Senior Surgery Flashcards
A 23 y/o man presents to A&E with a 1 day history of 8/10 central abdominal pain, that is now more prominent in the RIF. He has not vomited but describes a loss of appetite and some diarrhoea. On examination he has a tender abdomen especially in the RIF, with rebound tenderness and Rovsing’s sign +.
What is the most appropriate next step?
A. Book a laparoscopic appendicectomy
B. Give I.V. fluids and analgesia, then observe the patient for 24 hours
C. Order a CTAP
D. Order an USS of the RIF
E. Discharge with oral rehydration salts and safety-netting
A. Book a laparoscopic appendicectomy
No imaging is required in this patient because there is a clear history of appendicitis, so it can be diagnosed clinically. Whilst there is debate about medical vs. surgical management of appendicitis, removing the appendix is the gold standard treatment, and would be most appropriate in this patient given the severity of the presentation. This patient would also receive I.V. fluids and analgesia.
A 79 y/o man is brought to A&E by one of the nurses at his care home for new onset abdominal pain. The pain comes and goes in bursts, though the abdomen is still tender in between episodes. The abdomen is notably distended and resonant to percussion, and the nurse reports the patient has not passed stool for at least 24 hours. The patient has a background of severe Alzheimer’s disease and chronic constipation for which he takes Memantine and Movicol respectively.
Investigations:
HR - 106, BP - 134/78, Temp - 36.9, SO2 - 97% RA
An abdominal x-ray shows the coffee bean sign
Given the likely diagnosis, how should this patient be managed?
A. I.V. fluids, make the patient NBM, sigmoidoscope decompression, and insertion of a flatus tube
B. I.V. fluids, make the patient NBM, and order a colonoscopy
C. Urgent transfer to theatre for laparotomy
D. I.V. fluids, make the patient NBM, insert an NG tube, observe for 24 hours
E. I.V. fluids, make the patient NBM, give laxatives
A. I.V. fluids, sigmoidoscope decompression, and insertion of a flatus tube
This patient has presented with bowel obstruction, most likely due to a sigmoid volvulus - twisting of a section of bowel around its mesenteric axis causing obstruction and sometimes infarction of the bowel. Risk factors include laxative overuse, chronic constipation, neuropsychiatric disorders, advanced age, care home residence, male sex, and previous operations.
It is important to give fluid resuscitation to compensate for 3rd spacing of fluid, and the patient must be NBM in preparation for surgery (and because trying to pass food through obstructed bowel will only exacerbate symptoms). An NG tube serves to decompress proximal bowel, which may well be done here. However this does not actually address the volvulus and it is not suitable to insert an NG tube then leave the patient for 24 hours without addressing the issue.
Management depends on the type of volvulus. They can be sigmoid or caecal: sigmoid constitutes 80% of cases. The caecum doesn’t usually twist because it is retroperitoneal in most people, but in 20% of people it is not and so can twist causing volvulus. The ‘coffee bean’ sign on AXR indicates sigmoid volvulus, whereas the ‘embryo sign’ indicates caecal volvulus.
Management of a sigmoid volvulus starts with conservative measures: IV fluids, analgesia, and a rigid sigmoidoscope decompression with insertion of a flatus tube. If this fails then a flexible sigmoidoscope is needed for decompression. If decompression fails or there is evidence of bowel ischaemia or peforation then a laparotomy will be required.
NB: DO NOT give an obstructed patient laxatives - this will not solve the problem and increases the risk of perforation.
A 56 y/o woman is admitted to hospital with severe epigastric pain and vomiting on a background of previous biliary colic. She is diagnosed with acute pancreatitis, and an USS of the biliary tree shows gallstones within the bile duct, which is dilated.
Which of the following steps should be taken in addition to treatment of the pancreatitis?
