VIVA Flashcards
suspected LBO/SBO — approach + Tx
approach
impression = SBO or LBO
resus: ABCDEs
focused Hx
symptoms
abdominal scars, hernias
constipation vs obstipation
abdominal distension
vomiting — contents
colicky pain
causes of LBO/SBO
SBO: prev abdominal surgery, known hernias
LBO
CRC: fam Hx, unexplained weight loss, when was last scope
volvulus: happened before
physical exam
bowel sounds
r/o peritonism
McBurney’s point — LBO + McBurneys point tenderness = ?closed loop obstruction
check notes & kardex
Ix
bloods
FBC
U&E
VBG
amylase — raised = ?strangulation or perforation
imaging
erect CXR
PFA — dilated loops of bowel
small bowel >3cm; large bowel >6cm; caecum >9cm
small bowel — valvulae conniventes, large bowel — haustra
CT abdomen w oral contrast
gastrograffin with follow through via NGT
barium study
Tx
conservative
keep NPO
drip & suck — IV fluids + insert wide bore NGT tube
decompress stomach + leave NGT in
maintenance fluids – electrolytes
insert urinary catheter — I/O charting
medical Tx
analgesia
antiemetic: cyclizine (not metoclopramide since prokinetic)
Abx: cefuroxime + metronidazole
surgical Tx = open laparoscopy
indications:
closed loop obstruction
PILOT – peritonism, strangulation, sepsis
obstructing neoplasm
failure of conservative Tx (>72 hrs)
options — acc to cause
adhesions = adhesiolysis
hernia = hernia repair
CRC = resection
diverticular stricture = resection
bowel perforation VIVA — approach + Tx
impression = bowel perforation
resus ABCDEs
focused Hx
symptoms (Hx)
severe abdo pain
shoulder pain
DDx causes
PUD
IBD
diverticulitis
acute appendicitis
Closed loop obstruction
CRC
physical exam:
scaphoid abdomen (anterior abdo wall concaves inwards)
peritonism — guarding, rigidity, rebound tenderness
absent bowel sounds!!!
Ix
bedside: VBG + lactate
bloods: FBC, U&E, CRP, Coag profile, GXM 2 units, amylase, beta hCG
imaging: erect CXR, PFA, CT abdo w oral contrast
Tx
NPO + maintenance fluids
IV Abx
analgesia
antiemetic: cyclizine
conservative = careful monitoring – omentum may seal perforation
surgical = exploratory laparotomy + peritoneal lavage
most common cause of air beneath diaphragm?
iatrogenic — post laparoscopy or laparotomy
approach to suspected appendicitis —- Tx
impression = acute appendicitis
other DDx = ….
resus ABCDEs
focused Hx — acc to alvarado score
symptoms:
migratory RIF pain
anorexia
N&V
signs
tenderness RIF
temp >37.3
rebound tenderness
labs leukocytosis
left shift of neutrophils
interpretation
4-6: CT scan
7 or more: surgical consult
physical exam
McBurneys point tenderness
Rovsing sign
psoas sign
obturator sign
Ix
bedside: VBG + lactate, beta hCG
bloods: FBC (neutrophilia, leukocytosis), U&E, coag profile, amylase
imaging: US/CT abdomen
CT abdomen findings:
enlarged appendix >6mm
thickened appendix wall >2mm w enhancement – target sign
periappendiceal fat stranding
Tx
conservative:
NPO + maintenance fluids
analgesia
antiemetic: cyclizine
IV Abx: cefuroxime + metronidazole
+/- surgical Tx = laparoscopic appendicectomy
acutely or in 6 wks
ED: BP 90/50 + HR 110 + vomiting blood – approach + Tx
approach
impression = upper GI bleed
resus: ABCDEs
2 wide bore 14-16G IV cannula
500ml of normal saline over 10-15 mins
if severe bleeding = unmatched O-ve blood
permissive hypotension: aim SBP 100 mmHg
