Surgical Problems in Primary Care
Ronald H. Labuguen, MD Clinical Professor UCSF Department of Family and Community Medicine -o- UCSF Family Medicine Board Review Course March 7, 2017 Faculty Disclosure
• I have nothing to disclose The closest I’ll get to being a surgeon Road Map for Our Journey
• Gastrointestinal Problems/Acute Abdominal Pain • Preop/periop/postop care, wounds, and infections • Other surgical specialties: – Trauma surgery – Vascular surgery – Thoracic surgery – Otolaryngology/head and neck surgery – Urology – Neurosurgery
Top 30 High Yield Items GASTROINTESTINAL PROBLEMS ACUTE ABDOMINAL PAIN
Right Upper Quadrant Pain
• 42 year old woman with right upper quadrant pain • Worse with eating • Nausea, no vomiting • No fever • Exam: – Tender to palpation in the RUQ – Murphy’s sign: reproducible pain & halts breathing on inspiration on palpation at right costal margin at the midclavicular line
RUQ Ultrasound = Test of Choice
Heilman J. File:Gallstones.PNG [Wikimedia Commons Web site]. March 18, 2011. Available at: http://commons.wikimedia.org/wiki/File:Gallstones.PNG. Cholangiocarcinoma Cholangiocarcinoma
• Treatment: complete surgical resection • Generally poor prognosis – Only 10% present at an early enough stage to consider curative resection – 5-year survival rate up to 40% for patients with completely resected tumors
Cholangiocarcinoma: Klatskin tumor
Hellerhoff. File:Klatskintumor-ERC.jpg [Wikimedia Commons Web site]. July 15, 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-ERC.jpg . Klatskin tumor: Palliative stent placement
Hellerhoff. File:Klatskintumor-Stents.jpg [Wikimedia Commons Web site]. July 15, 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-Stents.jpg. RIGHT LOWER QUADRANT PAIN Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care • History – Periumbilical for 3 days, then right lower quadrant for 2 days • Physical exam – Tenderness to palpation at McBurney’s point McBurney’s Point (#1)
Fruitsmaak S. File:McBurney’s_point.jpg [Wikimedia Commons Web site]. September 24, 2006. Available at: http://commons.wikimedia.org/wiki/File:McBurney%27s_point.jpg. Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care • 5 day history – Periumbilical for 3 days, then right lower quadrant for 2 days • Physical exam – Tenderness to palpation at McBurney’s point – (-) psoas, (+) obturator signs • Labs – Normal Physical Diagnosis
• McBurney’s point tenderness LR+ 3.4 • Peritonitis: – Rigidity LR+ 3.6 – Abdominal wall tenderness LR+ 0.1
LR+ 10.0 = +45% probability LR+ 0.1 = -45% probability
McGee S, Evidence-Based Physical Diagnosis, 4th ed. Philadelphia: Elsevier, 2018, pp. 449-453 Labs
• no WBC cutoff has sufficient sensitivity or specificity to rule out appendicitis • 25% of appys have normal WBC
Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007 Jul 25; 298(4): 438-51 Cartwright SL, Knudson MP. Evaluation of Acute Abdominal Pain in Adults. Am Fam Physician 2008, Apr 1;77(7):971-8
Alvarado (MANTRELS) Score
• Migration (1 pt) • Score ≥ 7 LR+ 3.1 • Anorexia (1) ≤ 4 LR+ 0.1 • Nausea and vomiting (1) • Tenderness RLQ (2) • Better to help rule out • Rebound tenderness (1) appendicitis than to • Elevation of temperature (1) diagnose it • Leukocytosis WBC > 10 (2) • Shift to the left > 75% neutrophils (1)
McGee S, Evidence-Based Physical Diagnosis, 4th ed. Philadelphia: Elsevier, 2018, pp. 449-453 Appendicitis on CT
Heilman J. File:Appy4.jpg [Wikimedia Commons Web site]. April 24, 2010. Available at: http://commons.wikimedia.org/wiki/File:Appy4.jpg. Imaging: ACR appropriateness criteria
• Classical presentation – CT abd/pelv w/ contrast (8 – usually appropriate) – CT abd/pelv w/o contrast (7 – usually appropriate) – RLQ US (6 – may be appropriate) • Atypical presentation – CT abd/pelv w/ contrast (8 – usually appropriate) – X-ray abd, RLQ US, pelvic US, CT abd/pelv w/o contrast (6 – may be appropriate) American College of Radiology. ACR Appropriateness Criteria: Right Lower Quadrant Pain - Suspected Appendicitis. Available at https://acsearch.acr.org/docs/69357/Narrative/. Accessed 24 February 2017. Bottom Line: Diagnosis of Appendicitis
• H&P and labs low sensitivity and specificity by themselves • CT and MRI have better sensitivity/specificity compared to H&P and labs; ultrasound slightly less sensitive than CT/MRI (studies varied widely) • No single lab or clinical test has superior sensitivity or specificity. Specific cutoffs could not be defined. • Few studies evaluating clinical decision aids
Dahabreh IJ, Adam GP, Halladay CW, et al. Diagnosis of Right Lower Quadrant Pain and Suspected Acute Appendicitis AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. Report No. 15(16)- EHC025-EF (Review) PMID: 27054223
Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care
What is the most appropriate treatment for this patient? 71% A. Appendectomy B. IV broad spectrum antibiotics
C. PO antibiotics 12% 9% 9% D. Watchful waiting
PO antibiotics Appendectomy Watchful waiting
IV broad spectrum antibi... Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care • Appendectomy is historically the treatment of choice
Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care • Conservative treatment with antibiotics and watchful waiting? Historically, reports of cases treated successfully with antibiotics – Coldrey E. Treatment of acute appendicitis. Br Med J 1956;2(5007):1458-1461 • 471 pts treated • Mortality 0.2% • Recurrent appendicitis 14.4% Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care • Conservative treatment with antibiotics and watchful waiting? – Antibiotics not definitively “non-inferior” to surgery
Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008359. Uncomplicated Appendicitis: Antibiotics vs. Surgery • APPAC – Did not demonstrate “noninferiority” of antibiotics: 27% in Antibiotics group had surgery within 1 year of presentation (cutoff for “noninferiority” ≤24% ) – Surgery group had higher rate of complications 20.5% vs. 7.0% in Antibiotics group
