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Surgical emergencies Surgical Emergencies Antony Parsons November 2007 S J Manou November 2007 Emergency Medicine LGI Overview • Cases (10) – Acute abdomen • Break – – – – Acute abdomen Acute scrotum Acute limb Et cetera 1400-1500 1500-1515 1515 -1600 • Quiz 1600-1615 • 1630 Taxi What is surgery? “The branch of medicine.. deals with the diagnosis and treatment.. injury, deformity, and disease.. by manual and instrumental means” The acute abdomen • Appendicitis • Bowel Obstruction • • • • • Congenital – Atresias, Hirschsprungs, ARM Meconium Ileus Hypertrophic Pyloric Stenosis Intussusception Hernia • Testicular Pain • Medical Causes • Abdominal Pain • Vomiting • crying • Shock & collapse • Abdominal Pain – character, localization, radiation • Emesis – Projectile, colour, amount • Bowel Habits – BNO, diarrhoea, colour of stool • Flatus • Activity • Hydration • Past History – CF, Surgery • Birth History – Hypoxia, Diabetic mother, Meconium, gastroschisis/omphalocele • Drugs – Steroids • Family History – Hirschsprungs, CF • Immunization - intussusception Hx Abdominal Pain • Historical Features – Pain • • • • • onset, & duration location, quality, severity, aggravating and alleviating factors – PMHX • similar symptoms • Med/ surgical history • Associated symptoms – GI- anorexia, nausea, vomiting, diarrhea, constip, bleed po/ pr – GU-dysuria, urgency, frequency – Gynecologic system • LMP, pregnancies, PV vaginal discharge Surgical Emergencies Age important: • ~10% severe abdominal pain in elderly = vascular cause (e.g. ruptured AAA, mesenteric ischaemia). • Perforation: DD/carcinoma > appendicitis in elderly • peritonitis ↑ mortality in elderly. • Children – appendicitis is common • Pancreatitis any/medium age group (gallstone > women or alcohol groups. • Younger women ?gynaecological causes Examination- The acute abdomen • General appearance – sweaty, pallor, agitation • Vital Signs • Abdominal exam – Inspection distention, scars, masses – Palpation- most clinically useful • Start at point farthest from maximum pain • While patient breaths • Rigidity- involuntary guarding – reflex spasm of abdominal muscles • check for masses, hernias – +/- PR exam – +/- GU exam in men – +/- pelvic exam in women • ABC • General Appearance • Abdominal Distension & movement • Visible peristalsis • Palpation – tenderness, rigidity, guarding, mass • Auscultation • PR – Surgical finger only!! • ABC • Adequate hydration • NBM • AXR • Early Referral • NG free drainage • USG Abdominal Pain- IX • Path Labs – FBC? – U&E – CRP? – Amylase? – Lipase? – LFTs ? • Xray – Radiographs • CXR, AXR Abd Pain - Treatment • Fluid – NPO – IV Fluid • Analgesics – Opiates • Antiemetics • Antibiotics • Cefuroxime • Metronidazole Abd Pain- Discharge? • General indications for admission – Intractable pain or vomiting – Those who appear acutely ill – Pts. With a specific diagnosis – Elderly pts with unclear diagnosis Case # 1 • 38 year old man presents with: -Epigastric pain, -Vomiting • What else do you want to know? Case # 1 - History • Sudden onset severe epigastric pain • Vomited 3 times • Pain eased by sitting forward • Bowels not opened today • Never had similar episode • Hypertension, angina, diabetes • Pub landlord • Enjoys a pint of mild Case # 1 Examination • Pale • Hypotensive • Tachycardic • • • • • Rigid abdomen Generally tender Guarding No rebound BS present Case # 1 • Differential Diagnosis of Upper Abd Pain? – – – – – – ? MI ? RTI ? Gastritis/Perforation? ? Biliary colic ? Hepatitis ? Pancreatitis • Investigations? Cardiac • Hx epigastric pain • XM • ECG Pulmonary • Hx – Pain • ? Pleuritic • XM • CXR Gastritis/ Perf • Hx – Esp alcohol – Assoc H pylori – ? GI bleed • XM – Epigastric tenderness – Po/Pr bleed? • Ix – CXR Erect • Rx – Antacids – PPI? • Refer – for OGD? – For Sx? Other common surgical emergencies • Gall