Emergency Flashcards
What is the risk of CT scan in pregnancy?
?doubled risk of child cancer from 1-2/1,000
about 10mSv dosage for CTAP
What are the common causes of colonic pseudo-obstruction?
Orthopaedic trauma/surgery
Pneumonia/sepsis
ARF
Medications (opiates)
Electrolyte abnormalities
What pathogens most frequently cause cholecystitis?
E.coli > Enterococcus > Bacteroides
What factors are vital to obtain informed consent ?
-Understand information relevant to decision
-Retain information
-Use or weigh up that information
-Communicate decision
What legal principle underlies capacity?
Mental Capacity Act 2005
Assumption of capacity until proved otherwise
Decision specific
What risk factors are there for C.Diff infection?
Host -immune status, comorbidity, age >65, IBD, malnutrition
Exposure - hospitalisation, community sources, care facilities
Disruption - antibiotics, surgery
What factors suggest Severe C.diff infection?
WCC >15
AKI stage 1+
T>38.5
Albumin<25
Fulminant 1-3%
What type of organism is C.Diff?
Gram +ve anaerobic spore-forming bacillus
Produces enterotoxin (A) and cytotoxin (B)
How can ERCP perforations be Graded?
STAPFER classification
1 - GI tract wall (traction)
2 - peri-ampullary (sphinctertomy)
3 - bile ducts (guide wire/basket)
4 - retroperitoneal
What are the risk factors for ERCP perforation?
Periampullary diverticulum
Ampullectomy
Small calibre CBD
Longer duration of procedure
Sphincterotomy
What adrenaline is used in UGIB?
1:10,000 in quadrants
NICE recommends this + something else
What are the NICE indications for CT scan after head injury?
GCS <13 any time
GCS <15 at 2 hours
Suspected open/depressed/basal skull fracture
Seizure
Neurological deficit
>1 episode of vomiting
Amnesia >30minutes
Also any LoC with age >65 or coagulopathy, dangerous mechanism
What are the causes of ischaemic colitis?
Occlusive (small vessel disease inc radiation/vasculitis)
Non-occlusive (flow)
What is the role of nuclear red cell scanning in LGIB?
Technetium-99m labeled RBC scan can detect as low as 0.1-0.5ml/min bleeding (>1 for CT)
What factors increase the likelihood of mesenteric venous thrombosis?
Portal hypertension (Liver Cirrhosis)
Inflammatory (Sepsis, IBD, pancreatitis)
Hypercoagulable states (Malignancy, Dehydration, thrombophilia, thromboyctosis, COCP)
What are the zones of the neck?
Zone 1 - Sternal notch to cricoid (Subclavian, inomminate, common carotid, vertebral, jugular)
Zone 2 - Cricoid to angle of mandible (common carotid, bifurcation, veterbral arteries and jugular veins)
Zone 3 - Angle of mandible to base of skull (branches of ECA, ICA, vertebral, internal jugular)
What are hard and soft signs of vascular injury?
Hard - absent pulses, bruit/thrill, active haemorrhage, expanding haematoma, distal ischaemia
Soft - haematoma, past haemorrhage, hypotension, peripheral nerve injury
What scoring system is helpful for Nec Fasc?
LRINEC scoring system
Biochemical markers
What is the definition of an infant, toddler, pre-school, school-age and adolescent?
Infant - 0-1
Toddler - 1-3
Pre-school 3-5
School age - 6-12
Adolescent >12
How can a Childs weight be estimated?
2 x (age + 4)
What size ET tube should be selected for children?
Cuffed - 3.5 + (age/4)
What abdominal injuries are more common in children than adults?
Duodenal haematoma
Pancreatic injury
Bladder rupture
Small bowel rupture at ligament of Trietz
What is acceptable SBP in children?
70 + (age x 2)
UO 1.5-2ml/kg
What fluid resuscitation should be given to children?
10-20ml/kg warmed crystalloid
What size chest drain would use in a trauma setting?
28-30fr
What are the indications for thoracotomy in blunt chest trauma?
> 1500ml initial blood
200ml/hr for 4 hours
Consider - exsanguinating abdominal vascular injuries, unresponsive hypotension (<70), with witnessed signs of life
What are the indications for thoracotomy in penetrating chest trauma?
Witnessed cardiac arrest with <10minutes loss of CO
What is Beck’s triad?
Muffled heart sounds
Low blood pressure
Distended neck veins
- Tamponade
How should perforated peptic ulcer be closed?
WSES
<2cm primary repair +/- omental patch
>2cm consider resection
nb biopsy gastric
in septic shock adopt a damage control approach
What are the principles of non operative management of splenic trauma?
1) Fasted patient
2) Admission to critical care setting
3) Bed rest with analgesia for 5-7 days
4) Regular reassessment of patients clinical condition
5) Consider repeat CT scan at 10 days for evidence of splenic artery pseudo-aneurysm (peak rupture at 7-10days)
What are Truelove and Witts criteria?