Salminen P, Paajanen H, Rautio T et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340-2348. Uncomplicated Appendicitis: Antibiotics vs. Surgery Meta-analyses • Higher rate of complications in surgery group • Antibiotics group: 8.2% had surgery at 1 mo 22.6% had recurrence at 1 yr • No difference in hospital length of stay or incidence of complicated appendicitis
Sallinen, V., Akl, E. A., You, J. J., Agarwal, A., Shoucair, S., Vandvik, P. O., Agoritsas, T., Heels-Ansdell, D., Guyatt, G. H. and Tikkinen, K. A. O. (2016), Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg, 103: 656–667. doi:10.1002/bjs.10147
Rollins KE, Varadhan KK, Neal KR, et al. Antibiotics Versus Appendicectomy for the Treatment of Uncomplicated Acute Appendicitis: An Updated Meta-Analysis of Randomised Controlled Trials. World J Surg. 2016 Oct;40(10):2305-18. doi: 10.1007/s00268-016-3561-7. (Review) PMID: 27199000 Non-operative treatment of uncomplicated appendicitis in children • Preliminary reports of ongoing studies indicate: – Success rates 89.2% at 30 days 75.7% at 1 year – Lower incidence of complicated appendicitis (2.7% vs. 12.3%) – Fewer disability days – Lower costs
Minneci PC, et al. JAMA Surg. 2016;151:408-415 Antibiotic treatment post appendectomy in children • Extended-spectrum antibiotics not superior to narrow-spectrum antibiotics re: 30 day readmission rates of children
Kronman MP, Oron AP, Ross RK, et al. Extended- Versus Narrower- Spectrum Antibiotics for Appendicitis. Pediatrics. 2016;138(1):e20154547 Appendicitis: Red Flags
• Signs of rupture – Change in condition: • Fever • Increased pain • Abdominal rigidity – Could see improvement in pain (think of a walled- off ruptured abscess) until peritonitis more fully develops Appendicitis: Red Flags
• Higher proportion of patients with ruptured appendicitis at the extremes of age (early childhood, elderly) – May be due to lower incidence, because absolute rate of rupture is constant across ages
Psychopoesie. File:Grandma&me_at_my_cousin’s_wedding.jpg [Wikimedia Commons Web site]. October 31, 2011. Available at: http://commons.wikimedia.org/wiki/File:Grandma%26me_at_my_cousin%27s_wedding.jpg . Chan Ho Park Meckel’s Diverticulum Meckel’s Diverticulum: Rule of 2’s
• 2% prevalence • 2 years of age at presentation • 2 feet from the ileocecal junction • 2 inches in length • 2 types of common ectopic tissue – Gastric – Pancreatic • 2% symptomatic • 2 times more symptomatic in boys
LEFT LOWER QUADRANT PAIN Diverticulitis
• Typical story: – Acute constant abdominal pain in LLQ – Fever – Can also see nausea, vomiting, constipation, diarrhea, “sympathetic cystitis” (dysuria and frequency caused by bladder irritation from inflamed colon) • Typical physical exam findings: – LLQ tenderness, guarding, rebound
Which one of the following is NOT associated with complications of 30% diverticulitis? 27% 27% A. NSAIDs B. Opioids 15% C. Corticosteroids D. Recurrences of diverticulitis
NSAIDs Opioids
Corticosteroids
Recurrences of diverticulitis Diverticulitis
• Risk factors: Smoking, obesity • Negative risk factor: Increased physical activity • Associated with complications: – Yes: NSAIDs, opioids, corticosteroids – No: Recurrences • Recurrences are uncommon (13.3%) & not clustered
Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid Diverticulitis: A Systematic Review. JAMA. 2014;311(3):287-297. Diverticulitis
• Diagnostics: – CBC (leukocytosis) – Urinalysis – CT of abdomen and pelvis with contrast (US, MRI acceptable alternatives)
Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94. Diverticulitis
Heilman J. File:Diverticulitis.png [Wikimedia Commons Web site]. June 2, 2011. Available at: http://en.wikipedia.org/wiki/File:Diverticulitis.png.
Treatment of diverticulitis with antibiotics has been shown to reduce which of the following? 41%
A. Complications 30% B. Need for surgery 16% C. Recurrence 10% D. Median length of inpatient stay 3% E. None of the above
Recurrence Complications Need for surgery None of the above
Median length of inpati... Uncomplicated Diverticulitis: Treatment • Stable, tolerating oral fluids: outpatient Cochrane review – best available data do not support abx No effect on complications, need for surgery, recurrence, median length of inpatient stay 1st episode – observation decreased hospital LOS, no effect on complications or recovery time • Older or ill pts, not tolerating fluids: admit IV fluids, bowel rest/NPO, ? Antibiotics
Daniels L, Unlu C, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017 Jan;104(1):52-61. Chabok A, Pahlman L, Hjern F et al. Randomized clinical trial of antibiotics for acute uncomplicated diverticulitis. Br J Surg 2012;99(4):532-539. Shabanzadeh DM, Wille-Jorgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012 Nov 14;11:CD009092. Diverticulitis: Treatment
• Complicated (sepsis, perforation, abscess, fistula, obstruction) • stabilize, IV fluids, antibiotics, surgical consultation, percutaneous drainage, intraperitoneal lavage • Broad-spectrum antibiotics to cover anaerobes, gram negative rods Diverticulitis: Treatment
• Indications for surgery – Sepsis, acute peritonitis – No improvement with medical therapy, percutaneous drainage, or both – Trend toward minimally invasive surgical techniques (laparascopic preferred in American Society of Colon and Rectal Surgeons guideline) – Consider after complicated episode
Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic Review. JAMA Surg. 2014;149(3):292-303. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
AGA Recommendations: Diverticulitis
For Against • Selective use of abx • Elective colon resection • Colonoscopy after after 1st uncomplicated resolution to r/o CA episode • Fiber • NSAIDs • ASA, seeds, nuts, • Mesalamine popcorn OK • Rifaximin • Vigorous physical • Probiotics activity Stollman N, Smalley W, Ikuo Hirano I, and AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology 2015;149:1944–1949. Which of the following is the most common cause of lower GI bleeding?