call for senior help
possibly activate massive transfusion protocol
focused Hx
symptoms
haematemesis — quantity
melena
any precipitating event — alcohol + retching, etc
DDx cause
CLD + oesophageal varices
PUD
gastritis/oesophagitis
mallory weiss tear
vascular ectasia
kardex
anticoagulants
NSAIDs
Glasgow-Blatchford score
aim: to decide if urgent CT endoscopy is needed
rockall score
determine if surgery required
physical exam
signs of CLD
signs of shock
Ix
bedside: VBG + lactate
bloods: FBC, U&E, Coag profile, LFTs, GXM 6 units
imaging: urgent endoscopy +/- erect CXR +/- CT abdomen
Tx
NPO + maintenance fluids
correct any coagulopathy if present
warfarin = vit K + prothrombin complex
dabigatran = idarucizumab
xabans = andexanet alfa
heparin = protamine sulphate
if suspect variceal bleed = terlipressin (splanchnic vasoconstrictor) + octreotide (somatostatin analogue)
vasopressin (ADH analogue)
prophylactic Abx for SBP — ciprofloxacin
endoscopy
if unstable = urgent; stable = within 12 hrs
if ulcer = endoclip
if varices = balloon tamponade via Sengstaken-Blakemore tube
if still bleeding = TIPSS transjugular intrahepatic portosystemic shunt
post-endoscopy
NPO for at least 24 hrs + maintenance fluids
high dose IV PPI — omeprazole
aim: allow clots to form
h.pylori testing + eradication — omeprazole + amoxicillin/metronidazole + clarithromycin
+/- surgical Tx = laparotomy with portosystemic shunting
indications:
rebleeding
rockall score: >3 pre-endoscopy; >6 post-endoscopy
bleeding despite endoscopic Tx
transfusion of 6 units
brisk bright red blood PR + 3 days post-liver resection — approach + Tx
approach
impression:
lower GIB
secondary post-op haemorrhage
oesophageal varices in post-op liver patient
resus ABCDEs
500ml normal hartmanns solution 10-15 mins
if severe = unmatched O -ve blood
if severe = call for senior help — may need to activate massive transfusion protocol
focussed Hx
symptoms
how is recovery post-surgery — any complications
any haematemesis
DDx cause
rectal: haemorrhoids, anal fissue
diverticulitis
CRC/polyps
other less common causes but impt:
massive upper GI bleed (15%)
ischaemic colitis — acute/chronic mesenteric ischaemia
IBD
angiodysplasia
kardex
anticoagulants
physical exam
signs of cause
signs of shock
Ix
bedside: VBG + lactate
bloods: FBC, U&E, GXM 4 units, LFTs, CRP
imaging: erect CXR, PFA
procedure: rigid endoscopy — proctoscopy, sigmoidoscopy, OGD, colonoscopy
CT angiogram
diagnostic peritoneal lavage
Tx
keep bed bound — if pass stool + bleeding PR = may pass ou t
IR: selective mesenteric embolisation
return to theatre to stop the bleed
epistaxis —- approach + tx
approach
impression = epistaxis
resus ABCDEs
focused Hx
symptoms
vol of bleeding
trigger
DDx causes
trauma
foreign body
infection
haemophilia — eg. hereditary haemorrhagic telengiectasia
kardex
anticoagulants
Ix
bloods: FBC, U&E, coag profile, INR
if severe = GXM 2 units
Tx
90% anterior (little’s area) 10% posterior (usually elderly)
1st line = compression of nasal ala for 10 mins — Trotter’s method
+/- phenylephrine spray or adrenaline soaked gauze
if not resolved in 10 mins = anterior packing with inflatable nasal tampons (rapid rhino pack) + consult ENT
if anterior packing insufficient:
posterior packing by ENT
cauterisation of anterior bleeds — silver nitrate sticks or electrocautery