For severe UC
Severe if:
Bowel motions >5
T >37.5
HR >90
ESR>30/CRP>45
Hb<10
What are the causes of mesenteric ischaemia?
Arterial embolism (50%)
Arterial thrombosis (20%)
Mesenteric venous thrombosis (10% - ProteinC/S/AT-III/FVL or secondary)
NOMI (20%)
How might you assess intestinal viability at cut edges?
Clinical - colour, pulsation, peristalsis, bleeding
Physiological - doppler probe, flourescence, IcG
Temporary abdominal closure
What are the 6 ps of acute limb ischaemia?
Pale
Pulseless
Paralysed
Paraesthesia
Painful
Perishingly cold
What is the risk of abnormality in a macroscopically normal appendix?
25-35%
What is a hydatid of morgagni?
Embryological remnant of cranial end of Mullerian duct attached to tunica vaginalis
What clinical signs are suggestive of torsion?
swollen, high-riding testicle
difficult to palpate cord
horizontal lie
absent cremasteric reflex
What are the causes of anastomotic leak?
Local factors
- Technique (tension, vascularity)
- Infection
- Radiation
- Missed proximal obstructing lesion
- Low anastomosis
- >500ml Blood loss
General factors
- BMI>30
- Crohns disease
- Malnutrition
- Anaemia
- Steroids
- Diabetes
- Age
- Smoking
How is cellulitis classified?
1 - No systemic toxicity
2 - Significant comorbidity
3 - Significant systemic upset
4 - Necrotising fasciitis
What is the purpose of damage control surgery?
Arrest haemorrhage
Minimise contamination
Which patients are most likely to need a damage control laparotomy?
pH<7.2, T <34, coagulopathy
Lactate >5, BD >6
At what B-HCG level would you expect a visible intra-uterine gestation to be visualised on USS?
> 1500
How are entero-cutaneous fistulae classified?
High (>500ml),
Moderate (200-500ml),
Low (<200ml) output
Location
- Type 1 (OGD)
- Type 2 (Small bowel)
- Type 3 (Colonic)
- Type 4 (Entero-atmospheric)
What are the common causes of enterocutaneous fistula
Iatrogenic 75-85% (Trauma, inter-operative, leak)
Spontaneous 15-25% (IBD, Malignancy, infection e.g. TB/actinomycosis, radiation, ischaemia)
How should patients with entero-cutaneous fistula be managed?
SNAP
Procedure - >6 weeks
What is the differential diagnosis of a painful groin lump?
Skin (Cyst, abscess)
Fat (lipoma)
Muscle (hernias)
Vein (Varix)
Artery (aneurysm)
Nerve (Schwannoma)
Lymph node
Psoas bursa
How do bullets cause injury?
Laceration and cutting (higher with Low velocity)
Cavitation (negative pressure due to temporary expansion entraining air, higher with HV)
Direct energy transfer
Fragementation
What are the causes of a raised ICP?
Surgical
- Extradural haematoma
- Subdural haematoma (tearing of dural bridging veins)
- SAH
- Contusions
- Diffuse axonal injury
Medical (Electrolyte, ischaemia, infection)
How does CO2 embolus present?
Pressure differential between abdomen and thorax forces gas through
Sudden cardiovascular collapse by interfering with RV function
Machinery-type murmur, hypotension and hypoxia
How should CO2 embolus be treated?
Vent abdomen
Place in left lateral position with head down
Insert central line into RV and aspirate air bubbles
What is the risk of seroconversion after needle-stick?
0.3% needle stick HIV+
0.1% Mucocutaneous contamination HIV+
0.5-1.8% needle stick HCV+
30% Hbe Ag+ non-immune
What would make you abandon a resuscitative thoracotomy?
Visible air in coronary vessels
Aortic disruption
Unable to fill heart after 5 minutes
No spontaneous rhythm after 10 minutes
Unable to maintain SBP >70 or carotid pulse after 15 minutes
What are the potential sources of bleeding in pelvic trauma?
Venous plexus (90%)
Bony surfaces
Arterial
Intra-pelvic organs
Extra-pelvic injuries
How can pelvic fractures be classified?
WSES Minor (Grade 1) Haemodynamically/mechanically stable
WSES Intermediate (Grade 2/3) Haemodynamically stable /mechanically unstable
WSES Major (Grade 4) Haemodynamically unstable
Also Young-Burgess and Tile classifications.
If more than 1 breakpoint then unstable
Vertical shear or open book
What are the common causes of postoperative fever?
Seven Cs - Cut, Chest, Cannula, Catheter, Central Line, Collection, Clot
Immediate - endocrine
Day 0-2 - Atelectasis, reaction to implanted graft
Days 3-5 - UTI/Pneumonia
Days 5-7 - Wound infection, abscess, leak
Days 7-10 - DVT
Any time - Line sepsis, transfusion reaction, drug reaction
What are the components of the GCS?