A. Hemorrhoids 72% B. Diverticulosis C. Inflammatory bowel disease 23% D. Colon polyps E. Ischemic bowel 3% 2% 0%
HemorrhoidsDiverticulosis Colon polyps Ischemic bowel
Inflammatory bowel disease Causes of lower GI bleeding Diagnosis Frequency (%) Diverticulosis 30 Hemorrhoids 14 Ischemic 12 Inflammatory Bowel Disease 9 Post-polypectomy 8 Colon cancer/polyps 6 Rectal ulcer 6 Vascular ectasia 3 Radiation colitis/proctitis 3 Other 6
Source: UCLA-CURE Hemostasis Research Group database. Ghassemi KA, Jensen DM. Lower GI Bleeding: Epidemiology and Management. Curr Gastroenterol Rep (2013) 15:333. Diverticulosis
• Typical story: abrupt onset of painless voluminous bleeding (arterial) • Diagnostics: nuclear bleeding scan, angiography, colonoscopy • Treatment: colonoscopy; may require surgery
Diverticulosis
Hellerhoff. File:Sigmadvivertikulose CT axial.jpg [Wikimedia Commons Web site]. December 23, 2010. Available at: http://commons.wikimedia.org/wiki/Sigmadivertikulose_CT_axial.jpg. Diverticulosis Case: 53 yo woman with hemorrhoids Hemorrhoids
WikipedianProlific. File:Hemorrhoid.png [Wikimedia Commons Web site]. September 12, 2006. Available at: http://commons.wikimedia.org/wiki/File:Hemorrhoid.png. Volvulus
• Midgut volvulus from malrotation of the gut • Sigmoid volvulus Midgut Volvulus: Malrotation of the Gut • Typical story: – 1st month of life: bilious vomiting, feeding intolerance, sudden onset of abdominal pain, upper abdominal distention – Older children: More vague (chronic, unexplained) abdominal pain, irritability, anorexia, nausea/vomiting, failure to thrive
Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children BMJ 2013;347:f6949
Midgut Volvulus: Malrotation of the Gut Midgut Volvulus: Malrotation of the Gut • Diagnostics – Physical exam: normal, or subtle findings – Abdominal x-ray: “double bubble” sign (gastric and duodenal dilatation); lack gas in lower GI tract; pneumatosis coli (ominous sign) – UGI contrast w/ “bird’s beak”, spiral, corkscrew signs of duodenal obstruction • Sensitivity 96%, false negative rate 3-6% – Ultrasound scanning of the mesenteric vessels • Sensitivity 86.5%, specificity 75%, positive predictive value 42%, negative predictive value 96% Midgut Volvulus: Malrotation of the Gut • Treatment: Ladd’s procedure
(1) untwist the intestine, (2) divide any adhesive bands, and (3) widen the mesentery to result in the bowel being in a “safe” non-rotated position Sigmoid Volvulus
• Older patients • Typical story – sx of bowel obstruction/ischemia: – Abdominal pain, distention, inability to pass stool or flatus (obstipation), history of constipation – Vomiting may be late presenting feature • Diagnostics: abdominal x-ray shows distended sigmoid colon • Treatment: sigmoidoscopy/rectal tube placement; resection & primary anastomosis Sigmoid Volvulus
Hellerhoff. Files:Sigmavolvulus_Roentgen_Abdomen_pa.jpg, Sigmavolvulus_Roentgen_Abdomen_LSL.jpg [Wikimedia Commons Web site]. 22 September 2014. EPIGASTRIC PAIN Case: 34 yo man with epigastric pain
Ranson’s criteria at Ranson’s criteria at 48 hours: admission: GA LAW Cal(vin) & HOB(BE)S • Glucose > 200 • Calcium < 8 • AST > 250 • Hematocrit drop > 10 % pts
• LDH > 350 • pO2 < 60 • Age > 55 • BUN incr > 5 after fluid hydration • WBC > 16 • Base deficit > 4 (Base Excess < -4) • Sequestration of fluid > 6 L Grey Turner’s Sign
Fred H, van Dijk H. Images of Memorable Cases: Case 21 [Connexions Web site]. December 3, 2008. Available at: http://cnx.org/content/m14942/1.3/. Cullen’s Sign
Fred H, van Dijk H. Images of Memorable Cases: Case 120 [Connexions Web site]. December 8, 2008. Available at: http://cnx.org/content/m14904/1.3/. Pancreatitis
• Surgery indicated for infected necrosis – 80% of deaths from acute pancreatitis caused by infection of dead pancreatic tissue • Pancreatic pseudocysts – Endoscopic drainage as effective as surgery, both more effective than percutaneous drainage
Johnson MD, Walsh RM, Henderson JM, et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol 2009 Jul;43(6):586-90.