surgical = functional endoscopic sinus surgery
alternative = radiological embolisation
FYI: complications of packing
toxic shock syndrome
septal perforation
adhesions
on call: nurse calls you + elderly male patient has fallen on the ward —- approach + Tx of NOF#
approach
impression = falls review on call — impt to r/o a hip fracture + work up to prevent future falls
ask the nurse to get an up to date set of vitals for me
is the patient currently conscious or unconscious — whats his GCS
resus ABCDEs
+/- cervical collar —- if head injury, paraesthesia, pain, or reduced GCS
focused Hx
HOPC
before fall
what was he doing
chest pain, palpitations
SOB
weakness —- unilateral vs bilateral
presyncope
during fall
witnessed vs unwitnessed
any LOC
any seizure-like activity or (tongue biting, incontinence)
hit head
how did he land
after fall
any long lie
any post-ictal phase
any other injuries, bleeding
decrease weight bearing of joint
pain
amnesia, vomiting
risk factors of fall
prev fall
PMHx: cardiac, neuro, dementia, delirium
meds: ANTICOAGULANTS, sedating drugs, opioids, antihypertensives
DDx causes
sepsis
haemorrhage
electrolytes — hypoNa
meds change
physical exam
vitals
orientated
full neuro exam + check GCS
hip + long bone exam
NOF# = affected lower limb shortened + internally rotated
standing & lying BP — ?postural hypotension
Ix
bedside: ECG, cap blood glucose, urine dipstick
bloods: FBC, U&E, CRP, grp & hold 2 units, coag profile
if warfarin = INR
if long lie = CK
imaging
urgent pelvic xray — AP & lateral view
finding: loss of shenton’s line
+/- CT Brain — esp if >65 y/o, LOC, head injury, new neuro deficit, on anticoagulants
Tx of NOF# sec to fall
immediate Tx
resus fluids
dress/suture minor wounds where possible
analgesia
IV paracetamol —- if >50 kg = 1g per dose every 6 hrs
if <50kg = 15mg/kg per dose every 6 hrs
+/- oxynorm 2.5mg
monitor patient — esp if GCS lower than baseline
vitals
EWS score
call orthopaedics
move patient to orthogeriatric ward
pre-op CXR
anaesthetics review
consult blue book guidelines + arrange for MDT review (esp physio)
post-op = follow ERAS protocol (enhanced recovery after surgery)
early mobilisation & rehabilitation
determine cause of fall if not alr established
24 hr holter
ECHO
lying + standing BP
+/- tilt table test (?reflex syncope)
osteoporosis Tx
bisphosphonated — if C/I = denosumab
calcichew D3 forte
wound management
DVT prophylaxis
pressure sore prevention — pressure relieving mattress + regular mobilisation
nutrition
CGA comprehensive geriatric assessment — get patient as close to baseline as possible + prevent future falls
Barthel score — ability to perform ADLs
Rockwood fraility index
meds review
physio: weight bearing & muscle strengthening exercises
OT: foot wear + home safety assessment
dietician: nutrition
MSW: meals on wheels, referral to nursing home if required + consents, or C-SAR form for homecare package
suspected C-spine injury —- approach + how to clear the c spine
SPINE mnemonic
S: stay still + support if necessary
c-spine collar
P: past history + mechanism of injury
I: injury — midline neck pain
N: neuro deficit
E: exacerbating factors —- LOC, intoxication, distraction
aim: supportive immobilisation — while keeping patient as comfortable as possible
how to clear C-spine?