Eyes 1-4 None, Pain, Voice, Spontaneous
Motor 1-6 None, Extension, Flexion, Withdraws from pain, Purposeful to painful stimulus, Commands
Voice 1-5 None, Incomprehensivble, Inappropriate with discernible words, Confused, Oriented
Which organ is most often damaged by penetrating stab wounds?
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Which organ is most often damaged by gunshot?
Small bowel (50%)
Colon (30%)
Liver (20%)
What proportion of abdominal stab wounds do not penetrate the peritoneum
1/3
How should a colonic laceration be repaired?
In general with a primary closure
Which organ is most frequently injured by blunt trauma?
Spleen
Which organisms are involved in Post splenectomy sepsis?
Encapsulated organisms - Neisseria meningitides, Haemophilis Influenzae and Streptococcus Pneumoniae
In major perineal wounds (E.g. devolving), what abdominal procedure is often required
End colostomy
Which artery is the classical cause of a traumatic extradural haemorrhage?
Middle meningeal
What is the Cushings reflex?
Hypertension and Bradycardia caused by raised ICP (Munroe Kellie doctrine)
What is an appropriate cerebral perfusion pressure (MAP-ICP) in adults and children?
70 in adults, 40-70 in children
What cranial nerve is most frequently involved after head injury and raised ICP?
3rd nerve - occulomotor - caused dilated pupils with poor light response
Often associated with 4,5 and 6th nerve palsies
What is the major mechanism of pancreatic injury?
Deceleration injury
What is the most reliable imaging where pancreatic injury is suspected?
MRCP >CT for ductal injuries
What are the indications for clamshell thoracotomy?
Penetrating trauma with cardiocirculatory arrest, <15min of CPR
What blood products should be given in a major haemorrhage situation?
PRC, FFP and Platelets in a 1:1:1 ratio
Remember TXA (CRASH study)
What is the most common cause of diaphragmatic injury?
Blunt trauma causing large radial tears (laceration –> smaller tears)
More common on left
Initial CXR normal in 50% of cases
Treatment with surgery
What are the defining characteristics of the 4 stages of shock?
Stage 1: <750ml/15%
Stage 2:750-1500ml 15-30%
Stage 3:1500-2000ml 30-40%
Stage4: >2000ml, >40%
Stage 1 Normal
Stage 2 Tachypnoea, HR100-120, reduced UO
Stage 3 HR120-140, BP reduced, poor UO, confused
Stage 4 HR>140, v.low UO
What antibiotic prophylaxis is required after splenectomy?
Probably 250mg BD Amox.
Consider septrin if allergic
What are the classification systems for splenic trauma?
AAST (1-5)
1 - sub capsular haematoma <10%, capsular tear <1cm depth
2 - sub capsular haematoma 10-50%, intraparenchymal <5cm, 1-3cm lac
3 - haematoma sub capsular >50%, ruptured haematoma, intraparenchymal haematoma >5cm or >3cm laceration
4 - devascularisation of >25% of spleen
5 - shattered spleen, hilar disruption
and WSES (1-4)
1- AAST 1-2, stable (NOM)
2- AAST 3 , stable (consider angio)
3 - AAST 4-5, stable (all angio)
4 - AAST 1-5, unstable - Operative managment
What are the risk factors for failure of non operative management of splenic injuries?
Age >55
High injury severity score
AAST IV-V injuries
Where will an embolus most frequently lodge in mesenteric ischaemia?
SMA distal to origin of middle colic and pancreaticoduodenal
How do you perform a four compartment fasciotomy?
Anterior incision - for anterior and lateral compartments - 2 finger breadths lateral and below tibial tuberosity to two finger breadths proximal to lateral malleolus - then 2 x fascial incisions
Posterior incision - 2 finger-breadths posterior to medial border of tibia and 2 FB distal to head to 2FB sup to medial malleolus, then sup fascia opened and deep entered by taking gastrocneumeus/soleus down
Risk - Anterior - superficial peroneal
Posterior - long saphenous vein
How would you gain access and to and control of the femoral artery?
- Longitudinal incision from midinguinal point down
- Through fascia lata to identify CFA, SFA and PFA, then sling and clamp
Which vein is most at risk when dissecting out the PFA?
Lateral femoral circumflex vein
If the CFA is inaccessible through haematoma how may proximal control be obtained?
Through dividing the inguinal ligament or posterior inguinal canal
Which vessel injury carries the highest rate of limb loss?
Popliteal
How is the popliteal artery accessed through a medial approach?