Peptic Ulcer Disease
• Surgery rarely needed • Vagotomy • Gastrectomy Surgical Treatment for GERD Surgical Treatment for GERD
• Unresponsive to aggressive antisecretory therapy (proton pump inhibitors) • After surgery, some patients still require antisecretory therapy • Potential obstructive complications of Nissen: – dysphagia – rectal flatulence – inability to belch or vomit
Right Inguinal Hernia Hernia Inguinal Inguinal Hernia 16th Century Hernia Surgery 21st Century Hernia Surgery Hernia Surgery
• Indications for surgery – Emergent • Strangulated hernias –Nonreducible bulge with pain, sometimes after heavy lifting – Urgent • Incarcerated hernias
Hernia Surgery
• Indications for surgery – Elective • Inguinal hernias – watchful waiting recommended • Femoral hernias – higher risk of strangulation • Ventral hernias • Umbilical –Normally resolve without intervention by age 5
Umbilical Hernia Hernia Surgery: What about mesh?
• Fewer recurrences – 5-7% absolute risk reduction • More long-term complications requiring surgical intervention – 3-5% absolute risk reduction
Scott N, Go PM, Graham P, McCormack K, Ross SJ, Grant AM. Open Mesh versus non- Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD002197. DOI: 10.1002/14651858.CD002197. Kokotovic D, Bisgaard T, Helgstrand F. Long-term recurrence and complications associated with elective incisional hernia repair. JAMA 2016 Oct 18; 316:1575. Case: 6 year old boy with severe abdominal pain in the Peds ED Small Bowel Obstruction
Heilman J. File:SBO2009.JPG [Wikimedia Commons Web site]. November 8, 2009. Available at: http://commons.wikimedia.org/wiki/File:SBO2009.JPG. Large Bowel Obstruction
Heilman J. File:LargeBowelObsUp2008.jpg [Wikimedia Commons Web site]. August 28, 2008. Available at: http://commons.wikimedia.org/wiki/File:LargeBowelObsUp2008.jpg. Heilman J. File:LargeBowelObsFlat2008.jpg [Wikimedia Commons Web site]. August 28, 2008. Available at: http://commons.wikimedia.org/wiki/File:LargeBowelObsFlat2008.jpg.
A 48-year-old male presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 o’clock position.
The most appropriate initial treatment would be topical: 71%
A. Botulinum toxin B. Clobetasol (Temovate) 24% C. Capsaicin (Capzasin-HP, Zostrix) 2% 3% D. Nitroglycerin
Nitroglycerin Botulinum toxin
Clobetasol (Temovate)
Capsaicin (Capzasin-HP, Z... Anal Fissure Anal Fissure
• Nonsurgical measures that are proven effective in relaxing the sphincter: – Topical nitroglycerin ointment – Diltiazem, nifedipine (topical preparations usually have to be compounded by a pharmacist) – Botulinum toxin injected into the internal sphincter – Corticosteroid creams may decrease the pain temporarily • Surgery: internal sphincterotomy
Fargo MV, Latimer KM: Evaluation and management of common anorectal conditions. Am Fam Physician 2012;85(6):624-630. Pilonidal Cyst
GiggsHammouri. File:Pilonidal cyst.JPG [Wikimedia Commons Web site]. April 1, 2010. Available at: http://commons.wikimedia.org/wiki/File:Pilonidal_cyst.JPG. PREOP/PERIOP/POSTOP CARE WOUNDS INFECTIONS
Preoperative Workup
• Source #1: 2014 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2007 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation. 2014;130:e278-e333 Preoperative Workup
• Source #2: Feely MA, Collins CS, Daniels PR, et al. Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations. Am Fam Physician. 2013 Mar 15;87(6):414- 418. • Free App: Joshua Steinberg
Preoperative Workup
• No routine/indiscriminate testing • Base testing on H&P, perioperative cardiac risk assessment, clinical judgment • Not required for cataract surgery Preoperative Workup
• EKG: – Signs/symptoms of cardiovascular disease – Consider in elevated-risk procedure, patients with cardiac risk factors – Not needed for low-risk procedures
Preoperative Workup
Noncardiac Surgery Risk of Cardiac Death or Nonfatal MI: • Elevated (≥ 1%) • Low (< 1%) – Ambulatory, breast, endoscopic, superficial, cataract Preoperative Workup
Revised Cardiac Risk Index (RCRI) • Risk factors: – Cerebrovascular disease RF’s % Risk major cardiac – Congestive heart failure event (95% CI) – Creatinine level >2.0 mg/dL 0 0.4 (0.05 to 1.5) – Diabetes mellitus requiring 1 0.9 (0.3 to 2.1) insulin 2 6.6 (3.9 to 10.3) – Ischemic cardiac disease ≥3 ≥11 (5.8 to 18.4) – *Suprainguinal vascular surgery, intrathoracic surgery, or intra-abdominal surgery
Preoperative Workup Stress Tests
• Elevated cardiac risk and poor or unknown functional capacity • Only if a positive test would change management
Preoperative Workup
CXR: UA: • New or unstable • Urologic procedures cardiopulmonary signs • Implantation of foreign or symptoms material (e.g., heart • Increased risk of postop valve or joint pulmonary replacement) complications if results would change management Preoperative Workup
BMP: CBC: • At risk of electrolyte • At risk for anemia abnormalities or renal • Significant blood loss impairment (based on anticipated history, medications) Glucose, A1c: Coags: • Signs/symptoms or very • On anticoagulants high risk of undiagnosed • History of abnormal diabetes, if abnormal bleeding result would change • At risk for coagulopathy periop management (e.g., liver disease)
Perioperative Areas of Focus
• Anticoagulation management • Venous thromboembolism (VTE) prevention • Beta-blocker therapy • Antibiotic prophylaxis • Chronic disease
Anticoagulation
• Stop ASA 7-10 days (3 days?) pre-op (unless benefit preventing ischemia outweighs bleeding risk), restart 8-10 days post-op • Stop warfarin 4-5 days pre-op • Stop heparin – LMWH 12 hrs pre-op – UFH • IV 4-6 hrs pre-op • SQ 12 hrs pre-op
Devereaux PJ et al for the POISE-2 Investigators. Aspirin in Patients Undergoing Noncardiac Surgery. N Engl J Med 2014;370:1494-503. Venous Thromboembolism
• Assess risk • Check renal function • Consider prophylaxis • Bridge therapy (treat w/ LMWH after holding warfarin) for patients with mechanical heart valve, h/o VTE BRIDGE trial: Do patients w/ atrial fibrillation on warfarin need bridge therapy with LMWH when warfarin is held pre-op?