clinically = NEXUS criteria
x-ray C spine — AP + lateral + PEG views
PEG view = some view looking mainly at C1 & C2
CT C Spine
barriers to discharge
decompensated in ADLS or off baseline — impt to get MDT input
not as mobile as previously = physio
swallow assessment = SALT
home safety assessment = OT
malnourished = dietician
pain uncontrolled
not on stable discharge meds
C-SAR form for homecare package = MSW
post-op delirium — approach + Tx
approach
ABCDEs check: GCS, vitals, capillary blood glucose 4AT --- determine if delirium or not criteria: alertness --- name + home address AMT abbreviated mental test 4 --- DOB, place, current year attention -- months of year backwards acute change or fluctuating course interpretation 4: delirium or CI 1-3: possibly delirium or CI 0: delirium or severe CI unlikely focused Hx + collateral Hx causes of delirium --- DELLIRIUUM D; drugs E: electrolyte & metabolic disturbances L: lack of sleep L: lack of drugs (ie withdrawal) I: infection, illness, recent surgery R: reduced sensory input --- glasses, hearing aids I: intracranial --- stroke, head injury, non-convulsive status U: untreated pain U: urinary retention M: myocardial (MI, CCF) & pulmonary recent med changes baseline cognition fluid balance, urine output chart, stool chart exam urinary retention, constipation dehydration infection meningism Ix bedside: ECG bloods: confusion screen, troponin confusion screen: TFTs, Ca, B12, folate, glucose imaging: CXR, CT Brain Tx Tx underlying cause dehydration = encourage PO intake + consider IV supplementation constipation = laxatives pain = analgesia meds = withdraw offending meds alcohol = pabrinex + chlordiazepoxide +/- glucose patient centred + environmental management minimise pharmco re-orientation + aids --- calm & predictable routine, calendar, clock, regular nurse supervision educate caregivers + involve them in patient care correct sensory issues normalise sleep --- light as appropriate to day/night, reduced ambient noise, give side room encourage early mobilisation + return to fully independent ADLs try to avoid urinary catheters, restraints, starting more drugs medical Tx if rapid tranquilisation protocol required = haloperidol + lorazepam/promethazine
can also consider: quetiapine, risperidone
day 1 post-anterior resection + abdominal pain + fever + tachycardia —- approach + Tx (of anastomotic leak)
approach
impression anastomotic leak -- give day 1 post op + anterior resection + abdo pain sepsis --- since fever + tachycardia given urgency of situation = call surgical reg on call ABCDEs focused Hx abdominal --- SOCRATES what analgesia is he on post-op ---- what has changed what surgery, when, any complications exam peritonism --- rebound tenderness, guarding signs of bleeding --- haematoma Ix bedside: ABG + lactate bloods: FBC, U&E, CRP blood C&S sepsis 6 --- empirical Abx add metronidazole (anaerobe cover) CT TAP Tx of anastomotic leak IR for percutaneous drainage theatre --- stenting or surgical revision
65 y/o M + day 3 post-op + PMH CVD + O/E: weak pulse & BP 70/40 – approach + Tx (its STEMI)
approach same as hypotension
Tx after ECG shows STEMI DAPT dual antiplatelet therapy --- aspirin 300 mg + clopidogrel 600mg prepare for definitive Tx = call cardiology if <120 mins onset = PCI if >120 mins = consult senior re thrombolysis since he is 3 days post-op (relative C/I) anticoagulate patient --- UFH or LMWH place defibrillator pads on patient analgesia: 2.5mg cyclomorph IV and/or IV paracetamol if not inferior infarct (II III aVF) + SBP >90 = consider GTN spray \+/- rate control and antiarrhythmics --- beta blocker & amiodarone C/I; anterior (V1-V4) or lateral infarct (I aVL V5-V6)
monitor for LV decompensation or severe hypotension
Day 5 post op patient + O/E: fever + hypotension — approach + Tx
impression = septic shock
ABCDEs is it sepsis? EWS >7 = escalate to senior help SIRS criteria ---- >2 = SIRS temp <36 or >38 HR >90 RR >20 WCC <4k or >12 k glucose >7.7 + no DM acute change in mental status focused Hx --- LUCAS (for source of infection) Lungs Urine CNS Abdomen Skin physical exam -- find for possible source surgical site respi tract urosepsis central line sepsis 6 --- within 1st hr take 3 bloods blood cultures insert urinary catheter bloods incl ABG + lactate FBC U&E CRP other Ix urine dipstick + C&S covid 19 swab give 3 supplementary O2 fluid resus empirical Abx Tx empirically acc to likely source of infection + PMH & local guidelines eg. tazocin IV
