Upload
caroline-barker
View
214
Download
0
Tags:
Embed Size (px)
Citation preview
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.
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.