• Placebo was noninferior to LMWH with respect to preventing atrial thromboembolism • More bleeding complications in LMWH group • Excluded patients: stroke, mechanical valves • Relatively low risk population (only 13% high- risk by CHADS2)
Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-33 In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?
A. Nonfatal MI 75% B. Stroke C. Death D. Hypotension E. Bradycardia 20% 5% 0% 0%
Stroke Death
Nonfatal MI Hypotension Bradycardia In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease? A. Nonfatal MI RR 0.69 B. Stroke RR 1.76 INCREASED risk C. Death RR 1.30* *excluding DECREASE D. Hypotension RR 1.47 trial data E. Bradycardia RR 2.61
Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative Beta Blockade in Noncardiac Surgery: A Systematic Review for the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):2246-64
Beta Blockade
• Stay on them if already on them • Modify or discontinue based on clinical picture • Assess risk (Revised Cardiac Risk Index) • If administering perioperative beta blockers: – Start well in advance of surgery (2-7 d preop) – Do not start on day of surgery Perioperative Beta blockade? Not routinely in pts w/ uncomplicated HTN • Increased incidence of CV death, nonfatal ischemic stroke, nonfatal MI • NNH 140 for pts > 70 yo 142 for men 97 for pts undergoing emergency surgery
Jorgensen ME, Hlatky MA, Kober L, et al. beta-Blocker-Associated Risks in Patients With Uncomplicated Hypertension Undergoing Noncardiac Surgery. JAMA Intern Med. 2015 Dec;175(12):1923-31. Perioperative Diabetes Management
• Best if A1c < 7 • Tight glycemic control controversial – 140-180 may be adequate
Statins
• Stay on them if already on them • Consider initiating in selected high-risk patients Postoperative Care
• Monitor cardiovascular, pulmonary, fluid status • Pain management • Complications
Postop fever
• Non-evidence based workup: 5 (or 6) W’s – Wind – atelectasis – Water – UTI – Wound – wound infection – Walk (“Wegs”) – deep venous thrombosis – Wonder drug – drug fever – Winnebagos (or upside down “W”) – Mastitis Postop fever
• Recommendations for Evaluation of Fever Within 72 Hours of Surgery
O'Grady NP, Barie PS, Bartlett JG et al., American College of Critical Care Medicine, Infectious Diseases Society of America. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med 2008 Apr;36(4):1330-49.
Postop fever
• Recommendations for Evaluation of Fever Within 72 Hours of Surgery – CXR, UA, UCx not mandatory if fever is only indication – UA, UCx in febrile patients w/ indwelling catheter > 72 hrs – High level of suspicion for VTE in at-risk patients – Open & culture incisions w/ signs of infection
Care of Surgical Wound
• Sterile dressing 24-48 hrs • Minor surgical wounds can be allowed to get wet in the first 48 hours without increasing risk of infection • Extremity wounds may be covered with a clear film dressing (reduced rate of blistering, exudates)
Case: 23 yo man with swelling, redness, pain, pus from thigh I & D of Skin Abscesses
• Antibiotics after I & D? – I & D alone is usually sufficient for uncomplicated abscesses – Indications: Large abscess > 10 cm, cellulitis, immunocompromised, multiple or recurrent abscesses, extremes of age, failure of I&D alone
Singer HJ, Thode Jr. HC. Systemic antibiotics after incision and drainage of simple abscesses: A meta-analysis. Emerg Med J 2014;31:576-578. I & D of Skin Abscesses
• Slight benefit using trimethoprim- sulfamethoxazole after I&D of uncomplicated abscesses – Increases cure rate by 7% (NNT = 14) – Already high cure rates in control group 80-85%
Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016;374:823- 832 Time Out OTHER SURGICAL SPECIALTIES: TRAUMA SURGERY VASCULAR SURGERY THORACIC SURGERY OTOLARYNGOLOGY/HEAD AND NECK SURGERY UROLOGY NEUROSURGERY
TRAUMA SURGERY
Primary Survey: ABCDE
• Airway • Breathing • Circulation • Disability • Exposure/Environment Secondary Survey
• Vital Signs • Repeat Primary Survey • Review patient’s history • Physical exam: “Fingers or tubes in every orifice” Shock Classification Signs of Basilar Skull Fracture
• Periorbital ecchymosis (raccoon eyes) • Mastoid ecchymosis (Battle’s sign) • Hemotympanum Raccoon Eyes (Periorbital Ecchymoses) Clearing C-spines: NEXUS Criteria
When a significant mechanism of injury is present, a cervical spine is stable if: • No posterior midline cervical tenderness • No evidence of intoxication • Patient is alert and oriented to person, place, time, and event • No focal neurological deficit • No painful distracting injuries (e.g., long bone fracture)
Clearing C-spines: Canadian C-Spine Rule • Only applies to GCS=15 and stable trauma • Not applicable for: – GCS<15 – Non-trauma – Hemodynamically unstable – Age <16 – Acute paralysis – Previous spinal disease or surgery
Clearing C-spines: Canadian C-Spine Rule X-ray if ANY of the following High Risk factors: • Age >65 years • Dangerous mechanism – fall from elevation ≥ 3 feet / 5 stairs – axial load to head, e.g. diving – MVC high speed (>100km/hr), rollover, ejection – motorized recreational vehicles – bicycle struck or collision • Parasthesia in extremities Clearing C-spines: Canadian C-Spine Rule If ANY Low-Risk factor present, assess clinically with ROM testing (If all NO: x-ray) • Simple rear-end MVC which DOES NOT include the following – pushed into oncoming traffic – hit by bus / large truck – rollover – hit by high speed vehicle • Sitting position in ED • Ambulatory at anytime • Delayed onset of neck pain • Absence of midline C-spine tenderness Clearing C-spines: Canadian C-Spine Rule • (If at least 1 low-risk factor present) Able to actively rotate neck 45 degrees left and right? – If able then NO x-ray needed – If unable, X-ray.
