Surgical emergencies Flashcards
investigations for peritonitis
- examination = rebound tenderness, widespread abdo pain, guarding, signs of sepsis
- bedside:
> bloods = FBC, U+E, LFT, CRP, lactate, amylase (rises in perforation), ABG, coagulation screen, G+S, blood culture
> ascitic tap - imaging: EXR, CT abdo + contrast
management for peritonitis
- ABCDE
- Aggressive fluid resuscitation + catheter
- Antibiotics (CEFUROXIME + METRONIDAZOLE)
- Nil by mouth
- Analgesia
- Antiemetic
- Oxygen
URGENT LAPAROTOMY = PERITONEAL LAVAGE +/- RESECTION
investigations for appendicitis
- examination = umbilical to McBurney’s point pain, may be rebound tenderness, guarding, mass in RIF, Rosvig’s sign (RIF pain on palpation of LIF)
- bedside:
> bloods = FBC, U+E, LFT, CRP, lactate, coagulation screen, G+S, blood culture - imaging: abdo USS, CT abdo
management of appendicitis
- ABCDE
- Fluid resuscitation + catheter
- Antibiotics (CO-AMOXICLAV)
- Nil by mouth
- Analgesia
- Antiemetic
LAPAROSCOPIC APPENDICECTOMY
causes of bowel perforation
DIRECT OBSTRUCTION OF BLOOD FLOW • Volvulus • Strangulated Hernia • Mesenteric ischaemia/infarction TISSUE TENSION OBSTRUCTS BLOOD FLOW • Bowel obstruction • Cholecystitis • Appendicitis
features of small bowel obstruction
- colicky pain becoming continuous pain
- pain starting off localised, becoming diffuse
- vomiting (projectile, bilious, faecal)
- bloating/distension, may have mass (fluid or gas)
causes of small bowel obstruction
- intraluminal: malignancy, gallstone, meconium ileus, atresia, diaphragm disease
- intramural: malignancy, inflammation, strictures (ischaemic stricture/radiation stricture)
- external: malignancy, abscess, appendicitis, volvulus, hernia, ADHESIONS
investigations for small bowel obstruction
- examination: signs and symptoms as above
- bedside:
> bloods: FBC, U+E, LFT, CRP, lactate, ABG, coagulation screen + G+S (Ca, Mg, TFTs ?pseudoobstruction) - imaging:
> AXR: dilated bowel loops, free air
> CT abdo with oral and IV contrast
3 - 6 - 6 - 9 rule for AXR interpretation
small bowel <3cm
large bowel <6cm
appendix <6mm
caecum <9cm
most common area affected by volvulus
1) . Sigmoid Colon (76%)
2. Caecum (22%)
3. Small Bowel (rare – caecal rotation or adhesions)
management of small bowel obstruction
- ABCDE
- Aggressive fluid resuscitation + catheter
- Nil by mouth
- Bowel decompression (NG tube)
- Antibiotic cover
- Analgesia
- Antiemetic
- Oxygen
- Emergency laparotomy for:
» Radiological or clinical signs of strangulation / ischaemia
» Clinical peritonitis or free air on AXR - If bowel still viable, resection not required, can stent/bypass/untwist
causes of large bowel obstruction
- intraluminal: malignancy, faecal compaction, atresia, diaphragm disease
- intramural: malignancy, inflammation, Hirschprungs, diverticulitis, strictures
- external: malignancy, abscess, volvulus, hernia, adhesions
features of large bowel obstruction
- colicky pain becoming continuous pain
- pain starting off localised, becoming diffuse
- bloating/distension, may have mass (fluid or gas)
- DRE = empty, hard stool or blood
- PR bleeding
investigations for large bowel obstruction
- examination: signs and symptoms as above
- bedside:
> bloods: FBC, U+E, LFT, CRP, lactate, ABG, coagulation screen + G+S - imaging:
> AXR:
»_space; Competent IC – dilated air filled loops of lower intestine in periphery, with haustration, large caecum and normal SI
»_space; Incompetent IC – dilated LI, haustration, central dilated SI loops
> CT abdo
> flexible sigmoidoscopy (rigid in emergency)
large bowel AXR findings
- coffee bean (L facing = sigmoid volvulus, R facing = caecal volvulus
- strictures
- apple core = colon carcinoma
- thumb printing = ischaemia
management of large bowel obstruction
- ABCDE
- Aggressive fluid resuscitation + catheter
