism presents with cold intolerance, bradicardia, and myxedema. Thyroid cancers include epithelial and medullary types. Surgery involves total thyroidectomy or lobectomy, with risks of hypocalcemia or recurrent nerve injury.

Breast pathology can be benign (fibroadenoma, cysts, mastosis) or malignant. Mastosis fibrocistică presents with painful, diffuse nodules. Cancerul mamar risk factors include early menarche and late menopause. It evolves over $2-9$ years. Boala Paget is a specific form involving the nipple. Diabetic foot involves neuropathy and micro-angiopathy, leading to insensitive ulcers and potential osteomyelitis. Prevention focuses on daily inspections and specialized orthopedic footwear.

BURNS AND ELECTRICAL INJURIES

Burns are graded: 1 (epidermal, erythema only), 2 superficial (epidermis and superficial dermis, blisters/vesicles), 2 profound (deep dermis, waxy white), 3 (total skin destruction, black/charred, insensitive), and 4 (muscle/bone involved). Carbon monoxide intoxication requires intubation and $100\%$ oxygen. Fluid resuscitation is critical in the first $48$ hours; half of the calculated fluids are given in the first $8$ hours. Arsura electrică (voltage > $1000\,V$) causes extensive deep tissue damage despite small skin entry wounds, often leading to rabdomioliza (muscle breakdown) and renal failure. Degerături (frostbite) from cold exposure lead to ischemia and potential amputation; rewarming must be done in a warm water bath but not with direct heat/fire.