Clearing C-spines: Which is Better?
• Sensitivity: Canadian 99.4% vs. NEXUS 90.7% • Specificity: Canadian 45.1% vs. NEXUS 36.8%
Stiell IG, Clement CM, McKnight RD et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003; 349:2510-2518
C-Spine Films: Lateral
Monfils L. File:C1-C2 Lat.JPG [Wikimedia Commons Web site]. March 13, 2011. Available at: http://commons.wikimedia.org/wiki/File:C1-C2_Lat.JPG. C-Spine Films: Odontoid
Monfils L. File:C1-C2 AP.JPG [Wikimedia Commons Web site]. March 13, 2011. Available at: http://commons.wikimedia.org/wiki/File:C1-C2_AP.JPG. C-Spine Films: Flexion & Extension
Lamiot F. File:Cervical XRayFlexionExtension.jpg [Wikimedia Commons Web site]. November 10, 2010. Available at: http://commons.wikimedia.org/wiki/File:Cervical_XRayFlexionExtension.jpg. VASCULAR SURGERY
Peripheral Vascular Disease Peripheral Vascular Disease
• Intermittent claudication (many may not have classic symptoms) • Late symptoms: rest pain, ulcers, gangrene • Risk Factors = CAD, esp. smoking • Diagnosis: ABI, PE – pulses, bruits, hair loss (watering the plants), poor nail growth, dependent rubor, ulcers
Peripheral Vascular Disease
• Treatment: modify risk factors, exercise, meds (ASA, clopidogrel, cilostazol) • Ticagrelor no better than clopidogrel
Hiatt WR, Fowkes FG, Heizer G, et al. Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease. N Engl J Med. 2017 Jan 5;376(1):32- 40. Peripheral Vascular Disease
• Surgery: not enough evidence to favor bypass surgery over angioplasty
Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002000. DOI: 10.1002/14651858.CD002000.pub2.
Medical vs. Surgical Management: Asymptomatic Carotid Artery Stenosis • No evidence clearly favoring: – Carotid endarterectomy vs. carotid artery stenting – Surgery vs. medical management • Low rates of ipsilateral stroke in patients managed medically – 1.68% all studies, 1.18% newer studies
Raman G, Moorthy D, Hadar N, et al. Management Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158:676-685. THORACIC SURGERY Aortic Aneurysm Ruptured Aortic Aneurysm
Heilman J. File:CTRupturedTA.PNG [Wikimedia Commons Web site]. January 19, 2011. Available at: http://commons.wikimedia.org/wiki/File:CTRupturedTA.PNG. USPSTF Recommendation for Ultrasound Screening for AAA • One time screening in men aged 65-75 who have ever smoked (B recommendation) • No recommendation for or against screening in men aged 65-75 who have never smoked (C recommendation) • Recommends against routine screening in women (D recommendation)
Coronary Artery Disease
Häggström M. File:Coronary arteries.png [Wikimedia Commons Web site]. January 19, 2011. Available at: http://commons.wikimedia.org/wiki/File:Coronary_arteries.png . Indications for CABG
• Disease in left main, or all 3 coronary vessels (L Cx, LAD, RAD) • Diffuse disease not amenable to PCI • Severe CHF, diabetes
Valvular Surgery: Stenotic vs. Regurgitant Lesions • Stenotic: – can be monitored until symptoms appear • Regurgitant: – may require surgery even if asymptomatic – carefully monitor LV function by echo
Aortic Stenosis: Bicuspid Aortic Valve
Lynch PJ. File:Heart_bicuspid_aortic_valve.svg[Wikimedia Commons Web site]. December 23, 2006. Available at: http://commons.wikimedia.org/wiki/File:Heart_bicuspid_aortic_valve.svg. Aortic Stenosis
• Classical presentation: asymptomatic, then angina, exertional syncope, dyspnea • After symptoms develop – Average survival 2-3 years – 75% die w/in 3 yrs w/out valve replacement Aortic Stenosis: Workup
• Echocardiogram – mild/moderate AS – q2-5 yrs – severe AS – annual (to check LV function) • Critical stenosis: Valve area < 0.8 cm2 or gradient > 50 mm Hg • CXR, EKG • CT (thoracic – ascending aortic aneurysm) • NO stress testing Transcatheter vs. Surgical Aortic Valve Replacement • Clear mortality benefit in high-risk pts w/ severe aortic stenosis (NNT = 20 to avoid 1 death at 1 year) • Similar benefit in intermediate-risk patients at 2 years Popma JJ, Adams DH, Reardon MJ et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014 May 20;63(19):1972-81. Adams DH, Popma JJ, Reardon MJ et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis. N Engl J Med 2014;370:1790-8. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2016 Apr 28;374(17):1609-20. Mitral Stenosis
• Symptoms mimic CHF • Atrial fibrillation, pregnancy bring out symptoms Mitral Stenosis: Treatment
• Mild disease: diuretics • Atrial fibrillation: rate control • Surgery: > mild symptoms, or pulmonary hypertension – Balloon valvotomy, open commisurotomy, MV reconstruction, MV replacement Aortic Regurgitation
• Causes: endocarditis, rheumatic fever, collagen vascular disease, aortic dissection, syphilis • Typical presentation: Initially asymptomatic, then subtle initial signs (decreased functional capacity or fatigue), then sx of L-sided heart failure
Aortic Regurgitation: Treatment
• AV replacement even in asymptomatic patients – before EF < 55 % or end systolic dimension reaches 55 mm • Severe AR + normal LV function: – afterload reduction w/ vasodilators, especially nifedipine, can delay surgery
Mitral Regurgitation
• Causes: infectious endocarditis, mitral valve prolapse, rheumatic fever • Surgery: – if > mild sx – If asymptomatic but EF < 60%, or end-systolic dimension approaches 45 mm – Usually MV repair preferred over replacement
What about Mitral Valve Prolapse?