bladder disease (cholecystitis, gall stones) Colicky pain RUQ radiating to back/R shoulder, N&V, sometimes dark urine, pale stools & jaundice. Mgmt – IVF, IV Abx, LFT/U&E/Coag, Surgeons • Pancreatitis Central AP radiating to the back. Painful supine, ↓sat up/leant forwards. Risk factors. Mgmt – NBM/resus, amylase/scoring Biliary Tract Disease • History – Fat Fertile Forty – Abd pain • colicky – +/-Jaundice – +/- Rigors • XM – Murphys positive • Ix – FBC, LFT’s • Should be normal in Bil colic – Ultrasound • Treatment – IV Fluid, – Analgesia • NSAID/ • Morphine? – Antispasmodics – Antiemetics Hepatitis • History – Esp. drinkers, infection – Assoc malaise, anorexia, nausea – Over days/weeks • XM – Jaundice – Tenderness • IX – BM – LFTs • Rx Pancreatitis • Hx – 80% caused by alcohol or gallstones – Pain usually located in upper ½ of abdomen • XM – Tenderness diffuse • IX – – – – BM FBC , U&E, LFT ABG Best screening test• Lipase? Amylase? – Consider CT • Rx – NPO – NG – IV Fluid /Analgesia Case study # 2 • 69yr ♂ • PC – confusion/unwell • HPC – recent deterioration & confusion, poor appetite & ?recent chest infection. Past UTIs. • PMH – T2DM, Inv Prostate Ca, LVF, Anaemia • DH – Oral Hypoglycaemics, antiHTN, analgesia • SH – Lives with family, Normally coherent & mobile. Case Study #2 • O/E – Obs ↑HR, BP stable, sats>95%, apyrexial, BM 1.0. • Pt irritable & confused, Chest clear, HS PSM, JVP→, No ankle oedema, Abdo Soft. • Dextrose IV stat. IVF slow. • Bloods – WCC > 20 (neutrophilia), Glucose 0.5, TTU – weakly positive. CXR - NAD • IV Abx started • Referred to medics Case # 2 • Differential diagnosis of central Abd Pain – ? Int Obs – ? Constipation/ Gastroenteritis – ? Pancreatis – ? AAA/ – ? Vasc/ – ? Renal colic/ • Investigations? Other common surgical emergencies • Bowel obstruction (cancer, hernia, adhesions) Colicky pain, bloating, N&V, constipation/overflow & no flatus. Mgmt – resusc analgesia, AXR, NGT/Flatus Tube • Perforation (PUD, DD, IBD, cancer) Sudden severe AP. Systemic upset, peritonitic. Mgmt – resusc, ABG, eCXR, CT/surgery Surgical Emergencies – Special Considerations • Vascular • Ruptured AAA – Triad pain-hypotension-mass. Pain in abdomen, back or flank (acute, severe & constant) • • • • • Prevalence ↑ with age & ↑ risk rupture >5.5 cm. Bedside USS. Contrast CT (stable). 10-25% survive rupture Resusc: over v under resusc – BP/CVP Surgical Treatment definitive. Surgical Emergencies – Special Considerations • Vascular • Bowel Ischaemia - Sudden onset severe AP, postprandial, food fear/↓weight., PR Blood, Pain out proportion to exam. • Often other vascular problems e.g. IHD/PVD, valvular disease & arrhythmias. • 0.1% admissions. • Bloods (regular + coag), ABG (↓pH,↑lact), CT (>95%) • IVF, IV abx, urgent surgical r/v Intestinal Obstruction • Hx – Previous abdominal surgery – Intermittent/colicky pain – Generalized or central pain • XM – 1/3 have generalized tenderness – Abdominal distention • IX AXR – Loops of air • RX – NPO/ NG tube – IV Fluid Gastroenteritis • Hx – crampy abdominal pain with – vomiting and diarrhea • XM – Usually does not cause significant tenderness on palpation • Ix – Stool C&S – Diagnosis of exclusion • Rx – Fluid – Analgesia – no antibiotics – Home/ side room Constipation • Hx – esp. children • XM • Dx – AXR can help • Rx – Diet – Softeners – Stimulants Pancreatitis • Hx – 80% caused by alcohol or gallstones – Pain usually located in upper ½ of abdomen • XM – Tenderness diffuse • IX – – – – BM FBC , U&E, LFT ABG Best screening test• Lipase? Amylase? – Consider CT • Rx – NPO – NG – IV Fluid /Analgesia Abdominal Aortic Aneurysm • Hx – recent onset of flank, abdominal or low back pain • XM – Less than ½ of patients p/w classic triad • abdominal pain • hypotension, and • pulsatile abdominal mass • Diagnosis – Low suspicion – US for diameter – CT scan • RX IV – ? Fluid? – ?adrenaline? – Keep BP on low side