The acutely ill surgical patient

Question 1

what does acutely unwell mean

Answer 1

new onset
deranged physiology
unstable
shocked

Question 2

what is the definition of shock

Answer 2

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

Question 3

what are the 4 different types of shock

Answer 3

hypovolaemic
distributive
cardiogenic
obstructive

Question 4

summarise hypovolaemic shock

Answer 4

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

Question 5

summarise distributive shock

Answer 5

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.

Question 6

summarise cardiogenic shock

Answer 6

cant pump enough, HF, arrhythmia = insufficient CO

pump failure

Question 7

summarise obstructive shock

Answer 7

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

Question 8

where would you see an acutely ill surgical patient

Answer 8

o New pt in ED – severe abdo and cardiovascular conditions

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

Question 9

general causes of acutely ill new patient

Answer 9

• Inflammation / Infection
• Perforation
• Obstruction
• Haemorrhage
• Ischaemia
• Trauma

Question 10

inflammations

Answer 10

Oesophagitis
• Gastroenteritis
• Enteritis
• Pancreatitis
• Appendicitis
• Colitis
• Diverticulitis
• Cholecystitis
• Cholangitis
• Pyelonephritis

Question 11

perforations

Answer 11

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

Question 12

obstructions

Answer 12

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

Question 13

bleeding

Answer 13

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

Question 14

ischemia

Answer 14

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

Question 15

specific surgical complications

Answer 15

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

Question 16

Boerhave’s

Answer 16

vomiting against closed glottis cause oesophagus to blow out

Question 17

what does ‘general complication’ mean

Answer 17

indirect consequence

Question 18

CVS general consequences

Answer 18

MI
arrhythmia
tamponade

Question 19

resp general consequences

Answer 19

atelectasis
pneumonia
PE
pneumothorax

Question 20

renal general consequences

Answer 20

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

Question 21

endocrine general consequences

Answer 21

glucose derangement
addison’s after adrenalectomy
drugs - opiates
withdrawal

Question 22

what is atelectasis

Answer 22

collapse of lung basis = inadequate oxygenation

Question 23

what is the approach to an acutely unwell surgical pt

Answer 23

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

Question 24

airway assessment

Answer 24

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

Question 25

breathing assessment

Answer 25

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

Question 26

circulation assessment

Answer 26

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

Question 27

disability assessment

Answer 27

AVPU/limbs/neuro – droopy face

Question 28

exposure

Answer 28

unrecognised injuries, rashes – anaphylaxis

Question 29

DEFG

Answer 29

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

Question 30

what initial investigations will you do

Answer 30

``` 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 ```

Question 31

what are you looking for from an ABG

Answer 31

pH lactate - sauy if underperfused | Hb see if suddenly bled

Question 32

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

Answer 32

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

Question 33

interpretation of pneumoperitoneum on CXR

Answer 33

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

Question 34

considerations in R hypochondrium pain

Answer 34

GB liver lung colon

Question 35

considerations in epigastric pain

Answer 35

stomach duodenum pancreas GB

Question 36

considerations in L hypochondriac pain

Answer 36

spleen pancreas colon

Question 37

considerations in R flank pain

Answer 37

colon appendix kidney

Question 38

considerations on umbilical pain

Answer 38

small bowel appendix meckel's

Question 39

considerations on L lumbar pain

Answer 39

colon | kidney

Question 40

considerations in RIF pain

Answer 40

appendix colon ovary testes

Question 41

considerations in suprapubic pain

Answer 41

bladder appendix colon ovary

Question 42

considerations on LIF pain

Answer 42

colon rectum ovaries testes

Question 43

when would appendix cause RF pain

Answer 43

when it is retrocecal

Question 44

what abdo pain would pneumonia of the lower lobe cause

Answer 44

RUQ/epigastic

Question 45

what is Meckle's diverticulum

Answer 45

outpouching of the small bowel

Question 46

what is the type of shock for perforated duodenal ulcer

Answer 46

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

Question 47

what is the initial management for perforated duodenal ulcer

Answer 47

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

Question 48

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.

Answer 48

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

Question 49

management of atelectisis

Answer 49

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

Question 50

what is 3rd spacing

Answer 50

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

Question 51

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

Answer 51

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