Indications in Srgery

8/14/2019 Indications in Srgery

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INDICATIONS

INSRGERY

Dr. Hiwa Omer Ahmed

Assistant Professor in GeneralSurgery


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(a living problemis better than a

dead cert )

Grey Turner


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BURN


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The indications for admission include:

(1) All patients liable to shock (that is all burnsover 10%).

(2) Any patient who has burnt his face, eyes,

hands, feet or perineum, whatever the size of hisburn. ALWAYS admit a child with a burnt handsize.

(3) All patients who have inhaled smoke. Ifpossible, refer all these patients

4. Electrical and Chemical burn

5. cold burn 6. pregnant ladies


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HEAD injury


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A head injured patient should be referred tohospital if any of the following is present:

Impaired consciousness (GCS (15/15) at anytime since injury

Amnesia for the incident or subsequent events

Neurological symptoms, e.g. severe and persistent headache

nausea and vomiting

irritability or altered behaviour

seizure

Clinical evidence of a skull fracture (e.g. CSF leak,periorbital haematoma)

Significant extracranial injuries


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A mechanism of injury suggesting: a high energy injury (e.g. road traffic accident, fall from

height)

possible penetrating brain injury possible non-accidental injury (in a child)

Continuing uncertainty about the

diagnosis after first assessment Medical comorbidity (e.g. anticoagulant use,

alcohol abuse)


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INDICATIONS OF Head CT scan


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CT remains the investigation for the

diagnosis and management of manycentral nervous system diseases.

MRI is superior in the posterior fossa andparasellar region and for the assessmentin multiple sclerosis, epilepsy and

tumours. CT is superior to MRI in the assessment of

head injury.

Indications for CT imaging, CTAngiography, and CT venography include


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A CT scan is also recommended (within 8hours of injury) if there is either:

More than 30 minutes of amnesia of events

before impact Or any amnesia or LOC since injury if

Aged 65 years

Coagulopathy or on warfarin Dangerous mechanism of injury

RTA as pedestrian

RTA - ejected from car Fall > 1m or >5 stairs


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GCS


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Indication of anti-tetanus


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Every simple wound in patient notimmunized in the previous 5 years

Give ATS

Every laceration or maceration or deep

wounds in patient not immunized in

the previous 5 yearsGive ATS & Toxoid


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Indications for snakeantivenin


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G 1; 1-2 AMPULES

G2 ; 2-3

G3 ; 5-15

G4 ; FREELY IN DRIP TILLNEUTRALIZATION


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Advice for the person taking a

patient home from the A&EDepartment

[Name] ........................... has suffered a headinjury, but does not need to be admitted to ahospital ward. We have examined the patient,

and believe that the injury is not serious. Veryrarely complications can develop as a result ofthe injury, so please watch the patient closely

over the next day or so and rouse gently everycouple of hours, and follow this advice:


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Do not leave the patient alone in the

home.

Make sure that there is a nearby

telephone, and that the patient stayswithin easy reach of medical help.

Symptoms to look out for:

Is it difficult to wake the patient up?

Is the patient very confused?

Does the patient complain of a verysevere headache?


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SRGERY inAcute abdominal pain


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represents 1% of hospital admissions and 6% ofemergency visits

1.These cases cause a burden on the hospital andphysician especially the nonspecific abdominal

pain, which is defined as acute abdominal painof less than 7 days duration, and for which thereis no diagnosis after examination and baseline

investigations2. Challenging as it is, a careful history-taking,

thorough evaluation of symptoms, head-to-toe

physical examination, and judicious use oflaboratory tests can simplify the evaluation ofthis complaint.


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LAPAROSCOPC FNDNGS N

THESE CASES Laparoscopic finding Number of patient

Appendicitis 73

Pelvic inflammatory disease 14

Significant ovarian cysts 7 Endometriosis 3

Ectopic pregnancy 2 Meckels diverticulitis 1


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SURGERY

IN

THYROID


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Surgery is indicated in

simple goitre if:

There is clinical or radiological evidence ofcompression

Substernal goitres: are best removed

surgically, as biopsy is difficult and clinicalobservation without frequent CT or MRIscans is impossible

The goitre continues to grow

Cosmetic reasons if large or unsightly.