• Typical symptoms: chest pain, dyspnea, anxiety, palpitations • Treatment: reassurance – no need for surgery OTOLARYNGOLOGY HEAD AND NECK SURGERY Otitis Media with Effusion
Descouens D. File:Tympan-normal.jpg. [Wikimedia Commons Web site]. November 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:Tympan-normal.jpg. welleschik. File:Trommelfell_Paukenerguss.jpg. [Wikimedia Commons Web site]. November 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:Trommelfell_Paukenerguss.jpg. Otitis Media with Effusion
• Candidates for surgery – persistent hearing loss or other signs and symptoms – recurrent or persistent OME in at-risk children regardless of hearing status – structural damage to the tympanic membrane or middle ear • Shared decision-making re: surgery • Tympanostomy tube insertion is the preferred initial procedure (+/- adenoidectomy in children ≥ 4 yo)
Rosenfeld RM, Shin JJ, Schwartz SR et al. Clinical Practice Guideline: Otitis Media with Effusion Executive Summary (Update). Otolaryngology–Head and Neck Surgery 2016:154(2):201–214 Indications for Functional Endoscopic Sinus Surgery (FESS) • Failed medical therapy for chronic rhinosinusitis • Nasal polyps
Luong A, Marple BF. Sinus surgery: indications and techniques. Clin Rev Allergy Immunol. 2006 Jun;30(3):217-22.
Epistaxis
• Pressure • Silver nitrate cauterization (only 1 side of nasal septum at a time) • Packing – Anterior: F/U w/ ENT w/in 2-3 days, avoid ASA & NSAIDs but can continue warfarin – Posterior: Admit
Management of Acute Epistaxis. Author: Ola Bamimore, MD; Chief Editor: Steven C Dronen, MD, FAAEM http://emedicine.medscape.com/article/764719- overview#showall. Accessed February 24, 2017.
For which of the following patients with recurrent pharyngitis/tonsillitis is tonsillectomy indicated?
A. History of peritonsillar abscess 56% B. 2 episodes in each of the last 3 years
C. 4 episodes in each of the last 2 years 24% D. 7 episodes in the past year 13% 6% E. Allergies to or intolerance of multiple 0% antibiotics
7 episodes in the past year History of peritonsillar2 episodes a...in4 each episodes of the in ... each of the Allergies... to or intoleranc... Tonsillectomy in Recurrent Pharyngitis/Tonsillitis: Paradise Criteria
• At least 7 episodes in past year, or 5/yr x 2yrs, or 3/yr x 3 yrs – Each episode: sore throat + one of the following: T>38.3, cervical adenopathy, tonsillar exudate, Group A beta hemolytic strep test + • Episodes of strep throat properly treated with antibiotics • Each episode documented OR subsequent observance by the clinician of 2 episodes • Modifying factors – allergies to or intolerance of multiple antibiotics, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), history of peritonsillar abscess Ref: Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310:674-683.
Peritonsillar Abscess
Heilman J. File:PeritonsillarAbsess.png [Wikimedia Commons Web site]. May 13, 2011. Available at: http://en.wikipedia.org/wiki/File:PeritonsilarAbsess.jpg.
