CONTENTS Page I TRAUMA (MULTI-SPECIALTY APPROACH) 22 IIII APPROACH TO ABDOMINAL PAIN 1100 Surgery Notes IIIII A PPROACH TO ABDOMINAL MASSES 1111 IIVV OESOPHAGEAL DISEASES 1122 For the M.B.B.S. VV UPPER BLEEDING GIT AND ITS CAUSES 2211 VVII COLORECTAL DISEASES 1199 By Andre Tan VII LIVER DISEASES 3399 VIII PANCREA TIC DISEASES 4455 IIXX BILIARY TRACT DISEASES 5511 XX BREAST DISEASES 6600 XXII HEAD AND NECK MASSES 6699 XII SALIVARY GLAND SWELLINGS 7744 XIII THYROID DISEASES 7788 XIV PERIPHERAL ARTERIAL DISEASE 8855 XV ABDOMINAL AORTIC ANEURYSM 9933 XVI PERIPHERAL VENOUS DISEASE 9955 XVII UROLOGICAL DISEASES 9999 XVIII SURGICAL INSTRUMENTS 111100 TRAUMA (MULTI-SPECIALTY APPROACH) Management o f breathing -- Supplemental oxygen -- Ventilate as required if patient requires assistance with breathing AADVANCED TTRAUMA LLIFEIFE SSUPPORT ALGORITHM -- Needle thoracotomy for tension pneumothorax, followed by chest tube MAIN PRINCIPLES: -- Occlusive dressing for open pneumothorax -- Treat greatest threat to life first -- Definitive diagnosis is less important 3.3. CIRCULATION -- Time is important – – the “golden hour” after trauma is when 30% of trauma deaths Assessment of organ perfusion occur, and are preventable by ATLS -- Level of consciousness -- Skin colour and temperature, capillary refill -- Pulse rate and character – – all major pulses APPROACH -- Blood pressure 1.1. Primary survey and Resuscitation with adjuncts 2.2. Re-evaluation of the patient Classes of haemorrhagic shock 3.3. Secondary survey with adjuncts I II III IVIV 4.4. Post-resuscitation monitoring and re-evaluation Bld loss 5.5. Optimise for transfer and definitive care Amt (ml) <750 750-1500 1500-2000 >2000 Percentage <15<15 15-30 30-40 >40>40 Ht rate <100 >100 >120 >140 PRIMARY SURVEY – – ABCDE BPBP Normal Normal Decreased Decreased Cap refill Normal Prolonged Prolonged Prolonged 1.1. AIRWAY Resp rate 14-20 20-30 30-40 >35 Assessment of airway patency Ur output (ml/h) >30 20-30 5-15 Oliguric-anuric -- Is patient alert, can patient speak? Mental state Sl anxious Mild anxiety Anxious- Confused- -- Gurgling, stridor confused lethargic -- Maxillofacial injuries Fluid Crystalloid Crystalloid Crystalloid ++ Blood replacement blood -- Laryngeal injuries -- Caution: C-spine injury Establishing patent airway Management -- Chin-lift or modified jaw thrust (protect C-spine) -- Sources of bleeding apply direct pressure or pressure on proximal pressure -- Remove any foreign objects in the mouth where possible point -- Oro/nasopharyngeal airway -- Be suspicious about occult bleeding e.g. intraperitoneal, retroperitoneal (pelvic -- Definitive airway – – endotracheal tube, cricothyroidotomy, tracheostomy fracture), soft tissue (long bone fracture) -- Venous access – – large bore, proximal veins 2.2. BREATHING -- Restore circulatory volume with rapid crystalloid infusion – – Ringer’s lactate Assessment of breathing -- Blood transfusion if not responsive to fluids or response is transient -- Look, listen, feel: chest rise, breath sounds – – rhythm and equality bilaterally -- Reassess frequently -- Rate of respiration -- Effort of respiration -- Colour of patient -- Percuss chest -- Look for chest deformities e.g. flail chest 33 4.4. DISABILITY SECONDARY SURVEY -- Glasgow coma scale When to do secondary survey Eye Verbal Motor -- Primary survey and resuscitation completed Spontaneous opening 44 Oriented speech 55 Obeys 66 -- ABCDEs reassessed Opens to voice 33 Confused 44 Purposeful 55 -- Vital functions returning to normal i.e. no need for active resuscitation at the moment Opens to pain 22 Inappropriate 33 Withdraws 44 No response 11 Incomprehensible 22 Flexion response 33 No verbal response 11 Extension response 22 1.1. AMPLE HI HI STORY Y No response 11 -- AAllergy -- MMedications GCS: 14-15 (minor); 8-13 (moderate); 3-7 (severe) -- PPast history -- LLast meal -- AVPU score: Alert, Verbal stimuli (responds to), Pain stimuli, Unresponsive -- EEvents leading to injury, Environment in which trauma occurred -- Pupillary reactivity 2.2. C C OMPLETE HEAD - - TO TO - - TOE EXAMINATION -- Call for neurosurgical consult as indicated Head -- Complete neurological examination 5.5. EXPOSURE -- GCS or AVPU assessment -- Remove all clothes -- Comprehensive examination of eyes and ears for base of skull fractures -- Check everywhere for injuries (log-roll to look at the back) -- Caution: unconscious patient; periorbital oedema; occluded auditory canal -- Prevent hypothermia Maxillofacial 6.6. ADJUNCTS TO PRIMARY SURVEY -- Bony crepitus/deformityity Monitoring -- Palpable deformity -- Vital signs – – BP, pulse rate, saturation (pulse oximeter) -- Comprehensive oral/dental examination -- ECG monitoring -- Caution: potential airway obstruction in maxillofacial injury; cribriform