Proximal - Incision between vastus medialis and sartorius. Incise deep fascia posterior to femur and palpate artery immediately behind bone - artery is medial here
Distal - separate incision 1cm behind tibia from medial femoral condyle, through the deep fascia avoiding the vein which is medial to the artery here
What is the most superficial structure in the popliteal fossa?
The tibial nerve. Starts laterally and passes medially
The artery is deepest
Encountered first in a medial exploration proximally then after the vein distally
What is the Mattox maneuver?
Complete left medial visceral rotation to access aorta
How is the axillary artery best accessed?
Supine, arm abducted. Transverse incision inferior to clavicle through pectoralis major.
Exposure and division of clavipectoral fascia to identify axillary vein.
May need to divide thoracoacromial artery (superficial branch)
Which is the most frequently injured peripheral artery?
Brachial
How is the brachial artery accessed?
Supine, arm abducted, incision in groove between biceps and triceps
Incise deep fascia, avoiding basilic vein at lower aspect
First aspect encountered is median nerve (starts lateral and passes anteriorly)
Distally - S shaped incision across ACF, with brachial artery bifurcation immdeidately deep to biceps tendon
How do you access the suprarenal aorta?
Open the gastrohepatic ligament and palpate the aorta against the vetebrae
How do you access the infrarenal aorta?
Kocher Maneuver to access retroperitoneum and dissect proximally to renal veins
What is the mortality of patients with acute pancreatitis?
15-20% as inpatient
If gallstones and alcohol are excluded as causes of pancreatitis, what other causes need to be investigated?
1 - metabolic (hypercalcaemia, hyperlipidaemia)
2 - prescription drugs
3 - microlithiasis
4 - hereditary causes PRSS1 mutation (AD)
5 - Autoimmune (IgG4)
6 - malignancy
7 - Anatomical abnormalities
When should enteral nutrition be instituted for patients with pancreatitis?
Within 48-72 hours. There is no difference between OG/NG if tolerated
(NICE)
Decreases sepsis, organ failure, surgery and mortality when compared to TPN (Frontline gastroenterology 2018)
Bakker RCT - no difference in Oral or NG feeding. Tolerated in 69% of severe
How should patients with infected pancreatic necrosis be managed?
Endoscopic if possible > Percutaneous
(NICE)
What complications are associated with chronic pancreatitis?
- Pancreatic duct obstruction (?surgery or ESWL)
- Pseudocysts (drain if symptomatic or duct disruption)
-Ascites
-Type 3c diabetes
(NICE)
What monitoring should patients with chronic pancreatitis undergo?
Exocrine function and malnutrition every 12 months, 2 yearly DEXA
(NICE)
What are Cullen’s, Grey-Turner and Fox’s signs?
Retroperitoneal bleeding –> bruising around:
Cullens - umbilicus
Grey-Turner - flank
Fox - inguinal ligament
How should patients with pancreatitis be fluid resuscitated?
Goal directed, with CSL at 5-10ml/kg/hr (APA guidelines)
Aim for HR< 120, MAP65-85, UO>0.5-1
What are the Atlanta criteria for fluid collections in pancreatitis?
<4 weeks - acute fluid collection or acute necrotic collection
>4 weeks - pseudocyst or walled off necrosis
A diagnosis of infection can be made from presence of gas on CT.
How should WON and pseudocysts be managed?
Best is probably cystogastrostomy, with lumen apposing metal stent (LAMS) for WON
What is the most common cause of mortality in patients with chronic pancreatitis?
Cardiovascular
What is the most prognostic criteria for pancreatitis?
Presence of SIRS - 2/4 of
T>38/<36, HR>90, RR>20, WCC<4/>12
At 48hrs >admission
CRP >150
Urea >20
How is pancreatitis graded on CT?
Balthazar severity index
- Grade 1-4 + necrosis <30,30-50,>50
What is the rate of recurrence in the short term following gallstone pancreatitis?
18% recurrence in 6 weeks.
If have ERCP, still 10%
What are the Atlanta criteria for severity of pancreatitis?
Mild - interstitial oedematous, no failure, resolves in 1 week (80-85%)
Moderate - transient organ failure, local complications
Severe - persistent organ failure
What are the classical signs of appendicitis?
Rosvings sign
Obturator sign - RLQ pain with int/ext rot right hip
Psoas sign - RLQ pain with extension of right hip
What scoring systems are useful in appendicitis?
Acute appendicitis score in women
Appendicitis inflammatory response score in men
Most important factor is location/severity of pain
If low risk - <1% risk of advanced appendicitis
What threshold should be used for CT in suspected appendicitis?
> 40 (WSES Jerusalem guidelines 2020)
What is the incidence of recurrence of appendicitis treated with antibiotics?
26.4% at 1 year and 39.1% at 5 years (APPAC trial)
Of IV antibiotics - 8% initial failure
CODA trial - 30% failure at 3 months
What technical aspects of appendicectomy are evidence based?