A. Give a 7-day course of broad spectrum antibiotics
B. An MRCP scan
C. ERCP, and later laparoscopic cholecystectomy within the same admission
D. Book an elective laparoscopic cholecystectomy within the next 3 months
E. Emergency cholecystectomy
C. ERCP, and later laparoscopic cholecystectomy within the same admission
ERCP is indicated for relieving the obstruction acutely given that gallstones were causative.
According to the UK guidelines on acute pancreatitis, patients presenting with disease caused by gallstones should ideally have a cholecystectomy within the same hospital admission. If this is not possible, then it should be done within 2 weeks to prevent recurrent, possibly serious attacks of pancreatitis.
Link to UK guidelines on acute pancreatiits:
https://gut.bmj.com/content/54/suppl_3/iii1
NICE guidelines:
https://www.bsg.org.uk/wp-content/uploads/2019/12/NICE-Guideline-Pancreatitis-September-2018.pdf
A 24 year old woman presents to A&E with RIF pain that woke her up this morning. The pain is 8/10 in severity, and there is rebound tenderness and involuntary guarding over the RIF.
Describe how this patient should be managed:
This question is asking you how to mention a presentation, not a particular condition, so the approach to investigating and initial management is broader.
A-E assessment first
History + exam:
Abdo + gynae history
Abdo exam +/- gynae exam
Bedside:
Full set of obs
Urine dip + pregnancy test
Bloods: VBG FBC U&Es LFTs CRP
Action: Make NBM I.V. fluids Analgesia Potentially antibiotics Contact emergency/ general surgeons +/- gynae
Imaging:
USS +/- CTAP
Describe the Modified Hinchley classification of diverticulitis
Stage 0 - Clinically mild diverticulitis Stage Ia - Pericolic inflammation Stage 1b - Pericolic abscess Stage II - Pelvic, distant intra-abdominal, or retroperitoneal abscess Stage III - Purulent peritonitis Stage IV - Fecal peritonitis
At what age are men invited to routine AAA screening?
65 years old
Routine screening consists of a single USS aged 65, as a AAA is unlikely to develop if it hasn’t by that age. Women are not routinely offered screening.
What are the 6 p’s of acute limb ischaemia?
Pale Pulseless Painful Paraesthesia Paralysis Perishingly cold
A 52 year old man presents to his GP with a 2 week history of gradual onset back pain. He is otherwise fit and well with no significant PMHx. The GP performs routine examinations including an abdominal exam, and finds a pulsatile, expansile mass in the midline of the abdomen. An USS reveals a 6cm abdominal aortic aneurysm. The patient is referred urgently to surgeons who plan to operate.
Which imaging should be performed, and which surgical technique should be used in this patient?
A. MRI + endovascular repair B. CT angiogram + endovascular repair C. MRI + open repair D. Non-contrast CT + endovascular repair E. CT angiogram + open repair
E. CT angiogram + open repair
Open repairs are preferred if possible because they have lower rates of re-intervention and aneurysm rupture, though they do have a higher 30 day mortality and length of hospital stay. Because of this increased short term-risk open repairs are not suitable for frail or surgically risk patients. Similarly if there is abdominal pathology that will make open intervention complex, open repair may be unsuitable.
However in a relatively young, otherwise fit and well person, an open repair is generally preferred. This is because of the increased need for re-intervention and increased rate of long-term complications following EVAR. There is even evidence that in patients who are truly too frail to undergo open repair do not benefit in terms of life expectancy from EVAR over conservative management.
Thin-slice contrast-enhanced arterial-phase CT angiography is used to evaluate the aneurysm before surgery, both for elective repair and when there is suspicion of rupture.
The European Society for Vascular Surgery guidelines (see p31 for a summary of the evidence):
https://www.esvs.org/wp-content/uploads/2018/12/Wanhainen-A-et-al-ESVS-AAA-GL-2019-epublished-041218.pdf
How often are patients with AAA offered surveillance?
