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DPD > The acutely ill surgical patient > Flashcards

The acutely ill surgical patient Flashcards

1
Q

what does acutely unwell mean

A

new onset
deranged physiology
unstable
shocked

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2
Q

what is the definition of shock

A

Life-threatening condition of circulatory
failure, causing inadequate oxygen delivery
to meet cellular metabolic needs + O2
consumption requirements’

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3
Q

what are the 4 different types of shock

A

hypovolaemic
distributive
cardiogenic
obstructive

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4
Q

summarise hypovolaemic shock

A

inadequate circ vol to maintain perfusion, heart working fine – haemorrhage and dehydration

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5
Q

summarise distributive shock

A

change in circ capacity eg 3rd space of fluid, gross vasodilation, heart pumping but tissue not receiving ox needed – sepsis = vasodilation increased demand and pump failure if secondarily effected, neurogenic = gross vasodilation from gross PNS overload = redistribution of fluid.

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6
Q

summarise cardiogenic shock

A

cant pump enough, HF, arrhythmia = insufficient CO

pump failure

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7
Q

summarise obstructive shock

A

pump is physically able to produce CO – block either from tamponade (compression in pericardium), pneumothorax – pressure external

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8
Q

where would you see an acutely ill surgical patient

A

o New pt in ED – severe abdo and cardiovascular conditions

o Post-op pt on ward – complications to surgery, or more general complications

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9
Q

general causes of acutely ill new patient

A
  • Inflammation / Infection
  • Perforation
  • Obstruction
  • Haemorrhage
  • Ischaemia
  • Trauma
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10
Q

inflammations

A 
Oesophagitis
• Gastroenteritis
• Enteritis
• Pancreatitis
• Appendicitis
• Colitis
• Diverticulitis
• Cholecystitis
• Cholangitis
• Pyelonephritis
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11
Q

perforations

A 
Oesophagus – Boerhave’s /
malignancy
• Stomach – Gastric Ulcer
• Duodenum – Duodenal Ulcer
• Small bowel – Foreign body / Crohn’s
• Appendix
• Colon – diverticulitis / malignancy /
iatrogenic
• Gallbladder – gallstone ileus
• Rectum - malignancy
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12
Q

obstructions

A

Small bowel – adhesions / hernia
• Large bowel – diverticulitis / malignancy
• Renal tract – stones / malignancy

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13
Q

bleeding

A

Upper GI – stomach / duodenum – ulcer
• Lower GI – colon / rectum – diverticulae / angiodysplasia /
malignancy
• AAA – retroperitoneal / intra / enteric
• Trauma

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14
Q

ischemia

A
  • Small bowel – thrombus / embolus
  • Colonic – watershed
  • Strangulation within hernia
  • Limb – thrombus / embolus
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15
Q

specific surgical complications

A

GI resection and anastomosis = leakage
– Cholecystectomy – biliary tree injury = leak / stenosis / occlusion
– AAA repair – haemorrhage / ischaemia
– Any surgery - secondary haemorrhage

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16
Q

Boerhave’s

A

vomiting against closed glottis cause oesophagus to blow out

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17
Q

what does ‘general complication’ mean

A

indirect consequence

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18
Q

CVS general consequences

A

MI
arrhythmia
tamponade

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19
Q

resp general consequences

A

atelectasis
pneumonia
PE
pneumothorax

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20
Q

renal general consequences

A

ARF in anyone – could have 3rd spacing, inadequate fluids, starved

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21
Q

endocrine general consequences

A

glucose derangement
addison’s after adrenalectomy
drugs - opiates
withdrawal

22
Q

what is atelectasis

A

collapse of lung basis = inadequate oxygenation

23
Q

what is the approach to an acutely unwell surgical pt

A

• Assessment, management and diagnosis all in 1 go – ABCDEFG approach

24
Q

airway assessment

A

look, listen, feel
if nothing = resp arrest – see if occlusion, listen for added sound = stridor, gurgling = excess secretions – manoevres – head tilt/jaw thrust – elevate soft tissue from airway and give high flow oxygen. If doesn’t work – airway adjunct – gaudell airway and oxygen

25
Q

breathing assessment

A

look, listen, feel

rate, expansion (pneumothorax), percussion (reduced resonance in atelectasis and pleural effusion), breath sounds

26
Q

circulation assessment

A

look, listen, feel, obs – perfusion – BP insufficient to reach peripheries/cap refill/HR/BP/ABDO exam IV cannula, bloods, fluid

