clinical scenario

Question 1

CCRISP formula for management

Answer 1

ABCDE
History
Examination
Chart/notes review
Investigations
Definitive management

Question 2

ABCDE

Answer 2

1. O2
2. Cannula, IVI
3. Bloods inc G+S
4. ABG
5. Catheter
6. Analgesia, antibiotics, NBM

Question 3

After ABCDE:

Answer 3

Hx: from patient/NOK

Examine: pulse, volume status, chest, abdomen

Chart review: electronic notes, observations, fluid balance, drug
chart, op note, anaesthetic chart

Results: blood, micro, radiology

Question 4

Gallstone pancreatitis definitive management

Answer 4

1. Goal directed resuscitation
2. Consider CT if pt unwell/diagnostic doubt
3. Involvement of gastro (ERCP)
4. Glasgow or APACHE 2 score
5. Escalation to ITU if may need organ support

Question 5

Structure to initial actions question

Answer 5

-Organise team (Fy1, SHO)
-Communicate with team members
-Review priority patient: ensure in safe environment (resus), delegate to team members, get initial info to plan assessment e.g. notes/observations, CCRISP

Question 6

Necrotising fasciitis

Answer 6

-Surgical emergency
-Key symptom is pain out of proportion to the clinical findings
-Treatment is surgical

Question 7

What is your priority question:

Answer 7

-Priority is patient safety
-This will involve resuscitation, diagnostic investigations and definitive management

Question 8

Clinical issues in demented lady with obstructed strangulated femoral hernia

Answer 8

-Surgical emergency, requires prompt resuscitation and surgical tx to rescue the bowel

-Needs thorough anaesthetic review

-? severity of dementia: may need form 4

Question 9

Organisational issues in demented lady with obstructed strangulated femoral hernia

Answer 9

-Organise team (SHO, consultant, anaesthetics, theatre coordinator, ITU SpR) and use available resources effectively (radiology, operating theatres, critical care)
-Attempt to contact NOK to gather info/keep them updated

Question 10

Delegate responsibilities to team members (as part of review priority patient)

Answer 10

-nurse to check observations, Fy1 to establish IV access and take bloods/ABG

Question 11

Demented lady with obstructed femoral hernia specific A-E management

Answer 11

CTAP
NG tube
IV antibiotics for intra-abdominal sepsis

Question 12

Demented lady with obstructed femoral hernia: definitive management if deemed fit for surgery

Answer 12

Escalate: consultant on-call
MDT: critical care, anaesthetist
Contact: theatre co-ordinator
Book and consent for theatre
Nela mortality
Offer to speak to next of kin

Question 13

Old lady with femoral hernia: what is she doesn’t want to have surgery?

Answer 13

1. Provide all information as clearly as possible
2. Capacity assessment: understand, retain, weigh up and communicate decision
3. Seek a second opinion from a colleague if uncertain about capacity
4. Discuss wishes with next of kin
5. Discuss with consultant and other team members (e.g. ICU, anaesthetist) about whether to proceed in best interests

Question 14

Clinical issues in pregnant lady with right sided abdo pain

Answer 14

-May have appendicitis, other differentials are cholecystitis and UTI
-GA can increase risk of miscarriage, ionising radiation relatively contraindicated
-However untreated appendicitis can increase risk of miscarriage
-Confirm diagnosis on imaging (US or MRI) and MDT on conservative vs surg management

Question 15

Organisational pregnant lady appendicitis

Answer 15

-Organise team (SHO, surgical/obstetric consultants, anaesthetics, theatre co-ordinator) and use available resources effectively (radiology, operating theatres)

Question 16

Conservative vs surgical management in pregnant patient with appendicitis

Answer 16

-Surgery: miscarriage from GA
-Antibiotic: risk of treatment failure, complicated appendicitis and/or recurrence later during pregnancy

Question 17

Wallace rule of 9s for adults:

Answer 17

9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso

Question 18

Wallace rule of 9’s for children:

Answer 18

9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso

Question 19

Parkland formula

Answer 19

Volume of Ringer’s lactate in 24 hrs = 4ml x % body surface area x weight 9KG)

First half in first 8hrs, the rest in remaining 16hrs

Question 20

Escharotomy

Answer 20

-Involves making incision through the eschar to alleviate pressure
-Necessary when elevated pressure in burned limb compromises circulation

Question 21

You are the ST3 on-call for General Surgery at a district general hospital. A 67-year-old man has been brought to A&E Resus after being removed from a burning house. He has burns to his abdomen, chest, neck and arms. He is beginning to become drowsy.

Clinical

Answer 21

-Pt has sustained major trauma
-may have multiple life-threatening injuries including burns, airway obstruction and smoke inhalation
-Mx according to ATLS principles

Question 22

You are the ST3 on-call for General Surgery at a district general hospital. A 67-year-old man has been brought to A&E Resus after being removed from a burning house. He has burns to his abdomen, chest, neck and arms. He is beginning to become drowsy.