3.0-4.4cm = every 12 months
4.5-5.4cm = every 3 months
Elective repair should be offered for aneurysms 5.5cm or above
What is the most common position of the appendix?
A. Preileal B. Subcecal C. Retroileal D. Retrocecal E. Pelvic
D. Retrocecal
The appendix is most commonly located posteriorly to the caecum.
A 31 y/o man presents with RIF pain which is diagnosed as appendicitis. The surgeon counsels him on laparoscopic appendicectomy, but he is reluctant for surgery and asks about the ramifications of antibiotic treatment.
Without surgery, what is his likely rate of recurrence?
NICE quotes 12-24%, but some studies estimate anywhere between 5-40%
This is a controversial point: some studies done on large numbers of patients bear out a 5-10% risk of recurrence, whereas others point to ~40% risk. Different surgeons will have different opinions on this, but it is important to be aware of the controversy of this and the range of estimates.
https: //cks.nice.org.uk/topics/appendicitis/management/managing-suspected-appendicitis/
https: //jamanetwork.com/journals/jamasurgery/fullarticle/508940
https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC4998395/
https: //jamanetwork.com/journals/jama/fullarticle/2703354
Where is the lump found in a femoral hernia, in relation to the pubic tubercle?
Infero-lateral to the pubic tubercle, and medial to the femoral pulse
This is an important piece of knowledge as it helps to distinguish femoral from inguinal hernias
Why are adhesions far more likely to cause small bowel obstruction rather than large?
Because the small bowel is far more mobile, and so twists itself around the adhesions and obstructs, whereas large bowel is fixed at several points in the abdomen
A 72 y/o woman presents to her GP with a lump at the top of her left leg. The lump is soft, continuous with the skin, infero-lateral to the pubic tubercle, and non-tender. The GP sends her to A&E where a hernia is diagnosed.
What is the best management option for this hernia?
A. Admission, I.V. fluids, insertion of an NG tube
B. Reduction, then surgery to resolve the hernia within 2 weeks
C. Manual reduction followed by discharge with safety-netting advice
D. Admission, I.V. fluids, and watchful waiting
E. Admission, I.V. fluids, and an emergency referral to surgeons
B. Reduction, then surgery to resolve the hernia within 2 weeks
Though the surgeons may well try to reduce the hernia manually, this patient will need surgery ideally within 2 weeks because of the risk of strangulation is high given the femoral canal is narrow and rigid.
A 28 year old 32 week pregnant woman presents to A&E with crampy abdominal pain and vomiting. She has not opened her bowels all day, and says her abdomen looks more distended than it did a couple of days ago. An abdominal exam reveals lower abdominal tenderness. The CTG trace is reassuring and she denies vaginal bleeding.
Which of the following is the most important next step?
A. A DRE B. Inspection of the hernial orifices C. A urine dipstick D. An amylase measurement E. Faecel calprotectin
B. Inspection of the hernial orifices
This is a history of a patient with a femoral hernia, her risk factors being female sex and pregnancy. Femoral hernias can often present with obstruction +/- strangulation due to the narrow, rigid structure of the femoral canal.
How does pancreatitis cause hypocalcaemia?
Fats are autodigested by lipase released outside the pancreas, and the free fatty acids forms complexes with serum calcium, thereby decreasing the serum calcium
What is the most common cause of acute pancreatitis?
Gallstones
Alcohol is the second biggest cause, and is the biggest cause of chronic pancreatitis
What is the basic pathophysiology of acute pancreatits?
Inappropriate activation of pancreatic enzymes, causing an inflammatory response which increases vascular permeability and causes third spacing of fluid.
Pancreatic enzymes enter the systemic circulation and autodigest fats and blood vessels (causing haemorrhage).