post-op hypotension — approach + Tx
impression = shock
hypovolaemic shock
esp 1st 24 hrs — impt to r/o bleeding
cardiogenic shock — MI or massive PE
septic shock
ABCDEs 2 wide bore 14-16G IV Cannulas 500ml bolus Hartmanns solution over 10-15 mins if PMH HF or small frail elderly = consider 250ml or consult senior help assess BP and vitals after each bolus -- repeat up to 3-4x call for senior --- esp if not responding after 2 boluses may require blood products, HDU/ICU admission, vasopressors, activation of massive transfusion protocol focused Hx what surgery, when, any complications any PMH heart issues, lung etc signs of infection --- fever, malaise exam assess volume status cap refill time, vitals (HR, RR, BP) clinical signs of dehydration --- dry mucous membranes, reduced skin turgor, oedema U/O charting feel peripheries --- cold = ?hypovolaemic or cardiogenic; warm = ?septic consult the american college of surgeons classess of acute haemorrhage to guide extent of blood loss check notes + kardex how did the surgery go --- any major blood loss kardex: any anticoagulation Ix bedside ABG + lactate --- ?end organ dysfunction if raised lactate bloods FBC U&E Coag profile GXM 4 units sepsis 6 Tx of hypovolaemic shock acc to cause --- may require re-intervention in theatre ensure ongoing maintenance fluid is prescribed --- which is ...
if NPO consider nutritional supplements too
what do you think of anticoagulation post-op
balance between risk of clotting and bleeding from the anticoagulation
if clotting = PE is potentially life threatening bleeding is also potentially life threatening ---- risk of complications + potentially re-intervention if it is day 3/4 post-op --- usually anticoagulation would be beneficial always consult senior for advice anticoagulant of choice = LMWH or UFH short half life reversal agent available = protamine sulphate
post-op PE — approach + Tx
approach
my impression = most likely PE
but other DDx incl = pneumonia, atelectasis, pneumothorax, MI
ABCDEs supplementary O2 -- esp since desaturating check for PMH of COPD decide acc to severity -- ideally 4L via nasal prongs (can take Hx) focused Hx when started when was surgery, what surgery on VTE prophylaxis any lower limb pain swelling exam signs of consolidation signs of DVT -- red unilateral swollen lower limb check notes + kardex any COPD, anticoagulation pre-existing pneumonia PMH IHD and interventions order Ix bedside ECG -- ?right heart strain, r/o MI ABG --- since desaturating bloods FBC CRP U&E troponin d-dimers (but likely raised since post-op) coag profile imaging venous duplex US --- ?DVT CXR --- r/o pneumonia, pneumothorax CTPA (gold std) --- as long as clear CXR + no contrast allergy, ESRD modified well's score --- decide if PE likely or unlikely Tx acute Tx ABCDs --- alr done if haemodynamically stable = apixaban/rivaroxaban if cancer or ESRD = LMWH + warfarin or LMWH + dabigatran if warfarin = start both LMWH & warfarin together --- once INR 2-3 can stop LMWH if haemodynamically unstable = UFH +/- thrombolysis if C/I to anticoagulation = pulmonary embolectomy or IVC filter monitor vitals --- esp if giving thrombolysis
long term: inpatient vs outpatient acc to PESI score (pulmonary embolism severity index)
post-op fever — approach + Tx
DDx — 5Ws
if 1st few hrs = ?normal systemic response to surgical trauma
Wind — pneumonia, atelectasis
Water — UTI or line infection
Wound – surgical site infection
anastomotic leak
walk — DVT, PE
wounder drugs — drug/antibiotic fever, transfusion reaction
Tx Hx & Exam -- to see which is most likely + take the timeline into consideration 1st day post-op = atelectasis most likely presentation: rattling cough or trapped mucus Tx chest physiotherapy (24 hr on call) analgesia supplementary O2 incentive spirometry also could be anastomotic leak but if >5 days = ?surgical site infection check EWS to see if ?sepsis -- if need be sepsis 6