Mesenteric ischemia?? • Hx – Esp. elderly • Xm – Abdominal tenderness • IX – ABG Hi Lactate – CT/Angio • Rx – IV Analgesia/Antibiotics – Radiology – Surgery • NB Beware d/c elderly with abd pain Renal Colic • History – – – – – • Severe pain abrupt onset colicky Unilateral flank, radiation to groin, Examination – Distress/ sweaty • Investigation – UA- haematuria in 2/3 – KUB- can be normal – Non-contrast CT • RX – Analgesia • NSAID/ Morphine Other Causes of Abdominal Pain • Metabolic – DKA • Sickle Cell Crisis – Usually due to vaso-occlusion Case Study #2 • Next day call from Medic SHO – Pt c/o backache when slightly ↑ coherence. • Large pulsating abdo mass. • CT – 12 x 10cm infrarenal AAA, worrying variable density thrombus layering in sac & dirty fat around edges (No substantial leak) • Urgent vascular r/v • Spotted on MRI >2 wk prior. • pt for palliative care. Case # 3 • 26 year old female presents with : -Lower abdominal pain What else do you want to know? Case # 3 History • Pain in periumbilical area for 3 hours • Constant ache with intermittent stabbing • Score 7/10 • Feels sick • Dysuria and loose stools for a day • LMP 1/52 ago, cycle normally regular • No PV-bleeding/discharge • Previous STI Case # 3: Examination • Tender around periumbilical area • No rebound or guarding • BS present • Obs all normal, temp 37.8 Case # 3 • Differential diagnosis of Lower Abd Pain – Appendicitis? – UTI? – Pelvic Inflam Disease? – Ectopic Pregnancy – Diverticulitis • Investigations? Acute Appendicitis • 10% of the population develop appendicitis • 70,000 appendicectomies/yr UK • ♂>♀ • Appendicectomy ♀> ♂ • ♀ more likely 'normal' appendix removed • 10-50% normal at removal • Perforation risk: – <10 yrs = 50% – 10-50 yrs = 10% – >50 yrs = 30% Appendicitis – Diagnostic Problems • Clinical diagnosis – Urinalysis – can be +ve – PT – Mortality: ectopic>appendicitis – USS – ?abscess suspected – Bloods – Normal WCC ≠ Normal. • Mgmt – Observe, analgesia, IVF Surgical Emergencies – Special Considerations • Females • PID – Lower AP,↑T°C , vaginal d/c • (Swabs, IVF, IV Abx, PT) • Ectopic pregnancy – Lower IF AP, late period, occasionally vaginal d/c • (Resus, Blood XM, PT, urgent refer) • Labour pains – all doctors can get caught out at some stage • (Stage pregnancy, careful exam +/- speculum) Diverticulitis • “left sided appendicitis” • Σ colon (95%). • Prevalence ~35 – 50% by 1970s. 65% 85 yrs+ some form DD. • <5% of <40 yrs DD. • L-sided DD> West, R-sided DD> Asia/Africa • 10-25% diverticulosis pts develop diverticulitis. Diverticulitis • Conservative mgmt, bowel rest, IVF & B.Spec abx. • Recurring attacks/complications (peritonitis, abscess, fistula) may need surgery. • Low residue diet. Low-fibre diet gives colon healing time. • Later high-fiber diet. Lowers recurrence rate Appendicitis • Hx – RLQ pain, – pain that migrates - periumbilical area to RLQ, – (Excluding appendicitis) – Absence of RLQ pain/ Previous similar pain • XM – RLQ tenderness • IX value of tests? – FBC? CRP? – Urinalysis • Dx – 20% of pts. Initial dx. is missed – Normal appendices found intraoperatively 15-40% • Rx – Observe – Sx UTI • Hx – Abd pain- loin/suprapubic • XM – Tenderness • Ix – Urinalysis • Leucocyte esterase • MCS • Rx – Antibiotics • Usu Trimethoprim Pelvic Inflammatory Disease • Hx – – – – • XM – – – – • Lower Abdominal pain Assoc Pelvic Pain Presence of vaginal discharge ? Risk of STD- 90% are STI Fever, Abdominal tender PV tender palpable adnexal mass, IX – elevated WBC – Must rule out pregnancy – Swabs? • High vaginal and cervical • Rx – Antibiotics (early) Ectopic Pregnancy • Hx – – – • XM – – • Ectopic pregnancy MUST be considered in any woman of childbearing age Many patients present prior to actual rupture Poor predictive value of historical “risk factors” and physical exam Vaginal bleeding may be only abnl. Sign Diagnosis – – • Normal Low BP –when ruptured