In gallstone-triggered pancreatitis, there is pancreatic duct hypertension and build-up of bile salts which triggers these changes. In alcohol-induced pancreatitis, the alcohol itself modifies plasma membrane function and disturbs the balance between proteases and protease inhibitors, leading to the cascade of enzyme activation and autodigestion.
https://pubmed.ncbi.nlm.nih.gov/8119636/#:~:text=The%20pathophysiology%20of%20acute%20pancreatitis,an%20activation%20of%20pancreatic%20enzymes.
A 53 year old lady presents to A&E with rapid onset epigastric pain. She leans forward while sitting as this improves the pain, and has vomited a few times. She is not jaundiced, and provides a prodigious alcohol history. The F2 clerking her suspects alcoholic acute pancreatitis.
Which of the following forms of imaging would be indicated at this stage?
A. ERCP B. USS of the RUQ C. Contrast CT D. CXR E. AXR
D. CXR
According to the UK guidelines for pancreatitis,
“Immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and APACHE II score”.
Th CXR is important because pleural effusions and ARDS are complications of acute pancreatitis.
An USS is unlikely to be helpful here, as there is evidence that this is alcoholic pancreatitis and wasn’t caused by gallstones.
An AXR is not generally helpful for acute pancreatitis.
An ERCP will not be helpful here as there is no suggestion of gallstones.
Contrast CT scans are not very helpful early on as the full extent of the damage takes at least 4 days to become apparent, hence early CT will underestimate the damage. Furthermore CT scans don’t generally affect decisions regarding management of the patient.
However CT scans with contrast are useful in cases where initial investigations are inconclusive or in patients with persisting/ new organ failure a few days after admission, or in those with signs of sepsis.
Link to UK guidelines on acute pancreatiits:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867800/pdf/v054p0iii1.pdf
Which of the following is NOT a predictor for a severe attack of acute pancreatitis when assessed within 24 hours of admission?
A. Amylase >3 times the upper limit of normal B. APACHE II score >8 C. Glasgow score >3 D. BMI >30 E. CRP >150
A. Amylase >3 times the upper limit of normal
Though a level >3 times the upper limit of normal is diagnostic of acute panreatitis, it does not correlate well with severity. Every other option is a predictor for a severe attack when assessed within 24 hours of admission.
Link to UK guidelines on acute pancreatiits:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867800/pdf/v054p0iii1.pdf
Name the 3 main branches of each of:
Coeliac artery
SMA
IMA
Coeliac artery - splenic, common hepatic, left gastric
SMA - right colic, ileocolic, middle colic
IMA - left colic, sigmoid artery, superior rectal artery
A patient has a section of bowel from the mid-descending colon to the mid-rectum removed. They are left with a closed rectal stump and a colostomy.
Which operation have they had?
A. Right hemicolectomy B. Hartmann's procedure C. Anterior resection D. Elective sigmoidectomy E. Left hemicolectomy
B. Hartmann’s procedure
Hartmann’s procedure is an emergency resection of the sigmoid colon e.g. for perforation or obstruction. It involves the formation of a colostomy and stump instead of an anastomosis because there will be bowel dilation proximal to the lesion which would make anastomosis difficult. The colostomy can be reversed and the bowel rejoined to the rectum at a later time.
Why does bowel resection for malignancy also involve removing the associated arteries?
Because the lymph nodes follow the arterial system, and the nodes must be removed for staging of the cancer and prognostic estimates.
There is also prognostic benefit to removing the nodes, as it reduces the chance of malignant spread.
A patient has a rectal tumour that needs to be electively resected. The tumour is low in the rectum, 0.5cm from the anal sphincter.
Which operation would be most suitable?
A. Anterior resection B. Sigmoidectomy C. Hartmann's procedure D. APER E. Extended right hemicolectomy
D. APER
Bowel malignancies are typically resected with at least 1cm of clearance. If the anal sphincter is within the 1cm clearance range, then an anterior resection would leave this patient permanently incontinent. Accordingly they undergo APER (abdomino-perineal resection of the rectum) instead, which includes formation of a colostomy.
