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