DX – – – – • p/w abnormal vaginal bleeding or abdominal pain, Nb diarrhea? Positive pregnancy test Transvaginal ultrasound Refer to Gynae /clinic Ovarian torsion/cyst • Hx – (rare) – Pain – Sudden unilateral severe • Xm – Tender mass on PV • Ix – US • Rx – SX Diverticulitis • Hx – Esp older population – Localized LLQ pain • XM – Tenderness • Generalized • Or LLQ • Ix – FBC? – CT with contrast • RX – IV fluid /Anti Bs/Sx • Complications – Pericolic abscess – Peritonitis – PR-bleeding Nonspecific Abdominal Pain • Most common ED diagnosis • Hx XM – Nausea is common – Tenderness usually not severe – Lab tests usually normal • Diagnosis of exclusion • Rx – Role of CDU protocol • Prognosis – – – – 90% pts discharged are better in 2-3 weeks Small percent readmitted Some further eval = diagnosis Key is follow-up- instructions and follow up advice Case # 3 • Tender around RIF • No rebound or guarding • Refered to Surgery – Pathological appendix found • Break • • • • • • • 2-10 week old First born male Projectile non-bilious vomiting Hungry dehydrated child, feeds vigorously Visible gastric peristalsis Palpable pyloric olive Hypochloraemic, hypokalaemic metabolic alkalosis • Ultrasound diagnostic • Definitive management - surgery Case 2 • Three week old male with bloody stools and emesis • On Examinationpale with a soft, distended abdomen • 6mo-4years • Intermittent colicky abdominal pain and vomiting – beware of the crying child • Each episode classically last 1-2 min and recurs every 15-20 min • Passage of blood - 'red currant jelly' per rectum • Sausage shaped abdominal mass • Diagnosis confirmed with water soluble contrast enema or ultrasound 3 day old baby progressive abdominal distension and vomiting Not passed meconium • Due to absence of autonomic ganglion cells in Auerbach's plexus of distal large intestine • Male : female ratio 4:1 • 75% cases confined to recto-sigmoid • 80% present in neonatal period with delayed passage of meconium Followed by increasing abdominal distension and vomiting • Child is at increased risk of enterocolitis and perforation Case 4 – Inguinal Hernia Incarcerated – Intestinal obstruction • sudden onset of severe unilateral scrotal pain. • Past history of similar episodes • Beware of the crying child!! • Involved testicle painful to palpation; frequently elevated in position when compared with the other side • Horizontal lie of the testicle • Erythema and oedema of the scrotum • no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign]) Why do Pediatric Surgeons always make such a big deal out of a little yellow or green emesis? Because it usually means bowel obstruction or necrosis in children! Question 2? Why are Pediatric Surgeons so interested in flatus? Contrary to popular belief, kids with obstruction can still have bowel movements, but they won’t pass gas! Case # 4 • Hx • 20 year old male • Co R testes pain – Sudden onset – Constant waxing / waning – History of similar episodes in the past – Assoc abd pain, nausea / vomiting – recent exercise Case # 4 • DDx – Testicular torsion – Torsion of appendix testes – Epididymitis – Orchitis – Inguinal hernia - strangulated – Fornier’s gangrene Genital exam approach • Inspect – Asymmetry – Swelling • Palpate – Inguinal + Femoral canals – Spermatic chord and vas deferens – Cremasteric reflex – Testes • Lie (transverse or vertical), • size, • tenderness – Epididymis – Mass • ? Can you get your fingers above it, • ? Tran illuminate – Glans/ Penile abnormality Case # 4 • XM – Abdo – tender LLQ but no guarding • Scrotum – Swollen, tender testicle – Testes higher horizontal lie – Absence of cremasteric reflex Testicular torsion Hx Newborns/ Puberty /up to 30 XM Palpable knot in the spermatic chord Testicular elevation Transverse lie of testicles Loss of crem reflex Dx clinical Ix Doppler color US Rx Detorsion <6hr symptoms 80% ok 6-10hr 20% Testicular appendix torsion •Hx •Peak incidence age 10 – 13, •precipitated by vigorous activity or trauma •Onset usually acute •Pain mild – severe •XM •Tender nodule •Cremasteric reflex intact •Dx Blue-dot sign is pathognomonic!! •RX •Limit activity •Indirect ice / heat •NSAIDS •Prognosis •Painful ~ 1 week No long-term damage Epididymitis • Most common in 19 – 40 yo • Hx – – – – • XM – – – – • Unprotected sexual activity Gradual onset of testicular pain Dysuria / urgency / frequency Urethral discharge +/- Fever Localised epididymal tenderness Swollen epididymis + Cremasteric reflex DX – Urine M C+S • Rx – Bed rest / Scrotal elevation – Analgesia – Antibiotics eg Ciproflox Orchitis • Hx – Young <10 – Assoc Mumps • XM – Fever – +/- parotitis bilateral – Swollen tender teste(s) • Dx – Exclude Torsion/Epidydmitis – Viral usu • Rx – Analgesia Hernia • Hx • Xm – Inguinal/Femoral • Dx – Reducible? – Irreducible? – Strangulated? • Rx Fournier’s gangrene • Hx • Xm – Fever – Gangrene • Dx • Rx – Sx Surgical Emergencies – Special Considerations • Urological • Acute urinary retention – Many GU Sx. Bladder may perforate & Post renal ARF. • Causes: BPH, Ca Prostate, pelvic malignancies. • Tests: post-void scan(bladder scan), PSA, serum U&E • Mgmt: SP/PU catheter, Urology r/v • Renal Colic/Obstructive pyelonephritis – e.g. calculi • Tests: U&E, CT/KUB (size ∞ intervention) • Mgmt: analgesia +/- IV Abx, urology Surgical Emergencies – Special Considerations • Urological • Paraphimosis – If persistent or ischaemia = urgent • Manual reduction. If fails urology. • Educate pt/carers on foreskin care • Priapism – erect penis does not become flaccid. Leads to ischaemia/gangrene • Causes: haematological (SCD, leukaemia), neurological (SC lesions/trauma), medications/drugs (e.g antipsychotics, cocaine, Viagra unlikely) • Mgmt: aspiration. Intracavernosal adrenaline & surgery (urologist) Greek god Priapus, myth that he was punished by other gods for attempting to rape a goddess & given a huge useless wooden genitals. Case # 5 • • • • 65 y o male Smoker R leg pain At rest • Pale leg Case # 5 • DDx of acute leg pain – DVT – Acute Vasc leg – Sciatica • Investigation? Acute Vasc Leg • Hx – Pain • Exercise • Rest • XM – Pallor – Paralysis – Parasthesia – Pulseless – Perishing cold Investigation Ankle-brachial pressure index, ABPI systolic ankle pressure / systolic brachial pressure. normal > 1, claudication 0.9-0.6, rest pain 0.3-0.6, impending gangrene 0.3 or less. Diagnosis Rutherford Classification Category Description Cap. refill Paralysis Sensory loss I IIa IIb Viable Not immediately threatened Intact - - Threatened Salvagable if treated Intact/slow - Partial Threatened Salvagable if treated emergently Slow/absent Partial Partial III Irreversible Primary amputation req. Absent Complete Complete Rx • 100% oxygen • IV fluids • IV Opiate analgesia • Vascular input Asap – – – – Thrombolysis Angiography Embolectomy Urgent arterial bypass Case # 6 • Hx – 20 y.o. IDDM – C/o thigh pain • XM – Swelling • DDx – Cellulitis – Fasciitis – Abcess Abcess- Hx XM • Hx • XM – ? fluctuant – ? crepitus Abcess- Treatment • Incise • Swab • Drain • Pack Thrombosed Pile • Hx – PR Pain – Bleed • XM – Cherry • Rx – Stop bleeding Anal Fissure • Hx – PR Pain • Xm • Rx – GTN paste Always inform surgeons early so they can prepare adequately! Quiz Quiz questions • 1) Which is most specific test for Pancreatitis? • 2) What may be raised in Mesenteric Ischemia? • 3) What’s the best way to dx appendicitis? • 4) Important surgical diagnosis in crying child? • 5) 80% of testes torsion are salvagable within? • 6) What is the Ankle-brachial pressure index? • 7) What can you treat anal fissure with? Quiz answers • 1) Lipase • 2) Lactate • 3) Clinically • 4) Intussusception • 5) 6 hours • 6) systolic ankle pressure / systolic brachial pressure • 7) Nitrate paste Questions ? Thank you Special thanks to web image contributors