UROLOGY Urinary Retention
Hellerhoff. File:Harnverhalt.jpg [Wikimedia Commons Web site]. January 8, 2010. Available at: http://commons.wikimedia.org/wiki/Harnverhalt.jpg. Urinary Retention: Treatment with Catheterization • Look out for: hematuria, hypotension, postobstructive diuresis • How long to leave in? – Unknown in pts with known or suspected BPH – Alpha blocker at time of catheter insertion x 3 d. can increase chance of returning to normal voiding • Urinary retention from BPH: at least one trial of voiding without catheter before considering surgical intervention • Long-term treatment with 5-alpha reductase inhibitors can prevent acute urinary retention in men with BPH Kidney and Ureter Stones: Indications for Surgery • No passage after reasonable period of time • Constant pain • Hydronephrosis • Damaging kidney tissue • Constant bleeding • Ongoing urinary tract infection • Too large to pass on its own or stuck • Growing larger
Ref: National Kidney & Urologic Diseases Information Clearinghouses. Kidney Stones in Adults. http://kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/
Kidney and Ureter Stones:Treatment
• Extracorporeal shock wave lithotripsy (ESWL) • Percutaneous nephrolithotomy • Large stone • Location does not allow effective use of ESWL • Ureteroscopic Stone Removal
Case: 53 year old man with gross hematuria
Renal Cell Carcinoma: Risk Factors • Men • African Americans • Exposure to household & industrial chemicals • Hypertension • Family history of RCC • Occupational exposure to cadmium • Dialysis patients w/ acquired cystic disease of the kidney (30x) • Hysterectomy (2x) Higgins JC, Fitzgerald JM. Evaluation of Incidental Renal and Adrenal Masses. Am Fam Physician. 2001 Jan 15;63(2):288-295. Renal Cell Carcinoma: Diagnosis
• Classic triad in 10-15%: hematuria, flank pain, abdominal mass • Often diagnosed incidentally at asymptomatic stage • Imaging – Sensitivities: CT 94%, ultrasound 79% – MRI better than CT at distinguishing benign lesions
Renal Cell Carcinoma
• Treatment – Nephrectomy – Doesn’t respond well to XRT or chemo
Incidental Adrenal Mass
• Depends on size – Refer >6 cm for surgery (high incidence of cancer) Incidental Adrenal Mass
– >3 cm < 6 cm: • MRI, additional endocrine eval – <3 cm: • Look for Cushing’s syndrome, pheochromocytoma, hyperaldosteronism (HTN, low K, high Na) • No signs/symptoms and labs normal: radiographic surveillance at 3 mos, then q6mo x 2 yr • Anything abnormal: refer
Bladder Carcinoma
• Demographics: older Caucasian male smokers – > 60 years old (80%) – men 3x > women – Caucasians > African Americans – mortality higher in African Americans because of delayed diagnosis
Ref: Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder Cancer. Am Fam Physician. 2009 Oct 1; 80(7):717-723
Bladder Carcinoma
• Risk factors: – smoking 4-7x > nonsmokers – Occupational exposure (aromatic amines – chemical dyes and pharmaceuticals; gas treatment plants) – Schistosoma haematobium – Radiation treatment to pelvis – Cytoxan – Arsenic in well water – Chronic infection
Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder Cancer. Am Fam Physician. 2009 Oct 1; 80(7):717-723
Bladder Carcinoma: Presentation
• Painless hematuria • “Irritative” symptoms (dysuria, frequency) • Urinary obstructive symptoms • Symptoms of advanced disease – lower extremity edema, renal failure, suprapubic palpable mass
Bladder Carcinoma: Diagnostics
• Urine cytology – 66-79% sensitive, 95-100% specific • Cystoscopy, bladder wash cytology • Evaluate upper urinary tract – CT preferred • Metastatic workup – CBC, chemistries (alkaline phosphatase, LFT’s), CXR, CT or MRI, Bone scan if alkaline phosphatase is elevated or other symptoms suggest bone metastases
Bladder Carcinoma
• Treatment: –Non-muscle invasive: transurethral resection +/- intravesical chemotherapy (mitomycin) or immunotherapy (intravesical BCG) –Muscle-invasive: radical cystectomy +/- chemotherapy –Metastatic: chemotherapy
NEUROSURGERY Case: 30 year old man with progressive sciatica
Herniated Disc
Edave. File:L4-l5-disc-herniation.png [Wikimedia Commons Web site]. April 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:L4-l5-disc-herniation.png. When do patients need surgery for low back pain? • Severe or progressive neurologic deficits • Serious underlying conditions are suspected • Persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis – Only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) • MRI (preferred) or CT
Chou R, Qaseem A, Snow V et al, Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007 Oct 2;147(7):478-91
Herniated Disc Which patients need neuroimaging (noncontrast head CT) for headaches? • Emergent: – headache and new abnormal neurologic findings (e.g., focal deficit, altered mental status, altered cognitive function) – new sudden-onset severe headache (thunderclap) – HIV-positive patients with a new type of headache (consider) • Urgent: – Patients > 50 years old w/ new type of headache but normal neuro exam
Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008 Oct;52(4):407-36.
Which patients need neuroimaging for headaches? • Atypical headaches and change in headache pattern (CT) • Unexplained focal neurological findings and recurrent headache (MRI) • Unusual precipitants – Exertion, cough, Valsalva (MRI) – Standing (MRI w/ gadolinium) – Lying down (CT, MRI) • Late onset (> age 50), no other red flags (CT)
Toward Optimized Practice. Guideline for Primary Care Management of Headache in Adults. Edmonton (AB): Toward Optimized Practice, 2012 Jul. 71 pp. Which patients need lumbar puncture for headaches? • Sudden-onset, severe headache + negative noncontrast head CT (rule out subarachnoid hemorrhage) • Who needs neuroimaging before LP? Adult patients with headache and signs of increased intracranial pressure – papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation Can this patient w/ HA go home?
• Patients with a sudden-onset, severe headache who have – negative findings on a head CT – normal opening pressure – negative CSF findings do not need emergent angiography can be discharged from the ED with follow-up When do you order head CT in patient with mild traumatic brain injury (TBI)? With loss of consciousness or posttraumatic amnesia only if one or more of the following is present: • headache • physical evidence of • vomiting trauma above the clavicle • age greater than 60 years • posttraumatic seizure • drug or alcohol • Glasgow Coma Scale intoxication (GCS) score less than 15 • short-term memory • focal neurologic deficit deficits • coagulopathy
Jagoda AS, Bazarian JJ, Bruns JJ Jr et al, American College of Emergency Physicians, Centers for Disease Control and Prevention. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008 Dec;52(6):714-48. When do you order head CT in patient with mild traumatic brain injury (TBI)?
Consider in patients with no loss of consciousness or posttraumatic amnesia if there is • age 65+ yrs • coagulopathy • GCS < 15 • dangerous mechanism of • focal neurologic deficit injury • vomiting – ejection from a motor vehicle • severe headache – a pedestrian struck • physical signs of a basilar skull fracture – fall from a height of more than 3 feet or 5 stairs
Can this patient w/ mild TBI go home?
• Isolated mild TBI + negative head CT – May be safely discharged from the ED – However, inadequate data to include patients • with a bleeding disorder • receiving anticoagulation therapy or antiplatelet therapy; or • had previous neurosurgical procedure • Inform about postconcussive symptoms
Phew!
• Questions?