Acute Surgical Conditions & Trauma Management :

Family Medicine PresentationBy K.V. Liew & H.K. Kwong

Common Principles : • History & Physical Examination.• Provisional Diagnosis.• Basic investigations (e.g. blood tests, X-

rays & bedside imaging).• ***Definitive Imaging (USG, CT-scan), if

patient is stable & fit for transfer to Radiology department.

• Resuscitation if needed, then definitive surgical treatment if possible, otherwise supportive treatment.

Acute Abdomen : • Abdominal Pain.• Physical Examination findings (e.g.

tenderness, rebound & guarding).• Fever.• Tachycardia; haemodynamicaly unstable.• Septic-looking.• Usually implies that there is peritonitis,

which if left untreated, will result in severe complications (e.g. DIC & shock) and eventually DEATH.

• Classically, requires urgent surgical treatment, especially if the precise cause is not known (i.e. exploratory laparotomy).

• Nowadays, with newer technology available, the incidence of laparotomy is reduced.

• Endoscopic treatments may be used, depending on the precise pathology (e.g. ERCP, therapeutic OGD & laparoscopy).

• Newer X-Ray, CT & USG can provide better image quality, enabling more precise diagnosis & treatment (e.g. interventional/therapeutic radiology).

Take-Home Message No. 1 :

• Not all acute surgical conditions requires surgery. Some can be solved by invasive non-surgical procedures.

• e.g. ERCP/papillotomy, therapeutic OGD, X-ray guided gel-foam embolisation.

Take-Home Message No. 2 : • How do you define “acute” ?• By time of onset or urgency for treatment ?• Acute surgical conditions actually comprise

a broad spectrum of time-frame, from hyper-acute (e.g. seconds to minutes in ruptured AAA) to super-acute (e.g. minutes to tens-of-minutes in GI bleed) to normal-acute (e.g. tens-of-minutes to hours in PPU, ischaemic bowel, strangulated hernia) to hypo-acute (e.g. more than a few hours in appendicitis, cholecystitis).

Acute Surgical Conditions (by anatomy) :

• Vascular conditions :

• Ruptured or Leaking AAA.

• GI Bleed.

• Thrombosis of arteries (e.g. SMA).

Ruptured AAA :

• Symptoms :• Central abdominal pain, usually of

persistent & continuous nature.• ***Low Back Pain***• Dizziness.• History of AAA.• Requires high index of suspicion,

especially when did not have Hx of AAA.

Signs : • Ill-looking. Need not necessarily be so

(maybe clinically quite well).• Hypotension, with fast pulse.• Pallor.• Abdominal tenderness, rebound &

guarding.• Pulsatile, expansile abdominal mass.• Expansile, pulsatile mass may not be

palpable, especially if haematoma has formed in abdomen.

Management : • Emphasis is on RAPID clinical diagnosis,

since survival depends on it.• H’cue, ? Hx of coffee ground vomitus, PR

to R/O GI bleed. Bedside USG.• ***Straight to OT, X-match, mention

large amounts of blood needed.• If relatively stable, URGENT CT-Abdomen,

especially if no previous Hx of AAA.• Poor prognosis with 50% mortality, some

centres claim 40%.

GI Bleed :

• Divided into upper & lower GI bleed.

• Can be rapidly fatal.

• ***No surgical patient should die from GI bleed, if managed promptly & properly.

UGI Bleed Symptoms :

• Coffee ground vomitus.• Tarry stool.• Dizziness/postural dizziness.• Epigastric pain.• Hx of peptic ulcer disease.

UGI Bleed Signs :

• Malaena (fresh/old, indication of urgency of treatment).

• Haematemesis.• Pallor.• Stigmata of liver disease.• Hypotension, fast pulse.

Differential diagnoses :

• Bleeding peptic ulcer.

• Gastro-oesophageal variceal bleeding.

• Meckel’s Diverticulum.

Management : • Try to assess volume of haemorrhage.• Urgent OGD is essential for diagnostic &

therapeutic purposes.• Sengstaken-Blakemore Tube for gastro-

oesophageal variceal bleed.• Close monitoring of vital signs.• Can attempt X-ray guided embolisation of

arterial bleeders.• If bleeding not controlled, proceed to

surgery (e.g. fundoplication; partial gastrectomy for GU).

Lower GI Bleed Symptoms :

• PR bleed, can be with blood clots.• Usually not associated with

abdominal pain.• Symptoms of hypovolaemia &

shock.• Symptoms of GI tract malignancy

(weight loss, decreased appetite, change of bowel habit).

Lower GI Bleed Signs :

• Fresh PR bleed, with/without clots.

• Signs of hypotension & shock.

• Signs of GI Tract malignancy.

Differential Diagnoses :

• Bleeding rectal ulcer.

• Haemorrhoids.

• Bleeding colonic tumours.

Management :

• PR & Proctoscopy is essentially for diagnostic purposes & assessing volume of blood loss.

• Close monitoring of vital signs.• Can attempt X-ray embolisation

too.• If bleeding persists, proceed to

surgery (e.g. suturing of rectal ulcer; hemicolectomy).

Thrombosis of arteries :

• For example, SMA, resulting in acute ischaemic bowel.

• Severe abdominal pain which is disproportionate to abdominal signs of tenderness/rebound/guarding.

• Severe metabolic acidosis.• Embolectomy +/- endarterectomy

+/- gut resection.

Urological conditions :

• Pyelonephritis +/- hydronephrosis.• If patient is septic-looking,

haemodynamiccaly unstable, degree of urgency is increased.

• Percutaneous nephrostomy (PCN).

GI Tract Conditions : • Perforated Peptic Ulcer (PPU) :• Symptoms can overlap with those of severe

Gastro-enteritis (G.E.)• Classically, sudden onset of continuous, severe

epigastric/central abdominal pain. May radiate to directly to back.

• P/E showed “board-like rigidity” of abdomen.• ***CXR=>free gas under diaphragm.• Omental patch repair (can be

open/laparoscopic).• SIRS=>OT within 6hrs. Of onset of symptoms.

Ischaemic bowel : • Can be due to other causes apart

from thrombosis of arterial supply.• Adhesion bands, strangulated hernia,

prolonged intestinal obstruction (I.O.)• CT-Abdomen is of significant value in

deciding whether to operate or not.• Laparotomy +/- gut resection +/-

ileostomy or colostomy.

Sigmoid Volvulus :

• Abdominal pain.• NBO nor flatus.• AXR findings of coffee-bean

shaped large bowel, spoke-wheel shaped bowel & ? shaped bowel.

• Flatus Tube can relieved obstruction and thus not necessarily need surgery.

Intussuception : • Right-sided abdo. Pain. • Mass in Right flank, RLQ feels empty.• Confused with appendiceal abscess.• Site of intussuception near region of

ileo-caecal valve.• Barium enema can both be diagnostic &

therapeutic.• Risk of ischaemic bowel/recurrence

after procedure.

Hepato-Biliary Conditions :

• Ruptured HCC.• Usually occurs in those who presents

with undiagnosed HCC.• CT-Abdomen if patient is stable for

transfer.• X-Ray guided embolisation of branches

of hepatic artery. ?Limited value. • Segmentectomy +/- partial

hepatectomy.

Cholangitis, Cholecystitis & Gallstone pancreatitis :

• Emergency ERCP +/- EPT can be life-saving.

• Treat the septic focus.

• Acute cholecystitis & appendicitis.