surgical emergencies yr 5 amk teaching
TRANSCRIPT
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Surgical EmergenciesSurgical EmergenciesMr. Paul MacKenzie BSc (Hons), BM BS, MRCSCT 2 Surgical TraineeRoyal Devon and Exeter Hospital
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Saturday Morning at the Saturday Morning at the RD&ERD&EYou’re feeling a bit worse for wear
from the Mess Night Out.You’ve just finished Post Take Ward
Round and are dutifully updating the Consultants list and putting out bloods that your colleague for got to do the night before.
The Consultant, Registrar and SHO are all in theatre and are going to be a while……..
You wished you stayed in bed and phoned in sick…….
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““FEEL FREE TO FEEL FREE TO COPE”COPE”
This is how to survive……..
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9.30 am Dorothy9.30 am Dorothy85-year-old –
Residential Home Resident
Sudden Onset Abdominal Pain at 7.30am
ConfusedClammyIn the Ambulance
passed a small amount of PR Blood
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Assess The Patient in an ABC Assess The Patient in an ABC MannerMannerA – Patent and ProtectedB – Good Air entry bilaterally
◦Sats 95% on Air◦Respiratory Rate 25
C – Cold, Clammy Peripherally Shut Down◦BP 85/70◦HR 135
D – Confused◦GCS 13/15◦Moving All four Limbs
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E – Abdomen diffusely Tender◦Feels Rigid◦Guarding◦Rebound Tenderness◦Patient is Lying Completely Still – Any
attempts to move her and she screams
◦PR Examination – Empty Rectum, small amount altered blood on the glove
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CXR (Portable)CXR (Portable)
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What is the abnormality on What is the abnormality on the CXR? (1)the CXR? (1)A – Left Lower Lobe PneumoniaB – Tension PneumothoraxC – Tissue Heart ValveD – Coronary Artery Bypass
GraftsD – Metallic Heart Valve
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ECGECG
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What Does the ECG Show What Does the ECG Show (2)(2)A – Atrial FlutterB – Ventricular FlutterC – Atrial FibrillationD – Ventricular FibrillationE – Supraventricular Tachycardia
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ABGABG
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How would you describe the How would you describe the ABG? (3)ABG? (3)A – Metabolic AlkylosisB – Metabolic AcidosisC – Respiratory AlkylosisD – Respiratory AcidosisE – Mixed Metabolic/Respiratory
Acidosis
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Differential Diagnosis?Differential Diagnosis?
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What is the most likely What is the most likely Diagnosis? (4)Diagnosis? (4)A – Bowel ObstructionB – DiverticulitisC – AppendicitisD – Ischaemic BowelE – Ruptured AAA
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ManagementManagementCall for Senior Help!Stabilise the patient
◦IVI◦IVABx◦Catheterise◦Oxygen
Take Bloods (Inc. G+S)CT Scan + ? Laparotomy
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11am Abigail23-year-oldSudden Onset
Severe Central Abdominal Pain
Recent Laparoscopy for Investigation of Pelvic Pain – Likely due to retrograde menstruation
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Abigail’s pain moves to the Abigail’s pain moves to the RIF over 24 hours, she has a RIF over 24 hours, she has a low grade temperature and low grade temperature and vomits once. She has a high vomits once. She has a high WCC and CRP. What is the WCC and CRP. What is the most likely diagnosis? (3)most likely diagnosis? (3)A – Renal ColicB – Ruptured Ectopic PregnancyC – Ovarian Cyst AccidentD – Retrograde MentruationE – Appendicitis
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Abigail’s pain moves to the Abigail’s pain moves to the RIF over 24 hours, she has a RIF over 24 hours, she has a low grade temperature and low grade temperature and vomits once. She has Normal vomits once. She has Normal Bloods. What is the most Bloods. What is the most Likely Diagnosis? (4)Likely Diagnosis? (4)
A – Renal ColicB – Ruptured Ectopic PregnancyC – Ovarian Cyst AccidentD – Retrograde MentruationE – Appendicitis
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Abigail’s pain moves to the Abigail’s pain moves to the RIF over 24 hours, she has a RIF over 24 hours, she has a low grade temperature and low grade temperature and vomits once. What is the vomits once. What is the most Important Diagnosis to most Important Diagnosis to Exclude? (5)Exclude? (5)
A – Renal ColicB – Ruptured Ectopic PregnancyC – Ovarian Cyst AccidentD – Retrograde MentruationE – Appendicitis
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11am Abigail23-year-oldSudden Onset
Severe Central Abdominal Pain
Recent Laparoscopy for Investigation of Pelvic Pain – Likely due to retrograde menstruation
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ABC AssessmentA- Patent and ProtectedB – RR 20, Sats 98% AirC – BP 100/80, HR 120D – NADE – Abdomen Distended, tender
in Epigastrium with rebound tenderness and guarding
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Elicit a good history!Background & PMHx
◦When was the laparoscopy?◦Who By?◦Read the Op note… Complications◦Any Medications?◦Gynae History
Presentation◦Onset of Pain, Nature of Pain,
Radiation
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InvestigationsBedside – Urine Dip & BHCG
Bloods – ABG, FBC, UE’s, LFT’s, Amylase, CRP
Imaging – Erect CXR
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ManagementCall For Help!
