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WFH > Surgical emergencies > Flashcards

Surgical emergencies Flashcards

1
Q

investigations for peritonitis

A
  • 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
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2
Q

management for peritonitis

A
  1. ABCDE
  2. Aggressive fluid resuscitation + catheter
  3. Antibiotics (CEFUROXIME + METRONIDAZOLE)
  4. Nil by mouth
  5. Analgesia
  6. Antiemetic
  7. Oxygen

URGENT LAPAROTOMY = PERITONEAL LAVAGE +/- RESECTION

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3
Q

investigations for appendicitis

A
  • 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
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4
Q

management of appendicitis

A
  1. ABCDE
  2. Fluid resuscitation + catheter
  3. Antibiotics (CO-AMOXICLAV)
  4. Nil by mouth
  5. Analgesia
  6. Antiemetic

LAPAROSCOPIC APPENDICECTOMY

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5
Q

causes of bowel perforation

A 
DIRECT OBSTRUCTION OF BLOOD FLOW 
• Volvulus
• Strangulated Hernia
• Mesenteric ischaemia/infarction
TISSUE TENSION OBSTRUCTS BLOOD FLOW
• Bowel obstruction
• Cholecystitis
• Appendicitis
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6
Q

features of small bowel obstruction

A
  • colicky pain becoming continuous pain
  • pain starting off localised, becoming diffuse
  • vomiting (projectile, bilious, faecal)
  • bloating/distension, may have mass (fluid or gas)
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7
Q

causes of small bowel obstruction

A
  • intraluminal: malignancy, gallstone, meconium ileus, atresia, diaphragm disease
  • intramural: malignancy, inflammation, strictures (ischaemic stricture/radiation stricture)
  • external: malignancy, abscess, appendicitis, volvulus, hernia, ADHESIONS
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8
Q

investigations for small bowel obstruction

A
  • 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
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9
Q

3 - 6 - 6 - 9 rule for AXR interpretation

A

small bowel <3cm
large bowel <6cm
appendix <6mm
caecum <9cm

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10
Q

most common area affected by volvulus

A

1) . Sigmoid Colon (76%)
2. Caecum (22%)
3. Small Bowel (rare – caecal rotation or adhesions)

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11
Q

management of small bowel obstruction

A
  1. ABCDE
  2. Aggressive fluid resuscitation + catheter
  3. Nil by mouth
  4. Bowel decompression (NG tube)
  5. Antibiotic cover
  6. Analgesia
  7. Antiemetic
  8. 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
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12
Q

causes of large bowel obstruction

A
  • intraluminal: malignancy, faecal compaction, atresia, diaphragm disease
  • intramural: malignancy, inflammation, Hirschprungs, diverticulitis, strictures
  • external: malignancy, abscess, volvulus, hernia, adhesions
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13
Q

features of large bowel obstruction

A
  • 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
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14
Q

investigations for large bowel obstruction

A
  • examination: signs and symptoms as above
  • bedside:
    > bloods: FBC, U+E, LFT, CRP, lactate, ABG, coagulation screen + G+S
  • imaging:
    > AXR:
    &raquo_space; Competent IC – dilated air filled loops of lower intestine in periphery, with haustration, large caecum and normal SI
    &raquo_space; Incompetent IC – dilated LI, haustration, central dilated SI loops
    > CT abdo
    > flexible sigmoidoscopy (rigid in emergency)
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15
Q

large bowel AXR findings

A
  • coffee bean (L facing = sigmoid volvulus, R facing = caecal volvulus
  • strictures
  • apple core = colon carcinoma
  • thumb printing = ischaemia
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16
Q

management of large bowel obstruction

A
  1. ABCDE
  2. Aggressive fluid resuscitation + catheter
  3. Nil by mouth
  4. Bowel decompression (NG tube)
  5. Antibiotic cover
  6. Analgesia
  7. Antiemetic
  8. 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
17
Q

features of mesenteric ischaemia

A
  • severe, acute, widespread abdo pain
  • systemic shock
  • ischaemic colitis
    > fresh PR blood
    > abdo distension
    > abdo tenderness
18
Q

investigations for mesenteric ischaemia

A
  • 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
19
Q

management of mesenteric ischaemia

A
  1. ABCDE
  2. Aggressive fluid resuscitation + catheter
  3. Nil by mouth
  4. Antibiotic cover
  5. Analgesia
  6. Antiemetic
  7. Oxygen
  • bowel resection
  • unfractionated heparin
  • revascularisation if viable
20
Q

investigations for acute limb ischaemia

A

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

21
Q

management of acute limb ischaemia

A
  • 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)
22
Q

AAA screening

A
  • 3.0 – 4.4cm: yearly ultrasound
  • 4.5 – 5.4cm: 3-monthly ultrasound
  • 5.5cm and over: surgery
  • > 6.5cm: DVLA and no driving
23
Q

investigations for AAA

A
  • 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
24
Q

management of AAA

A
  1. ABCDE
  2. High Flow O2
  3. Wide bore IV access
  4. Bloods including 6 units crossmatched
  5. Cautious fluids / Blood Tx - keep SBP <100mmHg
  6. Nil by mouth
  7. Analgesia
  8. Antiemetic

open surgical or endovascular repair

25
Q

when to consider surgery in AAA

A

1) . AAA >5.5cm
2) . AAA expanding at >1cm/year
3) . symptomatic AAA otherwise fit

26
Q

prevention of oesophageal varices

A
  1. propranolol – reduced incidence of re-bleeding
  2. Endoscopic Variceal Band Ligation (repeat fortnightly until all varices eradicated)
  3. PPI
  4. TIPS (trans-jugular intrahepatic portosystemic shunt) if recurrent
27
Q

emergency management of oesophageal varices

A
  • 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)
28
Q

management of gastric ulcer

A
  1. ABCDE
  2. Bloods (FBC, U&E, LFTs, clotting, Group and Cross Match)
  3. Transfusion of O- blood or correction of clotting (FFP/Vitamin K)
  4. UPPER GI ENDOSCOPY (Stable = within 24h, Unstable = immediate)
  5. IV OMEPRAZOLE
  6. CXR - ? perf
  7. Antibiotic cover if ? perf (CEF + MET)
29
Q

features of cauda equina

A
  • severe back pain
  • saddle anaesthesia + reduced sensation in legs
  • leg weakness
  • hyporeflexia of legs
  • reduced anal tone
  • urinary incontinence/retention
30
Q

investigations for cauda equina

A
  • PR exam
  • neuro exam (UMN signs at level of compression, LMN below)
  • whole spine MRI
31
Q

management of cauda equina

A
  1. Immobilise spinal trauma
  2. Early neurosurgical review
  3. Urgent decompression of the spine
  4. High dose dexamethasone
  5. Radiotherapy +/- chemotherapy in malignant CES

DECOMPRESSION WITHIN 24 HOURS OF AUTONOMIC SYMPTOMS
TO REDUCE POST-OP URINARY COMPLICATIONS

WFH (18 decks)

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