Why can a tumour in the splenic flexure not be treated with simple resection and anastomosis in that area?
Because it is within the watershed area - an area of bowel that receives dual blood supply from the most distal parts of two arteries. This means the blood supply is too poor to support an anastomosis in this area, and so surgery must either avoid the splenic flexure, or remove it.
Describe a Hartmann’s procedure
An emergency resection of the recto-sigmoid colon (e.g. to relieve obstruction) involving formation of an end colostomy and a rectal stump (they are not anastomosed at the time but can be later once the downstream bowel has recovered).
Indications include: Obstruction Diverticulitis leading to perforation Trauma Ischaemia/ volvulus
On examination of a patient, you see a double-barrelled stoma on the left of the patient’s abdomen which is flush with the skin.
What is the most likely purpose of this stoma?
To temporarily defunction the downstream bowel, e.g. after an anastamosis to allow it to heal. This type of stoma (loop stoma) is easier to reverse and so is preferable to forming an end stoma.
A 63 year old woman is brought to A&E by ambulance with acute left leg pain. On examination the limb is cold and the pulses cannot be felt. The patient has total loss of sensation below the knee, the limb is paralysed, and there is a fixed mottling pattern of the skin.
What is the most appropriate treatment?
A. Bypass grafts B. Embolectomy via a Fogarty catheter C. Amputation D. Local intra-arterial thrombolysis E. Angioplasty
C. Amputation
The paralysis, total loss of sensation, and fixed mottling all indicate that this limb is no longer viable and should be amputated. Patients who have had surgical management of acute limb ischaemia will often require HDU or ICU afterwards because of the consequences of reperfusion injury - hyperkalaemia, acidosis, AKI.
Acute limb ischaemia is classified using the Rutherford scale which correlates clinical features with viability of the limb.
Link to table of Rutherford classification:
https://www.researchgate.net/figure/Classification-scheme-for-acute-limb-ischemia-ALI_tbl2_260980080
A 70 y/o man presents to A&E with rapid onset right excruciating flank pain. When seen by the doctor he is sweaty and lying still in bed, but occasionally writhes around for short periods when his pain suddenly becomes worse and then abates. He has vomited several times and when he managed to pass urine it was bloodstained. His HR is 108, BP is 149/82, SO2 is 98 on room air, and temp is 37.0.
How should this patient be managed?
A. Contact the general surgeons and arrange for an urgent transfer to theatre
B. Give tramadol and I.V. fluids, and contact the general surgeons for a review
C. Give I.V. fluids, antibiotics, and oxygen, and take blood cultures, a VBG, and catheterise the patient to monitor urine output
D. Give I.V. fluids, tramadol, and tamulosin, then order an USS
E. Give NSAIDs, I.V. paracetamol, and I.V. fluids, and order an urgent non-contrast CT scan
E. Give NSAIDs, I.V. paracetamol, and I.V. fluids, and order an urgent non-contrast CT scan
This is a history of renal colic - a common condition especially in the summer as dehydration increases the risk. Treatment and investigations for renal colic are summarised below:
Pain relief:
1st: NSAIDs
2nd: add I.V. paracetamol
3rd: opioids e.g. tramadol
Investigations:
Urgent non-contrast CTKUB
Use USS if CTKUB contraindicated (e.g. in pregnancy) or in young people/ children
Bloods inc. calcium (given the high prevalence of primary hyperparathyroidism in patients presenting with renal stones)
Management:
I.V. fluids
Watch and wait if stone is <5mm, and sometimes in >5mm stones depending on patient wishes
Alpha blocker to facilitate passage of distal stones <10mm during watchful waiting
Surgery if other methods are insufficient, if stone is unlikely to pass, or if patient cannot tolerate pain
A 10 year old boy is brought to A&E with flank pain, dysuria, and blood in his urine. The clerking doctor suspects renal colic, and sees in the notes that the boy has a background of ongoing vesicoureteral reflux. A mid-stream urine sample is taken and sent for MC&S, and Proteus miribalis is grown. An USS shows a stone in the ureter.
