Surgical Emergencies

Question 0

Types of shock

Answer 0

Cardiogenic
Obstructive (pulmonary embolus)
Hypovolaemic
Distributive (anaphylactic, sepsis) due to leaky capillaries from systemic inflammatory response

Question 1

Signs of Shock

Answer 1

I SHOCKS
I increased resp rate
S sinus tachycardia
H hypotension
O Oligouria
C cold
K klammy
S slow cap refill
Plus confusion, cyanosis, acidosis if severe

Question 2

Systemic inflammatory response

Answer 2

Bacteraemia/tissue necrosis/Hypoperfusion ->
SYSTEMIC INFLAMMATORY RESPONSE ->
(Leukocyte and platelet activation & cytokine storm (IL, TNF, platelet activation factor, Bradykinins) ->
- vasodilation
- increased vascular permeability
- leukocyte endothelial adhesion
- microvascular thrombosis
- DIC (consumption coagulopathy)

Question 3

Signs of peritonitis

Answer 3

TRAPPED (TRA - crucial triad)
T tenderness (& tachycardia)
R reflex guarding (progresses to rigidity)
A absent bowel sounds (or reduced)
P pyrexia
P percussion pain (better than rebound)
E extremely unwell (with shallow resps)
D distant-local sign (distant palpation-local tenderness Rovsings sign

Question 4

Causes of pancreatitis

Answer 4

Gallstones
Alcohol
Idiopathic

Question 5

Adult respiratory distress syndrome

Answer 5

Pulmonary oedema not due to left ventricular failure
Leaking capillaries due to cytokine storm
Lungs - the first organ to fail in multi organ failure

Question 6

Acute Pancreatitis TXT

Answer 6

Initially conservative: “drip and suck”, IV fluids and nil by mouth or nasogastric tube -> to rest the stomach
Pain control, severe epigastric pain which radiates to the back
80% improve in 3-5 days
20% have a more severe attack requiring:
- enteral nutrition (via nasogastric/nasojejunal tube)
- IV Abx

Question 7

Indications of a severe attack of acute pancreatitis

Answer 7

PANCREAS
P PaO2 15 X10^9)
C calcium ( renal impairment)
R renal function (Urea >16mmol/L)
E enzymes (AST, LDH) >200 iu/L
A age >55yrs
S sugar glucose >10mmol/L (2o diabetes implies severe necrosis)

Need 3 or more

NB contrast CT at 72 hrs can help assess degree of necrosis and identify complications such as a pseudocyst.
CRP on admission also helpfully

Question 8

SIRS Systemic inflammatory response syndrome

Answer 8

2 out of 4 required
Fever (>38 or 12 or 90)
Tachypneoa (>20)

Question 9

Sepsis Six Bundle

Answer 9

3 out and 3 in
Out: urine output, blood cultures, lactate
In: oxygen, fluids, Abx

Or

B blood cultures
U urine output
F fluid resus
A Abx
L lactate
O oxygen

Question 10

Systemic Sepsis txt

Answer 10

Admit to ICU or HDU
Investigations: FBC, U&E, creatinine, ABG, CXR
Cultures: urine, sputum, wound, blood
Abdo US: evidence of a collection or renal obstruction

Question 11

Causes of anuria

Answer 11

Clerical/observational error
Pre-renal failure - dehyrdation or systemic sepsis
Renal failure - ATN (including drug toxicity-gentamycin)
Obstructive uropathy (hydronephrosis)

Question 12

Causes of bowel obstruction

Answer 12

Three common causes: adhesions, hernias, tumours
Less common gallstone, foreign body (in lumen), diverticulitis, Crohn’s structure, intussusception (in wall), volvulus (outside the wall)

Question 13

Symptoms of intestinal obstruction

Answer 13

Pain
Vomiting
Distension
Absolute constipation - no faeces or flatulence

Question 14

Small intestinal obstruction

Answer 14

Much commoner than large
Colicky pain occurs early
Dilated loops (>2.5cm) of small bowel on supine x-ray indicate obstruction
Small bowel is centre, with mucosal folds crossing complete diameter of bowel - valvular conniventes - unlike haustrations of the large bowel

Question 15

Large bowel obstruction

Answer 15

Caecum is weakest link
Major concern when it dilates up to 10cm - impending perforation
Impies competent ileo-caecal valve with closed loop obstruction

Question 16

Hartmann’s original procedure

Answer 16

Mucus fistula of rectum

Double barrelled stoma with two separate tubes