> For the complete documentation index, see [llms.txt](https://kam-1.gitbook.io/kam-docs/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://kam-1.gitbook.io/kam-docs/surgery/01_introduction.md).

# Surgery

***

### **Ultrasound**

The handheld Ultrasound unit is a portable imaging system that can quickly assess a number of medical states and enables the use of certain pieces of equipment and medical procedures. It is used on the chest under the “Surgery” tab and when used, will place the patient in an “imaged” state and return the conditions for three areas of the body, those being the Airway, Heart (marked as “Cardiac”), and Lungs (marked as “Thorasic”). Currently the Airway section will always read as normal and can be disregarded at this time. The Cardiac and Thoracic sections read as follows:

Cardiac: Shockable - Patient is either in a VF or VT rhythm\
Cardiac: Unshockable - Patient is either in a PEA or asystolic rhythm\
Cardiac: Tamponade - Patient has a building effusion and so the heart cannot be assessed. Note that a patient can be in arrest under the tamponade, but the only reading will be for tamponade.\
Cardiac: Normal - Patient has no critical rhythm conditions, although they may still have a condition like bradycardia or tachycardia

Thorasic: Pneumothorax - Patient has a pneumothorax of an undetermined intensity\
Thorasic: Hemopneumothorax - Patient has a hemopneumothorax\
Thorasic: Tension Pneumothorax - Patient has a tension pneumothorax

When the patient is in an “imaged” state, you can perform one action that requires the ultrasound. Currently there are two actions that require the patient to be imaged, those being the placement of the REBOA unit and the pericardial tap.

### **Pericardial Tap**

The Pericardial Tap involves placing a needle in the pericardium to remove excess fluids and clear the effusion and cardiac tamponade states, similar to how the needle decompression treatment works for the lungs in relation to pneumothorax and tension pneumothorax. This requires the patient to be in an “imaged” state and does not require additional equipment. Once performed, the patient moves back into an “unimaged’ state.

### **REBOA**

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a procedure which, as the name suggests, involves the placement of a catheter into the aorta that is tipped with a balloon and expanded at certain zones in the aorta to prevent bleeding under the zone. There are two placements, those being Zone III and Zone I, which prevent bleeding from the lower extremities and the chest respectively. The obvious benefit of this is that it allows for immediate control of hemorrhaging from the lower half of the body.

The REBOA is placed in the right leg and will only be available if the patient is in an “imaged” state and the medic has a REBOA catheter. Once placed, it will immediately stop all bleeding in both legs, along with stopping the flow of fluids and medications into the legs and put the patient in an “unimaged” state. From here, the medic can either advance or remove the REBOA. These actions do not require the patient to be in an “imaged” state. Advancing the REBOA will stop bleeding from the chest as well as both legs. Removing the REBOA will remove the catheter and all fluid movements will resume.

## **Fracture Care and Treatment**

***

Determine the fracture type by selecting a limb and choosing “Check Fracture” in the “Examine Patient” tab. Treating surgical fractures should be done quickly so that the patient doesn’t fall out of anesthesia which leads to cardiac arrest with certain settings.

### Simple Fracture

{% stepper %}
{% step %}

### Pain Management

Administer a painkiller (Morphine/Penthrox/Lidocaine).
{% endstep %}

{% step %}

### Reduction

Perform a **Closed Reduction** on the fractured limb.
{% endstep %}
{% endstepper %}

### Complex Fracture

Depending on the **Surgery Consciousness Controls** settings, the surgical procedure may be different:

* Surgery causes unconsciousness
  * Requires sedation/unconsciousness
  * Requires anesthesia
* Unconsciousness required for surgery
  * Requires sedation/unconsciousness
  * Requires anesthesia
  * Surgical actions fail entirely if the patient is conscious
* No unconsciousness required for surgery
  * Patient may be awake
  * Anesthesia not required
  * Causes pain
* Surgery anesthesia
  * Patient may be awake
  * Requires anesthesia

The patient is sedated with **Lorazepam** (sedation is removed with **Flumazenil**).\
The patient is given anesthesia with **Etomidate**, and may require multiple doses if the procedure is lengthy.

{% stepper %}
{% step %}

### Sedate the Patient (Optional)

**(SEDATION)** - Push **Lorazepam** to sedate the patient (if conscious).
{% endstep %}

{% step %}

### Induce Anesthesia

**(ANESTHESIA)** - Push **Etomidate** for general anesthesia and reapply it **every 35 seconds** to maintain the anesthetic state.
{% endstep %}

{% step %}

### Incise

Perform an **Incision** with a scalpel on the fractured limb.
{% endstep %}

{% step %}

### Expose Fracture

**Expose the fracture** with a retractor.
{% endstep %}

{% step %}

### Prepare for Open Reduction

Depending on the complex fracture subtype:

* **\[COMPOUND]**: **Irrigate the wound** with 250 ml of saline.
* **\[COMMINUTED]**: **Clamp the wound** with a clamp.
  {% endstep %}

{% step %}

### Open Reduction

Perform an **Open Reduction** using a bone plate.
{% endstep %}

{% step %}

### Discontinue Anesthesia

**(ANESTHESIA)** - Stop administering **Etomidate**.
{% endstep %}

{% step %}

### Reverse Sedation

**(SEDATION)** - Push **Flumazenil** to remove the sedation.
{% endstep %}

{% step %}

### Wake Patient

The patient is now ready to be woken up. Reorient the patient or use Ammonium Carbonate to assist revival.
{% endstep %}
{% endstepper %}