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Thyrotoxicosis Indications for thyroidectomy are1.Patient preference, e.g. fear of radio-iodine

2.Children (radio-iodine or prolonged drug treatmentremain an option)3.Pregnancy (medical treatment is usually preferred)4.Large goitre (particularly multinodular goiter, with local

compressive symptoms)5.Severe reaction to anti-thyroid drugs (but radio-iodine

remains an option)6.Severe ophthalmopathy (medical therapy remains an

option)7.Suspicious nodule plus hyperthyroidism (perform fine

needle aspiration cytology first)8.Complex situations, e.g. poor compliance with anti-

thyroid drugs and radio-iodine is refused.


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Thyroid nodules Indications for surgery :1.Malignant or suspicious fine needle aspiration cytology

2.Larger nodule with repeated non-diagnostic fine needle aspiration3.Continued growth of nodule after fluid removal and thyroid hormone

therapy4.Symptomatic nodules (pain or pressure)5.Continued patient anxiety6.Some clinicians recommend surgical removal of all nodules of

diameter over 4 cm7.Hot nodules: a hyperthyroid hot nodule should be treated with radio-

iodine or surgery. Surgical thyroid lobectomy is effective and safetherapy for hot nodules, and the risk of hypothyroidism after ahemithyroidectomy is low.


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Urethral catheterization is

contraindicated in the presence oftraumatic injury to the lower urinary tract

(eg, urethral tear).

This condition may be suspected in male patients with apelvic or straddle-type injury.

Signs that increase suspicion for injury are a

1.high-riding or boggy prostate2. perineal hematoma

3. blood at the meatus.

When any of these findings are present in the setting ofconcerning trauma, a retrograde urethrogram should beperformed to rule out a ureteral tear prior to placing acatheter into the bladder


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Chest tube


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1. Postoperative

2. Prophylactic3. (pneumothorax)

4. (hemothorax)5. (pneumothorax or hemothorax)

6. lung abscesses or pus in the

chest (empyema).


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NG tube


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1. DIAGNOSTC

to drain gastric contents

assessment of GI bleeding

obtain a specimen of the gastric contentsdecompress the stomach

Administration of radiographic contrast tothe GI tract


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2. THERAPUTIC

Administration of medication drainage and/or lavage in drug overdosage orpoisoning.

In trauma settings, NG tubes can be used to aidin the prevention of vomiting and aspiration

MANAGEMENT of GI bleeding. NG tubes can also be used for enteral feeding

initially. Comatose patients have the potential of vomiting

during a NG insertion procedure, thus requireprotection of the airway prior to placing a NGtube

GASTRIC Irrigation before operation


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CONTRAINDICATONS Absolute contraindications

Severe midface trauma Recent nasal surgery

Relative contraindications

Coagulation abnormality Esophageal varices or stricture

Recent banding or cautery of esophageal

varices Alkaline ingestion


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The indications for central lines1.Measurement of CVP

2. Central venous access devices (CVADs) are used todeliver larger volumes of irritating solutions, such asantibiotics, blood products, parenteral nutrition media,and sclerosing chemotherapeutic agents.

3.If patients need prolonged IV access, a CVAD ispreferred to a peripheral IV line.

4.Central access is also indicated when peripheral accesscannot be achieved; however, in an emergency situation,

an intraosseous needle is probably the primary choiceaccording to Pediatric Advanced Life Support (PALS)guidelines.

P i h l i t t l


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Peripheral intravenous central

cathetersAlthough the lines are placed peripherally, usually

in the antecubital or superficial saphenous vein,

the distal tip remains in a large central vein. PICC lines are indicated in children who requireintermediate-term IV access for prolonged homeor hospital therapy, such as those with human

immunodeficiency virus (HIV) infection, cysticfibrosis, osteomylitis, meningitis, or cancer. The success of introducing the PICC line is

greater if attempts at inserting noncentralperipheral lines are limited. Therefore, PICCplacement should be attempted as soon as theneed for intermediate-term access is apparent.

Umbilical arter catheters and


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Umbilical artery catheters and

umbilical vein catheters

Useful in the first few days of life. The umbilical vein can be used for access

during the first 5-7 days but is rarely used

beyond 7 days. Both and UACs and UVCs can be used:

UAC is used for blood pressuremonitoring, and UVC is used for centralvenous pressure monitoring.


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VENUS CUT DOWN Emergent venous access, when attempts

to gain access by the peripheral orpercutaneous routes have failed.

contraindications Coagulopathy or bleeding diathesis Vein thrombosis

Overlying cellulitis


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Surgery

and

Antibiotics


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Clean nil

Clean contaminated periop.

Contaminated periop.

Dirty therap.

