Surgical EmergenciesSurgical EmergenciesMr. Paul MacKenzie BSc (Hons), BM BS, MRCSCT 2 Surgical TraineeRoyal Devon and Exeter Hospital

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…….

““FEEL FREE TO FEEL FREE TO COPE”COPE”

This is how to survive……..

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

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

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

CXR (Portable)CXR (Portable)

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

ECGECG

What Does the ECG Show What Does the ECG Show (2)(2)A – Atrial FlutterB – Ventricular FlutterC – Atrial FibrillationD – Ventricular FibrillationE – Supraventricular Tachycardia

ABGABG

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

Differential Diagnosis?Differential Diagnosis?

What is the most likely What is the most likely Diagnosis? (4)Diagnosis? (4)A – Bowel ObstructionB – DiverticulitisC – AppendicitisD – Ischaemic BowelE – Ruptured AAA

ManagementManagementCall for Senior Help!Stabilise the patient

◦IVI◦IVABx◦Catheterise◦Oxygen

Take Bloods (Inc. G+S)CT Scan + ? Laparotomy

11am Abigail23-year-oldSudden Onset

Severe Central Abdominal Pain

Recent Laparoscopy for Investigation of Pelvic Pain – Likely due to retrograde menstruation

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

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

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

11am Abigail23-year-oldSudden Onset

Severe Central Abdominal Pain

Recent Laparoscopy for Investigation of Pelvic Pain – Likely due to retrograde menstruation

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

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

InvestigationsBedside – Urine Dip & BHCG

Bloods – ABG, FBC, UE’s, LFT’s, Amylase, CRP

Imaging – Erect CXR

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

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

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

The Importance of Cllinical Examination

PR and Listen for Bowel Sounds!

InvestigationsBedside – Urine Dip

Bloods – FBC, UE’s, LFT’s CRP, TRACE ELEMENTS, Mg, Phosphate, Calcium

CXR/AXR

?CT

ManagementCT Scan – To identify point and

Cause of Obstruction

Conservative vs Surgical Management

Concept of ‘Drip and Suck’ – NG tube and Catheterise

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

What Endocrine Hormones What Endocrine Hormones doe the Pancreas Produce? doe the Pancreas Produce? (1)(1)A – CholecystokininB – AmylaseC – LipaseD – Insulin and GlucagonE – Serotonin

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

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

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

Management?ITUCXRUSSCatheteriseAggressive Fluid Management?IVABxCT after 5 days – Surgery only

indicated in Severe Cases where necrosis is present

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

What is the most likely What is the most likely Diagnosis? (4)Diagnosis? (4)A – UTIB - Renal CalculiC – Inguinal HerniaD – Femoral HerniaE – Ruptured AAA

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

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

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

BUT…… 30 minutes laterA- Patent and ProtectedB – RR 24, Sats 95% airC – BP 80/40, HR 128D – GCS 13/15E – Abdomen tender ?More

distended

What is the definitive What is the definitive Investigation? (5)Investigation? (5)A – CT Angiogram AortaB – MR AngiogramC – USSD – FAST ScanE – Plain CT

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!

Causes of Abdominal PainCauses of Abdominal Pain

Key Surgical EmergenciesKey Surgical EmergenciesIschaemic BowelAAAPerforationBowel ObstructionPeritonitisPancreatitisAcute GI BleedIschaemic Limb

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