- Nil by mouth
- Bowel decompression (NG tube)
- Antibiotic cover
- Analgesia
- Antiemetic
- Oxygen
- Emergency laparotomy for:
» Radiological or clinical signs of strangulation / ischaemia
» Clinical peritonitis or free air on AXR (perforation) - If bowel still viable, treat cause eg. rigid sigmoidoscopy for sigmoid volvulus/reduction of strangulation
features of mesenteric ischaemia
- severe, acute, widespread abdo pain
- systemic shock
- ischaemic colitis
> fresh PR blood
> abdo distension
> abdo tenderness
investigations for mesenteric ischaemia
- examination: signs and symptoms as above
- bedside:
> bloods: FBC, U+E, LFT, CRP, amylase (rises in mesenteric ischaemia), lactate, ABG, coagulation screen + G+S - imaging:
> abdo CT with IV contrast and angiography
1. oedematous bowel
2. loss of bowel wall enhancement
3. intramural gas - diagnostic laparotomy
management of mesenteric ischaemia
- ABCDE
- Aggressive fluid resuscitation + catheter
- Nil by mouth
- Antibiotic cover
- Analgesia
- Antiemetic
- Oxygen
- bowel resection
- unfractionated heparin
- revascularisation if viable
investigations for acute limb ischaemia
examination: 6Ps
bedside:
- bloods: FBC, U+E, LFT, CRP, thrombophilia screen, lactate, G+S
- ECG = looking for AF/MI that could have caused thrombus
- bedside doppler
imaging: CT angiography
management of acute limb ischaemia
- Rutherford score
1. ABCDE
2. UNFRACTIONATED HEPARIN INFUSION
3. High Flow Oxygen
4. Nil by mouth
5. Fluids + Catheter
6. Analgesia - early input from surgeons
- complete occlusion leads to irreversible damage in 6 hrs
- Rutherford score 1 and 2A = conservative (unfractionated heparin)
AAA screening
- 3.0 – 4.4cm: yearly ultrasound
- 4.5 – 5.4cm: 3-monthly ultrasound
- 5.5cm and over: surgery
- > 6.5cm: DVLA and no driving
investigations for AAA
- examination: syncope, flank/abdo pain, hypotension, pulsatile abdo mass
- bedside:
> bloods: FBC, U+E, LFT, CRP, lactate, coagulation screen, G+S and crossmatch 6 units - imaging:
> abdo USS
> CT with contrast
management of AAA
- ABCDE
- High Flow O2
- Wide bore IV access
- Bloods including 6 units crossmatched
- Cautious fluids / Blood Tx - keep SBP <100mmHg
- Nil by mouth
- Analgesia
- Antiemetic
open surgical or endovascular repair
when to consider surgery in AAA
1) . AAA >5.5cm
2) . AAA expanding at >1cm/year
3) . symptomatic AAA otherwise fit
prevention of oesophageal varices
- propranolol – reduced incidence of re-bleeding
- Endoscopic Variceal Band Ligation (repeat fortnightly until all varices eradicated)
- PPI
- TIPS (trans-jugular intrahepatic portosystemic shunt) if recurrent
emergency management of oesophageal varices
- ABCDE
- vit K, FFP, platelets
- terlipressin 2mg every 4-6 hrs until controlled (reduces portal hypertension)
- IV Abx broad spec eg. co-amox
- urgent endoscopy once haemodynamically stable (variceal banding done with endoscopy)
management of gastric ulcer
- ABCDE
- Bloods (FBC, U&E, LFTs, clotting, Group and Cross Match)
- Transfusion of O- blood or correction of clotting (FFP/Vitamin K)
- UPPER GI ENDOSCOPY (Stable = within 24h, Unstable = immediate)
- IV OMEPRAZOLE
- CXR - ? perf
- Antibiotic cover if ? perf (CEF + MET)
features of cauda equina
- severe back pain
- saddle anaesthesia + reduced sensation in legs
- leg weakness
- hyporeflexia of legs
- reduced anal tone
- urinary incontinence/retention
investigations for cauda equina
- PR exam
- neuro exam (UMN signs at level of compression, LMN below)
- whole spine MRI
management of cauda equina
- Immobilise spinal trauma
- Early neurosurgical review
- Urgent decompression of the spine
- High dose dexamethasone
- Radiotherapy +/- chemotherapy in malignant CES
DECOMPRESSION WITHIN 24 HOURS OF AUTONOMIC SYMPTOMS
TO REDUCE POST-OP URINARY COMPLICATIONS