plate -- Arterial blood gas fracture with CSF rhinorrhoea do not insert nasogastric tube Diagnostic tools Cervical spine -- Screening X-ray films (trauma series): CXR, AP pelvis, lateral C-spine -- Palpate for tenderness, any step deformity -- Focused abdominal sonography in trauma (FAST) -- Complete neurological examination -- Diagnostic peritoneal lavage -- C-spine imaging -- Caution: Injury above clavicles; altered consciousness (cannot assess Urinary catheter accurately); other severe, painful injury (distracts from cervical spine pain) -- Functions: decompress bladder, measurement of urinary output -- Caution in urethral injury: blood at urethral meatus, perineal Neck (soft tissues) ecchymosis/haematoma, high-riding prostate -- Blunt versus penetrating injuries -- Airway obstruction, hoarseness Gastric catheter (orogastric or nasogastric) -- Crepitus (subcutaneous emphysema), haematoma, stridor, bruit -- Function: decompress stomach, look at aspirate (bloody? bilious?) -- Caution: delayed symptoms and signs of airway obstruction that progressively -- Caution in base of skull fracture: CSF otorrhoea/rhinorrhoea, periorbital develop; occult injuries ecchymosis, mid-face instability (grab the incisors and rock), haemotympanum insert orogastric tube instead of nasogastric Chest ABDOMINAL TRAUMA - Inspect, palpate, percuss, auscultate - Re-evaluate frequently TYPES OF INTRA-ABDOMINAL INJURY IN BLUNT TRAUMA - Look at CXR - Solid organ injury: spleen, liver – bleeding (may be quite massive) - Caution: missed injury; increase in chest tube drainage - Hollow viscus injury with rupture - Vascular injury with bleeding Abdomen - Inspect, palpate, percuss, auscultate - Abrasions and ecchymosis – “seat- belt sign” INDICATIONS FOR IMMEDIATE LAPAROTOMY - Lower rib fractures liver and spleen injury - Evisceration, stab wounds with implement in-situ, gunshot wounds traversing - Re-evaluate frequently abdominal cavity - Special studies: FAST, DPL, CT scan - Any penetrating injury to the abdomen with haemodynamic instability or peritoneal - Caution: hollow viscus and retroperitoneal injuries; excessive pelvic irritation manipulation - Obvious or strongly suspected intra-abdominal injury with shock or difficulty in stabilising haemodynamics Perineum - Obvious signs of peritoneal irritation - Contusions, haematomas, lacerations - Rectal exam reveals fresh blood - Urethral blood - Persistent fresh blood aspirated from nasogastric tube (oropharyngeal injuries - DRE: Sphincter tone, high-riding prostate, pelvic fracture (may feel fragments of excluded as source of bleeding) bone); rectal wall integrity; blood - X-ray evidence of pneumoperitoneum or diaphragmatic rupture - Vaginal examination: blood, lacerations Musculoskeletal – extremities INVESTIGATIONS - Contusion, deformity - If patient is stable: FAST and/or CT scan - Pain - If patient is unstable: FAST and/or DPL - Perfusion - Peripheral neurovascular status FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA (FAST) - X-rays as appropriate - Ultrasonographic evaluation of four windows: Pericardial, right upper quadrant, left - Caution: potential blood loss is high in certain injuries (e.g. pelvic fracture, upper quadrant, pelvis femoral shaft fracture); missed fractures; soft-tissue or ligamentous injuries; examine patient’s back - Advantages Portable 3. ADJUNCTS AND SPECIAL DIAGNOSTIC TESTS Can be done quickly in <5min - As required according to suspicion, but should not delay transfer Can be used for serial examination Does not require contrast, no radiation risk 4. F REQUENT RE - EVALUATION - Disadvantages - Have a high index of suspicion for injuries to avoid missing them Does not image solid parenchymal damage, retroperitoneum, diaphragmatic - Frequent re-evaluation and continuous monitoring rapidly recognise when defects or bowel injury patient is deteriorating Compromised in uncooperative, agitated patient, obesity, substantial bowel gas, subcutaneous air 5. P AIN MANAGEMENT Less sensitive, more operator-dependent than DPL and cannot distinguish blood - Intravenous analgesia as appropriate from ascites Intermediate results require follow-up attempts or alternative diagnostic tests 5 CT SCAN CARDIOTHORACIC TRAUMA - Only suitable for stable patient as quite long time involved in imaging with only patient in the room can collapse There are 5 clinical scenarios in chest trauma where bedside procedures are lifesaving: cardiac tamponade, airway obstruction, flail c hest, haemothorax, and pneumothorax. - Advantages Able to precisely locate intra-abdominal lesions preoperatively Able to evaluate retroperitoneum CARDIAC TAMPONADE Able to identify injuries that can be managed non-operatively - High index of suspicion required Not invasive - Clinical features - Disadvantages