WSES Jerusalem guidelines
- Suction only in complicated disease
- no difference in mesoappendix control
- stump control loop or suture
- no drains
For patients managed non operatively for perforated appendicitis how should they be followed up?
<40 - nothing unless symptomatic
>40 3-17% risk of cancer –> colonoscopy and CT
For patients managed non operatively for perforated appendicitis how should they be followed up?
<40 - nothing unless symptomatic
>40 3-17% risk of cancer –> colonoscopy and CT
What is the incidence of microscopic abnormalities in a macroscopically normal appendix?
25-35%
Which bacteria typically cause cellulitis?
Streptococcus pyogenes and staphylococcus aureus
What is the trauma triad?
Hypothermia
Metabolic acidosis
Coagulopathy
How can entero-cutaneous fistulae be classified?
Output -
High >500ml in 24 hours
Moderate 200-500ml in 24 hours
Low - <200ml in 24 hours
Organ
Type 1 - Oesophageal/gastroduodenal
Type 2 - Small bowel
Type 3 - Colonic
Type 4 - enteroatmospheric
What is the Catell Brasch manoeuvre?
Medial visceral rotation from the right
What are the zones of the retroperitoneum?
Zone 1 - midline from hiatus to bifurcation
Zone 2- lateral kidneys to bifurcation
Zone 3 - bifurcation to pelvis
Zone 1 all need exploring (also divided supra/inframesocolic - supra/infrarenal control)
Zone 2/3 explore penetrating if expanding. Can be observed blunt and not expanding
How are ERCP perforations classified?
Stapfer classification
1) Hole lateral/medial wall - endoscope mania
2) periampullary (sphincterotomy related)
3) Distal ductal
4) retroperitoneal air (guide wire)
What is the velocity of a high velocity gunshot wound?
> 300m/s
What are the mechanisms of injury with gunshot?
-Laceration/cutting
-Cavitation
-Direct energy transfer on impact
-Fragementation
When should OGD be performed with caustic ingestion?
<24 hours - risk of perforation maximal about 3 days
What pressure should a Sengstaken Blakemore tube be inflated to on insertion?
35-40mmHg then deflate to 25
Traction weight of 0.5-1kg after this
What proportion of patients with oesophageal caustic injuries develop cancer?
7-15% adenocarcinoma (x 1000 risk)
Where are areas of likely impaction in the oesophagus?
1) Cricopharyngeus
2) Aortic arch/tracheal bifurcation
3) Diaphragm
What are indications for emergency OGD (<6hours) after FB ingestion?
Sharp (35% perforation)
Batteries
Complete obstruction
What proportion of patients with an oesophageal FB obstruction will have underlying disease?
25% (Schatzki ring, eosinophilic oesophagi’s, achalsia, tumours)
What is the initial investigation for patients with caustic oesophageal injuries?
Contrast CT > OGD (absence of post contrast wall enhancement)
CT classification
1 - mucosal oedema
2a - mucosal/submucosal oedema - target appearance
2b - rim of external enhancement, necrotic muocsa
3 - necrotic (Absence of PCWE)
What is the Zargar classification of oesophageal caustic injury?
0 Normal
1 superficial mucosal edema
2a superficial ulceration, erosion
2b deep ulceration, erosion
3a focal necrosis
3b extensive necrosis
4 perforation
For grade 2b - 80% chance of strictures in future
Grade 1-2a usually recover quickly
Grade 3+ need surgery
When do strictures occur following caustic ingestion?
Within 4 months - usually should be attempted within 3-6 weeks here few (<3) and short <5cm
What are the aetiologies of oesophageal perforations?
60% OGD
15% Boerhaave
Other - trauma, malignancy, FB, caustics
What is the management of choice for endoscopic oesophageal perforation?
Endoscopic closure and SEMS
SEMS>Surgery - WSES guidelines
Minimum of 2-4 weeks
In which patients with oesophageal perforation can non-operative management be adopted?
Altorjay criteria
- Early
- Well
- Cervical or contained perforation
- No pre-existing pathology
- Can be surveilled
Also Pittsburgh classification
What are the principles of surgery for oesophageal perforation (6)?
Exposure
Debridement (mucosa>muscularis)
Closure (2 layer - 25% breakdown +/- T-tube)
Buttress
Drainage
Nutrition
How is haemodynamic instability defined in adults?
1) SBP <90 with skin vasoconstriction, confusion, dyspnoea or:
2) SBP>90 but
- requiring vasopressors
- requiring bolus infusions
- BE ≥-5
- PRC requirement of >4 in 8 hours
WSES 2020
How are liver injuries graded by the WSES?
Minor (AAST 1-2 stable)
Moderate (AAST 3 stable)
Severe (AAST 4-5 stable or 1-6 unstable)
What is the AAST liver trauma classification?