27
Q

disability assessment

A

AVPU/limbs/neuro – droopy face

28
Q

exposure

A

unrecognised injuries, rashes – anaphylaxis

29
Q

DEFG

A

don’t ever forget glucose
venous gas
lab glucose
replace if necessary

30
Q

what initial investigations will you do

A 
ECG
• Urine – pregnancy / bedside
urinalysis (urosepsis)
• Blood gas – oxygenation / lactate /
acid-base / Hb
• Bloods to lab – FBC, renal function &
elecs, clotting, G+S
• CXR (mobile) if chest history
31
Q

what are you looking for from an ABG

A

pH lactate - sauy if underperfused

Hb see if suddenly bled

32
Q

25 year old man p/w severe upper abdominal pain. Started this morning
suddenly. Has had previous such episodes but more mild. No definite past
medical history. Smokes 15 cigarettes / day and drinks c 5 units ETOH daily.
• In pain, speaking in sentences, respiratory rate 35 but otherwise resp exam
normal, HR 120, BP 90/60, ECG sinus tachy, abdo – peritonitic, blood gas –
glucose 6, Lactate 3, pH 7.30 – CXR and bloods pending

A

o Pt young and previous episodes
o Presenting shocked with peritonitis
o Airway and breathing fine
o Tachy
o Hypotensive acidotic with high lactate
o Pancreatitis could cause it
o Appendicitis could – not right pain distribution, but could become that unwell with perf app
o Perf duodenal – smoking, alc, previous episodes
o Perf gastric possible but less common
o AAA rupture – unusual with age and clinical details – people present in variety of ways – back/groin pain
o In older pt upper abdo pain and peritonism could be pneumonia
o If rapidly bleeding ectopic preg – blood spread around abdo cavity – upper epigastric pain as well as lower

33
Q

interpretation of pneumoperitoneum on CXR

A

air in peritoneal cavity
o Air under R hemidiaphragm not contained in a viscus
ddx perforation of viscus
o Therefore in case: duodenal perf most likely, gastic ulcer perf, bowel perf also possible

34
Q

considerations in R hypochondrium pain

A

GB
liver
lung
colon

35
Q

considerations in epigastric pain

A

stomach
duodenum
pancreas
GB

36
Q

considerations in L hypochondriac pain

A

spleen
pancreas
colon

37
Q

considerations in R flank pain

A

colon
appendix
kidney

38
Q

considerations on umbilical pain

A

small bowel
appendix
meckel’s

39
Q

considerations on L lumbar pain

A

colon

kidney

40
Q

considerations in RIF pain

A

appendix
colon
ovary
testes

41
Q

considerations in suprapubic pain

A

bladder
appendix
colon
ovary

42
Q

considerations on LIF pain

A

colon
rectum
ovaries
testes

43
Q

when would appendix cause RF pain

A

when it is retrocecal

44
Q

what abdo pain would pneumonia of the lower lobe cause

A

RUQ/epigastic

45
Q

what is Meckle’s diverticulum

A

outpouching of the small bowel

46
Q

what is the type of shock for perforated duodenal ulcer

A

wouldn’t bleed = distributive shock – septic because hole in GI tract

47
Q

what is the initial management for perforated duodenal ulcer

A

o CT scan – possibility that perf is from appendix/colon/small bowel – want to know what it is before op – consent, and see if can do laparoscopically
o Assess and resus
o Call reg
o Wide bore IV cannular – IV fluids
o Supplementary oxygen – prevent shock by allowing them to deliver more oxygen to peripheries
o AB

48
Q

Laparoscopic anterior resection of the rectum for cancer 2 days ago. You are
called by the ward to say she has deteriorated.
• She is speaking to you but breathless with RR 28, sats 91% on air, HR 125,
BP 110/70.
• Chest / CV exam not remarkable except for sinus tachy. Resp – seems to
have unequal expansion.
• Soft abdomen.

A

o Airway fine
o RR, sats HR not fine
o BP ok – not going to arrest
o Give ox, bloods, IV fluids
o Soft abdo – not peritonitis – so don’t suspect something that relates specifically to the surgery
o 2 days post op – atelectasis – GA don’t expand lungs, in pain so continue not to expand lung = collapse and consolidation at base – don’t aerate well

49
Q

management of atelectisis

A

oxygen, sit up, nebulisers, pain relief good – breathe, physio, spirometer to make sure expand lung (incentive – see how high they can get the yellow ball), maybe AB but physical pt rather than infection

50
Q

what is 3rd spacing

A

in sepsis tissues become more perm – loss of fluid across boundaries of compartments eg pleural effusion, pancreatitis release inflamm cytokines = fluid leak out of intravascular space to the tissues
o Pt acutely unwell with gross peripheral oedema – leaky cap – fuild lost to the 3rd space

51
Q

what is most common cause of temp, hypoxia, elevated HR 2 days post op

A

in sepsis tissues become more perm – loss of fluid across boundaries of compartments eg pleural effusion, pancreatitis release inflamm cytokines = fluid leak out of intravascular space to the tissues
o Pt acutely unwell with gross peripheral oedema – leaky cap – fluid lost to the 3rd space

DPD (38 decks)

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