Organisational

Answer 22

-Not based in MTC, resources limited
-Organise team (SHO, consultant, anaesthetics, theatre coordinator, ITU spr
-Organise resources (radiology, crit care)
-Communicate with MTC about transfer once patient is stable

Question 23

Specific points in burns patient

Answer 23

-Risk of airway obstruction due to oedema, need for early intubation if: facial burns, hoarseness, carbonaesous sputum, singed nasal heairs

Risk of hypovolaemic shock: catheterise, monitor urine output, resuscitation with parkland formula

Question 24

67 yr old long term care abdominal distension clinical issues with learning disability

Answer 24

-Sigmoid volvulus. Differentials are faecal impaction, other causes LBO e.g. tumour
-? capacity: formal assessment, consult disability/safeguarding team

Question 25

Sigmoid volvulus: a flatus tube decompression was performed, and repeat AXR shows resolution of the volvulus. Explain how you would counsel the patient and NOK about further management

Answer 25

-May recur: advise on sx/signs -Risks of untreated volvulus: colonic ischaemia, perforation, death -In this case the recommended treatment option is sigmoid colectomy to prevent recurrent episodes. There are other alternatives which may be less effective (e.g. sigmoidopexy, PEC). -Requires assessment of risks and benefits -Anaesthetic review, discussion between consultant and family, NOK or carers and learning disability team

Question 26

Classficiation of hypovolaemic shock

Answer 26

Question 27

Stab wound with fat protruding from wound: clinical

Answer 27

-Fat may be omentum indicating peritoneum has been breached -Exploratory laparotomy to detect and repair injuries -In trauma setting this is 'damage control laparotomy': prioritises physiological recovery over anatomical reconstruction in seriously injured/compromised pt -Make sure you mention will check for other stab wounds/injuries

Question 28

Referred breast abscess, but no discrete lump and breast is erythematous with no palpable lump, skin has appearance of orange peel. How would you manage this situation?

Answer 28

-May have inflammatory breast cancer rather than breast abscess -Exclude benign pathologies e.g. mastitis/breast abscess with hx and examination -Mastitis and breast abscesses more likely in woman <40 who is breastfeeding -Counsel pt on next steps

Question 29

Referred breast abscess, but no discrete lump and breast is erythematous with no palpable lump, skin has appearance of orange peel. How would you counsel pt?

Answer 29

-Private room with nurse/partner/NOK available -Explain possible diagnoses and why you are concerned -Explain next steps: referral to breast clinic for triple assessment -Give opportunity for questions -Write down info given -Safety net: reasons to return to GP/ED for assessment

Question 30

Differentials for mesenteric ischaemia

Answer 30

-Perforation of viscus -Ruptured AAA -Pancreatitis

Question 31

Mesenteric ischaemia in 89 yr old. After taking full hx, you learn pt has severe COPD and is on home O2. CTAP--> pneumatosis of majority of small bowel and colon. Explain how you would counsel the patient and NOK about his options

Answer 31

-MDT opinions: anaesthetist, ITU, consultant surgeon -Arrange meeting with pt/NOK in private room with nurse -Explain facts of the case to pt and NOK: unlikely to survive major surgery and no surgical options. The condition is incurable. -Explain all measures will be taken to ensure pt kept comfortable (palliative care) -Offer opportunity for pt/NOK to ask questions

Question 32

74 yr old with distended bowel loops on CXR and mass in RIF, has had previous MI and stents and has COPD. Clinical issues

Answer 32

-Unwell with ? caecal tumour causing SBO, will need operation -Co-morbidities make him high risk, need to calculate NELA mortality and consider how to optimise physiology

Question 33

74 yr old with distended bowel loops on CXR and mass in RIF, has had previous MI and stents and has COPD. Acutely confused. Organisational issues

Answer 33

-Organise team -Use available resources effectively -Due to confusion: discuss with next of kin for collateral history, performance status and to determine best interests decision -Capacity assessment--> if decision to operate should be in best interests and least restrictive option

Question 34

15 yr old with jehovah's witness dad who has splenic lac, father refusing to give blood products. Organisational issues?

Answer 34

-Decisions regarding use of blood products for jehovah's witnesses are complex and the advice of a jehovah's witness advocate, haematologist and paediatrician would be useful regarding the options and alternatives. -In decision making the views of the patient and parents (esp if disagreement) should be taken on board -The law supports giving blood products in an emergency if the pt is a child -Decisions like this should be multidisciplinary and consultant led.

Question 35

Splenic lac definitive management in young jehovah's witness patient

Answer 35

-Triple phase CTAP to grade injury +/- theatre/IR -Direct to theatre/endoscoy/IR suite if acquiring CT will cause unnecessary delay -Escalation to level 2/3 care post op -Active observation (NBM, regular review/bloods), fo low grade injuries/stable pt/no active extravasation of contrast Prepare for theatre -NELA -Escalate: consultant on call -MDT: critical care, anaesthetist, haematology -Contact: theatres -Book and consent for th (consent form 2)

Question 36

Pt day 5 post low anterior resection and tachycardic. Lots of patients tbs in emergency dept. Clinical issues

Answer 36

-Pt is unwell post op from low anterior resection. Differential is wide but could include anastamotic leak, haemorrhage, PE or MI - This pt will need urgent resuscitation, diagnostic investigations and preparation for th overnight if anastamotic leak is confirmed -There are also several other pts in the emergency department who may not have been seen, more information is required to prioritise them

Question 37

Pt day 5 post low anterior resection and tachycardic. Lots of patients tbs in emergency dept. What are the organisational issues?