1: Lac <1cm depth or sc haematoma<10%
2:Lac 1-3 depth <10cm or sc haematoma 10-50%
3:Lac >3cm depth or SC >50% or IC haematoma >10cm
4:Disruption of 25-75% hepatic lobe
5:Disruption of >75% hepatic lobe
6: Hepatic Avulsion
What is the AAST splenic trauma classification?
1 - <1cm or <10%
2 - 1-3cm depth lac or 10-50% surface SCH
3 - >3cm lac or SC haematoma >50% or IC haematoma >5cm
4 - >25% devascularised
5 - shattered spleen/devascularised hilum
What is the WSES Splenic trauma classification
Minor WSES 1 - AAST 1-2 stable
Moderate WSES 2 - AAST 3 stable
Moderate WSES 3 - AAST 4-5 stable
Severe WSES 4 AAST 1-5 unstable
When should stable patients with liver trauma undergo angioembolisation?
Positive blush, early aneurysm irrespective of injury severity (perhaps not in children)
In whom with splenic injuries should angioembolisation be mandatory according to the WSES?
Stable patients with AAST 4/5 disease
What are risk factors for failure of non-operative management in splenic trauma?
Age >55
High ISS
Moderate to severe splenic injury
In patients with splenic injuries how long should bed rest be recommended for?
72 hours
How should patients with Cirrhosis be surveilled for varices?
OGD at diagnosis
- No varices –> rescope 2-3 years
- G1 varices –> rescope 1 year
- G2/G3 varices or red signs –> Propranolol or VBL
How should patients presenting with bleeding oesophageal varices be managed?
Standard then VBL
+Antibiotics, terlipressin/somatostain/octreotide
Secondary prophylaxis after D5 with VBL+NSBB
If Childs B with bleeding or Childs C –> TIPSS
How should patients with gastric variceal bleeding be managed?
Cyanoacrylate injection or thrombin
+Antibiotics, terlipressin/somatostain/octreotide
Secondary prophylaxis after d5 with cyanoacrylate injection. Consider NSBB or thrombin
When should splenectomy be considered in variceal disease?
Gastric varices with splenic vein thrombosis or left side portal hypertension
What are the defining characteristics of a massive haemorrhage?
Loss of 50% Circulating volume in 3 hours
Loss of 100% Circulating volume in 24 hours
Loss of >150ml/min
Transfusion of 4 units in 4 hours with bleeding
Transfusion of 10 units in 24 hours
Where does the brachial artery begin?
Lower border of Teres Major
How should patients with delayed presentation of traumatic diaphragmatic hernia be managed?
VATS/Thoracotomy
What is the indication for vATS with traumatic pneumothorax?
Persistent air leak at 3 days
What is the most frequent biochemical abnormality seen in burns patients?
Hypernatraemia
What proportion of blunt renal injuries can be managed conservatively?
Up to 90%, even with urine extravasation.
If required consider endo-ureterologic and percutaneous drainage (if stable)
What are the most common organisms of infection after human bites?
Strep > Staph
When is the benefit of TXA seen in a trauma setting?
If given within 3 hours
What are the hard signs of major vascular injury in the neck?
Rapidly expanding or pulsatile haematoma
visible exsanguination
thrill or bruit
dense neurological deficit
Presence of any –> theatre
Which main vessel cannot be accessed easily through a midline sternotomy?
Proximal left subclavian (anterolateral thoracotomy at 3rd IC space)
What is the most common complication of peptic ulcer disease?
Bleeding - 0.02-0.06% annual incidence, 30d mortality of 8.6%
Perforation less common but higher mortality
What are risk factors for PUD?
NSAIDS (inhibit PDE synthesis)
Smoking (inhibits HCO3- increases acid)
H.Pylori
Bariatric marginal ulcer
FAsting
Drugs
Zollinger-Elliison
Steroids
Alcohol
Bevacizumab
How often is free air seen on cxr in a perf DU?
30-85% of cases
What predictors of outcome are available for Perf DU?
NELA
Boey, PULP, ASA, Hypoalbuminaemia
When might non-operative management be appropriate for perf DU?
-demonstrated sealed on water soluble contrast study
-<70 and less comorbid
need - NBM, IVI< NGT, PPI+/-octreotide, Abx
What evidence is there for laparoscopy in perf DU?
WSES guidelines recommend if stable then attempt laparoscopy.
Meta-analysis by Cirocchi - less pain, less wound infections
How would you fix a small perforated ulcer?
If <2cm, no evidence to support omental patch over suture closure alone (WSES 2020), however the additional risk appears small so its probably sensible
Single drain at suture site
How would you fix a large perforated ulcer?
- suspicion of gastric malignancy - 10-16% of gastric perforations
- if Gastric/D1 - resection/reconstruction
- if ampullary - pyloric exclusion, gastric decompression and external biliary diversion
What medical treatments are required in the post operative period after perf DU repair?