If Stable Enough – Likely Pat Will Need CT – You can request these on Medway
If Unstable, Patient will Need Laparotomy – You can help get things ready – Check G&S, Check Antibiotics Rx’d, Inform theatres and liaise , Catheterise
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12pm Barry77-year-oldGradual Onset,
Lower Abdominal Pain, came on over few days, getting worse
Distended, not opening bowels and not passing wind for 48 hours
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The Significance of Past Medical History!Barry had an Open Resection of a
sigmoid Tumour 4 years ago
Barry has Motor Neurone Disease
Barry has had a recent Urinary Tract Infection
Barry has had a recent nasty Chest Infection
Barry is awaiting a hip replacement and has severe pain from Osteoarthrtitis
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The Importance of Cllinical Examination
PR and Listen for Bowel Sounds!
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InvestigationsBedside – Urine Dip
Bloods – FBC, UE’s, LFT’s CRP, TRACE ELEMENTS, Mg, Phosphate, Calcium
CXR/AXR
?CT
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ManagementCT Scan – To identify point and
Cause of Obstruction
Conservative vs Surgical Management
Concept of ‘Drip and Suck’ – NG tube and Catheterise
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2pm Laura55-year-oldGrumbling RUQ
pain last 48 hoursNow much worse
Central, radiating through to the back
Associated with nausea and vomiting
Sweaty and Clammy
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What Endocrine Hormones What Endocrine Hormones doe the Pancreas Produce? doe the Pancreas Produce? (1)(1)A – CholecystokininB – AmylaseC – LipaseD – Insulin and GlucagonE – Serotonin
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What is the most common What is the most common cause for pancreatitis? (3)cause for pancreatitis? (3)A – TraumaB – AlcoholC – GallstonesD – Scorpian StingsE - Tumours
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GET SMASHEDG – Gallstones (45%)E – Ethanol (35%)T – TumoursS – Scorpian StingsM – Mumps (or Microbiology)A – AutoimmuneS – Surgery/Trauma/ERCPH – Hyperlipidaemia/MetabolicE – Emboli/IschaemiaD – Drugs/Toxins
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Modified Glasgow Score (Score 1 for)P – pO2 < 8A – Age 55>N – White Cell Count 15>C – Calcium <2R – Urea 16>E – LDH 600>, AST/ALT >200A – Albumin <32S – Blood Glucose >10
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Management?ITUCXRUSSCatheteriseAggressive Fluid Management?IVABxCT after 5 days – Surgery only
indicated in Severe Cases where necrosis is present
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3pm Mark67-year-old fit
tennis playerSudden Onset
Severe Loin to Groin Pain after a tennis match
Caused him to Collapse
Past Medical History – Previous Renal Colic and Hypertension
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What is the most likely What is the most likely Diagnosis? (4)Diagnosis? (4)A – UTIB - Renal CalculiC – Inguinal HerniaD – Femoral HerniaE – Ruptured AAA
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What is the most Important What is the most Important Diagnosis to Exclude? (3)Diagnosis to Exclude? (3)A – UTIB - Renal CalculiC – Inguinal HerniaD – Femoral HerniaE – Ruptured AAA
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What is the most Important What is the most Important First Line Investigation? (2)First Line Investigation? (2)A – CXRB – AXRC – FAST ScanC – Urine AnalysisD – Full Blood COunt
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ABC AssessmentA – Patent and ProtectedB – RR 16, Sats 96% AirC – BP 110/65, HR 98D – NADE – Tender in lower abdomen and
right flank & renal angle
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BUT…… 30 minutes laterA- Patent and ProtectedB – RR 24, Sats 95% airC – BP 80/40, HR 128D – GCS 13/15E – Abdomen tender ?More
distended
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What is the definitive What is the definitive Investigation? (5)Investigation? (5)A – CT Angiogram AortaB – MR AngiogramC – USSD – FAST ScanE – Plain CT
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ManagementUrgent Vascular Surgery Review –
Needs to be in theatre NOW!Cross Match (at least) 4 units –
Activate Massive Transfusion ProtocolPermissive Hypotension – Don’t Ram
him full of FluidsCatheteriseGoing to need Arterial Line/ Central
Line etc. So Let Anaesythetics team know!
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Causes of Abdominal PainCauses of Abdominal Pain
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Key Surgical EmergenciesKey Surgical EmergenciesIschaemic BowelAAAPerforationBowel ObstructionPeritonitisPancreatitisAcute GI BleedIschaemic Limb
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Key Points for Doing Well in Key Points for Doing Well in AMKAMKWork hard and revise all year –
this exam is not designed to be ‘revised for’
READ THE QUESTION CAREFULLYIf you can narrow the answer
down to two – its worth a shotTake a night off the night before
the exam
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