Answer 37

-Organise team, use available resources -Recognise that your junior colleague is in difficulty and provide as much support as possible -Educational: after this situation has resolved, there may be an opportunity to use it to teach the SHO about prioritisation and managing unwell surgical patients -Could suggest courses and further reading to support development

Question 38

Pt in anaesthetic room for lap appendix. Also on list is diabetic patient for incision and drainage of ischiorectal abscess. Clinical issues:

Answer 38

-Clinical priority is reviewing the patient with suspected ischaemic bowel who needs resuscitation, diagnostic imaging and a decision regarding immediate surgery -The other two patients also require surgery, but more info is required to determine how unwell they are

Question 39

Definitive management ischaemic bowel

Answer 39

-NBM -CTAP -Escalate to level 2/3 care -Commence heparin infusion -Discuss with vascular -Laparotomy to assess for ischaemic bowel Prepare for theatre

Question 40

Prepare for theatre

Answer 40

-Escalate: consultant on-call -MDT: critical care, anaesthetist, other relevant specialties -Contact: theatres -Book and consent for theatre (N.B. consent 4 if lacks capacity) -NELA mortality

Question 41

ST3, called to recovery in day surgery to review pt who has undergone lap chole and seems unwell. The consultant who performed it has gone to private hospital to start evening list. Pt appears cool and clammy, with HR 140 and BP 90/60. Recovery nurse mentions that recovery will be closing soon. Clinical issues

Answer 41

-DIfferential includes bile leak, visceral injury, haemorrhage and MI -Pt will need resuscitation and may need return to theatre for repeat laparoscopy

Question 42

ST3, called to recovery in day surgery to review pt who has undergone lap chole and seems unwell. The consultant who performed it has gone to private hospital to start evening list. Pt appears cool and clammy, with HR 140 and BP 90/60. Recovery nurse mentions that recovery will be closing soon. Organisational issues

Answer 42

-Organise team and use available resources -Pt may be in day surgery suite some distance from main hospital, where there are limited staff and resources -May be more appropriate to bring pt to main hospital theatres if the pt is stabilised for a brief transfer -If you are unable to contact the consultant who has gone to the private hospital, it will be the responsibility of the on-call consultant to make the decision about whether the pt needs to return to theatre

Question 43

What is the definitive management?

Answer 43

-Early bile leak: laparoscopy, washout and placement of drains -Visceral injury: laparoscopy, washout, repair of injury and placement of drains -Haemorrhage: laparoscopy +/- laparotomy and control of haemorrhage -Medical emergencies: peri-arrest call and discussion with relevant specialist (e.g. cardiology)

Question 44

79 yr old pt in ED, peritonitic and has HR 70, BP 90/60. Pmhx includes diverticulosis, AF, IHD, T2DM. Dhx takes warfarin. CLinical issues

Answer 44

-Pt is unwell and haemodynamically unstable (N.B use of a beta-blocker which may mask a tachycardia) and has acute abdomen -Differential is wide but includes ischaemic bowel, perforated viscus, ruptured AAA -Needs diagnostic investigations in the form of a CT scan, resuscitation and likely a laparotomy -Comorbid patient anticoagulated on warfarin: INR will need to be checked and reversed with PCC -Has severe AKI with hyperkalaemia which will need to be treated -Has IHD which will require evaluating prior investigations e.g. transthoracic echo, angiograms to determine severity of cardiac disease and fitness for surgery -Will need anaesthetic and ITU review ? fitness for surgery, support in ITU

Question 45

90 yr old in ED with severe left leg pain over last 6 hrs. Comorbid pt including CCF, T2DM, COPD, IHD. Pt and vamily are insistent you do everything possible to save his leg. Clinical issues

Answer 45

-Unwell pt with possible acutely ischaemic leg. -Needs urgent resuscitation, diagnostic imaging and decision regarding surgery -Multiple comorbidities, elderly pt: may not bre fit for anaeshtetic -If leg is viable, may be candidate for embolectomy which can be performed under LA -If leg is not viable, decision will need to be made regarding whether he is fit for amputation or receives palliative treatment.

Question 46

On call registrar for general surgery at DGH. About to go home as there are no cases on the emergency theatre list tonight and you are non-resident on-call. On call radiologist calls to say they have tried to get through to on-call SHO but not responding to bleeps. Radiologist is calling to inform you that one of the patients admitted earlier during the day with suspected acute diverticulitis has undergone CTAP which shows leaking AAA.

Answer 46

-Radiologist has identified pt with leaking AAA which is an emergency. You will need to review the patient urgently, commence resuscitation and arrange transfer to regional vascular unit.