Broad spectrum antibiotics covering gram+ve, gram-ve and anaerobes - e.g. Co-amoxiclav and gent
Collect fluid samples
Consider antifungals if immunocompromised, old or comorbid (Azoles if not previously exposed, if previously exposed then give echinocandins)
When would you endoscope following treatment of perf PUD?
for gastric at 6 weeks
What scores can be used to predict UGI bleeding risk pre OGD
Glagow-Blatchford - if ≤1 then very low chance of requiring intervention
if ≥7 very high risk
For patients with non-variceal UGI bleed, what adjunctive medical treatments should be used?
Prokinetics (erythromycin) and PPI infusion IV for 72 hours then 6-8 weeks -halves rebreeding risk.
If platelets <50 then infusion
Transfusion trigger of 70
What endoscopic interventions are suggested for UGI bleed?
If Forest 1a/1b/2a (i.e. vessel spurtin/oozing/visible) –> dual modality endoscopic
How should anticoagulants be managed with UGIB?
Continue aspirin
Stop clopidogrel etc until haemostasis unless stents (40% risk of death/MI within 1 year), aim restart 5-7 days)
Stop warfarin/doacs
What is the incidence of staple line bleed after colorectal surgery?
1-2%
When should a patients be taken back to theatre for a relook after having bowel stapled off inside?
24-48hrs
When should a cholangiogram be performed after insertion of a cholecystostomy?
4 weeks
What adjunctive therapies can be used for food boluses?
Buscopan and fizzy drinks
Are acid or alkali caustic injuries worse?
Acid –> Coagulation necrosis - protects against further damage
Alkali –> Liquifactive necrosis, saponification and cell death with threat to airway, more likely stricture
How can oesophageal strictures be graded
Archand classification
Grade 1 Short non circumferential
Grade 2 Short circumferential elastic,
Grade 3 <1cm circumferential, fibrotic
Grade 4a >1cm, easily dilated
Grade 4b - deep fibrotic progressive
How often is Mackler’s triad seen in Boerhaaves?
15%
What is the Forest Classification?
Endoscopic description of UGI bleeding findings
1-3
1- bleeding
2-pathology likely to bleed
3 - pathology
What treatment should patients identified to have a Forest 2c lesion receive?
Medical only for 2c/3 (i.e. haematin on ulcer or clean based ulcer)
What single preendoscopy treatment has been shown to improve outcome in patients with variceal bleeds?
IV antibiotics
When is the recommended timing of OGD for UGI bleed?
Within 24 hours (unless unstable or variceal)
What are the types of Peptic Ulcer?
Johnson criteria
1 - lesser curve
2 - gastric and duodenal (acid hyper secretion)
3 - prepyloric (Acid hyper secretion)
4 - GOJ
5 - drug induced, anywhere
What is a normal intra abdominal pressure?
5-7mmHg in critically ill
How is abdominal compartment syndrome defined?
Pressure >20mmHg with new organ dysfunction
What treatments should be instituted for a diagnosis of abdominal compartment syndrome?
Gastric decompression
Muscle relaxation/sedation
Drain collection
Consider fluid restriction/diuretics
If fails –> Laparotomy
How quickly will IV iron achieve results?
About 3 weeks
How does the AAST grade renal injuries?
1 - Subcapsular/no parenchymal/haematuria
2 - <1cm parenchymal injury
3- >1cm parenchyma injury without damage to collecting system or urinary extravasation
4 - parenchymal injury extending through cortext, medulla and collecting system or main vessel injury with contained haemorrhage
5 - shattered kidney or avulsion of hilum
In delayed ureteral injury presentation with complete transection, how should these patients be managed?
Nephrostomy and delayed reimplantation
How should intraperitoneal bladder rupture be managed?
Operative repair
What is the management of choice for anterior urethral injuries?
Endoscopic realignment - if fails –> surgery
How should bleeding from the main renal vein be managed?
If not self limiting this is an indication for surgery
How should bleeding from the main renal vein be managed?
If not self limiting this is an indication for surgery
What is the success rate of conservative management of SBO?
70%
(Bologna guidelines 2017)
What is the benefit of laparoscopy in the surgical management of SBO?
Reduced LoS (LASSO trial 2019)
What is the recurrence rate of adhesive SBO after surgery for similar?
19-53% (Bologna guidelines)
How may adhesions be classified?
Zuhkle classification
Grade 0 - none/insignificant
Grade 1 - Fimly adhesions dissected bluntly
Grade 2- mostly blunt and some sharp
Grade 3 - sharp dissection only with clear vascularisation
Grade 4 - dense adhesions with no planes and difficult to avoid damage
What is the Peritoneal adhesion index?
Grade of adhesions from 0-3 (similar to Zuhkle without the intermediate grade 2 from filmy to strong)
In 10 regions
therefore 0-30
What is the benefits of non-operative management of adhesive SBO?