What is the most composition of this stone?
A. Cysteine B. Magnesium ammonium phosphate C. Uric acid D. Calcium oxalate E. Xanthine
B. Magnesium ammonium phosphate
Match each of the scenarios with the most appropriate surgical intervention:
- Severe currently flaring UC not responding to medical treatment
- UC with colonoscopy showing dysplastic masses
- Bowel obstruction due to malignancy
- Adenocarcinoma of the descending colon
- Rectal cancer within 1cm of the internal anal sphincter
- High rectal malignancy
A. Pan proctocolectomy with ileoanal pouch B. APER C. Anterior resection D. Left hemicolectomy E. Sub total colectomy F. Hartmann's procedure
- Severe currently flaring UC not responding to medical treatment - E. Sub total colectomy
- UC with colonoscopy showing dysplastic masses - A. Pan proctocolectomy with ileoanal pouch
- Bowel obstruction due to malignancy - F. Hartmann’s procedure
- Adenocarcinoma of the descending colon - D. Left hemicolectomy
- Rectal cancer within 1cm of the internal anal sphincter - B. APER
- High rectal malignancy - C. Anterior resection
Usually have to make ileoanal pouch at time of colectomy, can’t do it afterwards if rectum removed
Ileoanal pouch is not usually recommended in perianal/ rectal Crohn’s due to the high risk of fistula formation
What is the most common location of colorectal cancer?
Rectum ~40%
Second commonest is sigmoid colon ~30%
A 68 year old woman visits her GP to discuss results of a recent routine blood test. Her FBC showed a microcytic anaemia, but she claims to have been feeling fine recently.
How should this patient be managed?
A. Make a 2 week wait referral
B. Order an anti-ttg antibodies test and fetal calprotectin
C. Perform a PR exam, if this is normal then review in 2 weeks
D. Safety net and ask her to return for repeat bloods in 1 month
E. Perform a FIT and act based on the result
A. Make a 2 week wait referral
This is a presentation of colon cancer - most likely right-sided given the insidious onset. Whilst this could easily be something else very benign, these are red flags that should be thoroughly investigated just in case. The criteria for 2 week wait colon cancer referral are:
≥40yrs with unexplained weight loss and abdominal pain
≥50yrs with unexplained rectal bleeding
≥60yrs with iron‑deficiency anaemia or change in bowel habit
Positive occult blood screening test
Faecal immunochemical tests (FIT) are used to guide referrals in cases where there is a possibility of malignancy but the patient doesn’t meet the 2 week wait criteria. Doing a FIT wouldn’t be the worst option here, but the point of this question is to emphasise that if someone has worrying criteria for bowel cancer, they should get a 2 week wait referral.
NICE 2 week wait criteria:
https://www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer#lower-gastrointestinal-tract-cancers
A 58 year old man presents to A&E with a 2 day history of gradually worsening 6/10 lower left quadrant pain. He feels generally well, but has not passed stool for 2 days and feels bloated. O/E he has left lower quadrant tenderness and guarding, and a DRE elicits pelvic tenderness. He has a fever of 38.4 and a WCC of 14 with neutrophils of 10.
How should this patient be investigated further?
A. Colonoscopy B. USS of the left iliac fossa C. Exploratory laparoscopy D. Pelvic MRI E. CT abdomen and pelvis
E. CT abdomen and pelvis
This is a history of diverticulitis: lower left quadrant pain, fever, neutrophilia, and constipation are all common features.