Clean wounds in the following groups must

receive perioperative antibiotics; Cancer

Immunodefiecent

have foreign bodies

With DM and Coagulopathy


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EVERY ANTITOXIN

EVERY NEW PARENTRAL DRUGS EVERY CONTRAST MEDIA


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A i h id d b f OP


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Antithyroid day before OP

beta blockers in toxic goiter 7-10day post-OP

Contraceptive 3 weeks pre OP in1.operations on pelvis

2.operations on lower limb

3.using of tourniquet

Oral antidiabetics day before OP and

replaced by soluble Insulin


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DONT GIVE

D t i t id i t h d i j


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Dont give steroid in acute head injury

Dont give opiate in biliary disease andsurgery

Dont give opiate in head injury Dont give analgesia in undiagnosed acute

abdomen before decision

Dont suture wounds (except facial andscalp) after 6 hours from the injury

Dont give heparin I.M. Don't give PP I.V.

D t i bl d l i di t d


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Dont give blood unless indicated

Dont give antibiotics unless indicated

Dont give K+ unless there is normal urine

output ( 30-50ml/ hr )


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DONTFORGET

Dont forget that 15 20 of all suspected acute


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Don t forget that 15-20 of all suspected acute

appendicitis there is normal appendix, and thiswell accepted scientifically

Dont forget to give antispasmolytics in biliary

disease and surgery Dont forget to search for features of

hypocalcemia in scorpian stings

Dont forget to ask every patient about allergy toany drug, contrast or anasthetic agents

Dont forget to remove any torniquet within 45minutes


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The indications forthoracotomy followingblunt thoracic trauma

are the following:

1 50 1000 l f bl d t th ti f i iti l


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1. 501000 ml of blood at the time of initial

drainage is common and may need no furtheraction, but greater volumes, especially if theblood is fresh, require intervention;

2. continued brisk bleeding (>100 mI/15 minutes)from the intercostal drains indicates a seriousbreach of the lung parenchyma and urgent

exploration is required;3. continued bleeding of >200 ml/hour for 3 ormore hours may require thoracotomy undercontrolled conditions;

4. rupture of the bronchus, aorta, oesophagus ordiaphragm;

5. cardiac tamponade (if needle aspiration is

unsuccessful).


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INDICATIONS OFSURGERY IN PEPTIC

ULCERS

1 l i t t t t f 5


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1.ulcer resist treatment for 5 years

2.Complicated PU as;

Perforation

Bleeding

Obstruction

Suspicion of malignancy

Priority in surgical lists


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Priority in surgical lists

Child first

Major OP first Co-morbidity first

Clean first

universal precautions for HIV &


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HEPATITIS wearing either safety spectacles or a face

mask a gown which provides waterproof

protection to the sur-geons anterior trunk

and arms.

boots rather than open-toed shoes should

be worn to improve protection to the feetshould something sharp be dropped.


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The operation should proceed in a slow and methodicalmanner with meticulous attention to haemostasis taking


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manner with meticulous attention to haemostasis, taking

care to avoid unexpected rapid bleeding which changesthe tempo of the procedure and increases the risk ofinadvertent injury to the operators

No sharp instruments or scalpels should be passed

across the operative field from hand to hand. Allinstruments are passed from the scrub nurse to thesurgeon and back to the scrub nurse in a dish

high risk patients are: homosexual lifestyle; a history of intravenous drug abuse; a history of haemophilia treated with factor VIII;

residents of sub-Saharan Africa; the partners of the above, higher risk groups.

0n exposure what to injury what to


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do ? immediately clean the contaminated area by washing

under running water.

postexposure prophylaxis to HIV should be started within1 hour of the injury where possible zidovudine 250 mg twice daily, lamivudine 150 mg twice

daily and indinavir 800 mg three times daily for I month.

The surgeon should then be given hepatitis prophylaxis A baseline HIV test should be carried out immediatelysince seroconversion will not have occurred immediatelyafter injury.

The HIV test should then be repeat-ed approximately 12weeks after contamination to determine whetherseroconversion has occurred.


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ATLS

component steps


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Elements of theprimary survey


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Airway with cervical spine control

Breathing and ventilation Circulation with control of haemorrhage

Dysfunction of the central nervous system Exposure in a controlled environment


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Criteriaof

discharge

1.Stable vital signs


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2.Up to Mild pain & nausea

3.Could move alone and walk

4.Could dress him self5.Not needs parentral drugs

6. There are some one to take care of him athome

7.Not far more than 60 minutes drive

8. Could take orally

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Indications in Srgery