Hajbandeh meta-analysis 2017
operation –> higher risk of mortality and complications
no difference in LoS or reintervention
What types of anti-adhesive can be used?
For open surgery
- seprafilm (carboxymethylcellulose)
For lap
-adept (icodextrin) liquid
How is WSCS useful in SBO?
Bologna guidelines 2017
- if no contrast in colon at >24 hours, cons mx likely to fail
- reduces need for surgery (OR 0.6)
- reduces LoS, time to resolution, no effect on complications
How should SBO be managed in pregnancy?
High rate of failure of cons mx (94%)
Risk of foetal loss of 17%
When should laparoscopy be attempted in sBO?
If surgery indicated and:
-sufficient expertise
-≤ 2laparotomies in history
- expecting single band
Bologna guidelines 2017
How is appendicitis graded by the AAST?
1 - acutely inflamed
2 - gangrenous intact
3 - perforated local contamination
4 - perforated with phlegm or abscess
5 - perforated with generalised peritonitis
What are the Zone for insertion of a Reboa?
1: Descending thoracic aorta above renal
2: Infradiaphragmatic Juxtarenal
3: Infrarenal to bifurcation
What is the key mediator of acute traumatic coagulopathy?
APC
How is the ISS score calculated?
The square of the 3 highest AIS scores
Maximum of 75
>16 is major trauma
What percentage of blunt trauma in the UK is caused by falls and MVCs?
50% and 30%
What percentage of cardiac index is produced by internal and external chest compressions?
Internal 40%
External 20%
How can traumatic brain injury be graded by GCS?
≤8 Severe
9-12 Moderate
13-15 Mild
When can rivaroxaban be restarted following removal of epidural?
6 hours
What is the NCEPOD urgency categories?
1 Immediate <2 hours
2a Urgent 2-6 hours
2b Urgent 6-18 hours
3 Expedited 18 hours +
What are NELA treatment criteria?
Presurgery - timely imaging, antibiotics and decision making by consultant (review 14 hours). Assessment of frailty/involvement of MOP
Intra-operative - care delivered by a consultant surgeon and anaethetist, particularly where high risk
Post-operative placement of high risk patients to critical care
What is the Alvorado score?
MANTREL
Migratory pain
Anorexia
Nausea
Tenderness RIF (2 points)
Rebound
Elevated Temperature
Leucocytosis/left shift (2/1 points)
5-6 pos
7-8 prob
9+ v prob
What is the anatomy of the presacral plexus?
Venous plexus from anastomoses between lateral and median sacral veins –> internal veterbral system
Covers anterior body of sacrum
Worsened by iliac vein ligation (obstructs tributary drainage)
Stop with packing (?re-look) or thumbtacks or haemostats or bone wax
How should a mesenteric haematoma be managed?
If no evidence of ischaemia or active bleeding + stable –> conservative
If stable and some bleeding –> IR
If unstable or ischaemia or significant bleeding –> Theatre + resection
How should a mesenteric haematoma be managed?
If no evidence of ischaemia or active bleeding + stable –> conservative
If stable and some bleeding –> IR
If unstable or ischaemia or significant bleeding –> Theatre + resection
What size of pneumothorax needs draining in trauma?
Evidence inconsistent
Data heterogenous - <1% if <1.5cm, 9% ≤35mm require drainage if initial conservative treatment
How are airway injuries managed with neck trauma?
Early identification of problem
Avoid positive pressure by Face mask
Ideally awake fibreoptic or LA tracheostomy if cooperative
Placement of tip of tube distal to site of injury
If non cooperative BJA recommend RSI and fibreoptic
Avoid cricothyroidotomy
How would you approach a Left subclavian traumatic injury?
High left anterolateral thoracotomy - 3rd interspace
What are the different mechanisms of injury to the bony pelvis?
AP compression (MTC, fall, crush) –> Open book
Lateral compression (MTC) –> internal rotation of hip –> bladder/urethral injury
Vertical shear –> major instability
Complex
How should patients with suspected pelvic injuries be managed?
Suspect if blood/bruising of flank, scrotum, perianal region, urethra
Signs - leg length discepancy in absence of fracture, high riding prostate
Evaluate for stability by pressing on bilateral iliac crest
If suspected injury –> binder
If significant bleeding, first line == IR
If intraperitoneal bleeding, consider laparotomy. If other indication for laparotomy –> that and exztraperitoneal packs
How long would you give antibiotics after appendix mass?
6 weeks (no evidence)
How do you access the popliteal artery
Medial approach
Proximal -
– Incise groove between sartorius and vastus medalis
– Incise deep fascia palpating posterior femur then palpate artery and dissect it out
Distal -
– Incise 1cm behind border of tibia posterior to femoral condyle anterior to GSV
– Open deep fascia to exposure neurovascular bundle behind the tibia with vein first structure