Diverticulitis is investigated with a CTAP which also helps to stage the disease
NB: PR bleeding is uncommon in diverticulitis, and if it occurs it is usually abrupt, painless, profuse bright blood. This occurs when the diverticular disease erodes into an artery/ arteriole, and isn’t usually associated with acute diverticulitis
Briefly describe the management of acute diverticulitis
Manage with analgesia alone if mild
If generally unwell or signs of complication (faeces via vagina, abdominal or rectal mass, peritonitic, septic, or obstructed) then:
Admit
I.V. fluids
Contrast CTAP
Oral antibiotics is generally unwell, but I.V. if complicated (fistula, obstruction, sepsis, abscess, or perforation)
May require drainage/ washout of collections, or emergency resection of the colon (Hartmann’s procedure)
Liquid diet for a few days, then low fibre diet while recovering, then high fibre diet for future
A 28 year old woman presents to A&E with a 2 hour history of sudden onset headache which she describes as “the worst of my life”. The clerking doctor suspects a sub-arachnoid haemorrhage (SAH).
Which of the following is the most useful way to confirm SAH at this stage?
A. Fundoscopy B. Collation of physical symptoms C. CT head D. Lumbar puncture E. MRI
C. CT head
Within the first 6 hours, CT head is a very sensitive and specific test with an extremely high negative predictive rate. Conversely an LP may well yield a false positive initially; this is because xanthochromia is caused by bilirubin which is a haemoglobin breakdown product. It takes time for the RBCs that have bled from the SAH to be destroyed and have their haemoglobin converted to bilirubin. Ideally an LP should be done 12 hours after onset of symptoms.
Symptoms are not a reliable way to diagnose SAH, as even classic symptoms like ‘worst headache of their life’ don’t actually have very good sensitivity or specificity. Even the time of onset of the headache is not necessarily very helpful.
Good articles on CT head in SAH and general management:
https: //www.bmj.com/content/343/bmj.d4277
https: //www.bmj.com/content/339/bmj.b2874
A 55 year old man presents to A&E with a 1 hour history of headache following tripping and falling on the street. The headache came on suddenly after he hit the ground, is 10/10 in severity, and is accompanied by nausea, 2 episodes of vomiting, and photophobia. He has a 10 pack year smoking history and is taking Lisinopril and Amlodipine for hypertension. He is sent for a CT head which is normal.
What is the most appropriate next step?
A. Cerebral angiogram B. Lumbar puncture after 6 hours C. Skull x-ray D. MRI E. Repeat CT head in 24 hours
B. Lumbar puncture after 6 hours
This is a history of subarachnoid haemorrhage - the history of fall is significant because most subarachnoid bleeds are caused by trauma (albeit on a background of pre-existing aneurysm). CT head is a very sensitive investigation for detecting sub-arachnoid haemorrhage. If it is negative, a lumbar puncture should be done, but this should be at least 6 (preferably 12) hours after onset to give time for the haemoglobin in blood in the brain to degrade (it is the haemoglobin degradation products that produces xanthachromia).
If LP and CT head are both negative, SAH can be excluded. Repeating the CT head in 24 hours is unlikely to help, as CT head sensitivity decreases with time as the blood in the subarachnoid space is cleared.
CT angiography will be performed by the neurosurgeons when the diagnosis is established, but is not part of the diagnostic work up.
BMJ page on SAH:
https://www.bmj.com/content/339/bmj.b2874
NHS page on SAH:
https://www.nhs.uk/conditions/subarachnoid-haemorrhage/treatment/
A 55 year old man presents to A&E with a 1 hour history of headache following tripping and falling on the street. The clerking F2 suspects SAH and orders a CT head which confirms the diagnosis. The patient is referred to the neurosurgeons who control his blood pressure, give analgesia, monitor his fluid balance, electrolytes and nutritional status, and arrange for coiling of the aneurysm.
Which drug should be prescribed to reduce the chance of secondary cerebral ischaemia?
Nimodipine
Nimodipine is a calcium channel blocker which acts to dilate arteries. It is given to counteract a trend in SAH for vessels to spasm causing ischaemia and stroke around day 7 post-bleed.
