Surgery for the on-call SHO

1. Surgery for theon-call SHO Matt Dunstan, ST4 Vanessa Brown, ST7

2. Surgery for the on-call SHO • Differentials for abdominal pain • Head injury • Abscesses • PR bleeding • Ischaemia • Breast • Consent • Abscess • Appendicectomy

3. Abdominal pain history • SOCRATES • Course – getting better /worse, had previously? • Vomit • Risk factors for gastroenteritis • Recent seafood / takeaways / travel • Others at home unwell • PU – dysuria / frequency / urgency / dark urine? • BO – when last, how often, any diarrhoea / blood / mucous / pale? • Gynae hx - LMP, ?regular, ?heavy, Intermenstrual bleeding / post coital bleeding, PV discharge, Prev STDs, risk of STDs • Weight loss, jaundice, fevers, change in bowels. FH cancer/other. PAST SURGICAL HX.

4. Abdominal pain Examination and Investigation • Examination • Scars • Soft? Tender? Guarded? Mass? • Renal angle tenderness • Hernias • External genitalia • Bowel sounds • PR • Investigations • Bloods (AMYLASE) • Urine dip • Pregnancy Test • Erect CXR, AXR • Blood gas/lactate • ECG

5. RUQ • Biliary colic • Known Gallstones? • Are LFTs and Amylase normal • Needs admission for analgesia? Home with OPD follow up? • Cholecystitis • Abx, cultures, IVI. USS. ?hot chole. If sick - ?cholecystostomy • ?amylase and LFTs normal • Obstructive jaundice/Cholangitis • Fever, RUQ, jaundice • Abx, blood cultures, IVI, catheter, USS/CT, NBM, ?ERCP, ?PTC ?ITU • Amylase normal? • Risk of hepatorenal syndrome

6. Epigastric pain • Always get an Erect CXR, amylase and ECG! • Perforation • CT • Abx, IVI, NBM, PPI, NGT, catheter, ?theatre, ITU • Pancreatitis • Analgesia, fluids, catheter • Score (ABG, Ca, LDH etc +/- ITU) • Cause? ETOH, gallstones, other • USS/MRCP/ERCP • AAA (“renal colic”) • 2 cannulas. XM. Urgent CTA. Call vascular. Don’t trust FAST scan! • Gastritis • PPI, Gaviscon, ?OGD

7. Lower abdo pain • Always get a pregnancy test! • Appendicitis • Sips, IVI, analgesia • ?USS – especially in women • Don’t start abx until decision to go to theatre • If >45 – CT (?sigmoid diverticulitis) • ?treat conservatively • Diverticulitis • Abx, IVI, CT scan. +/- percutaneous drainage. OPD scope. • Gynae pain • Mittleschmerz, cyst accident, retrograde bleed, TORSION (gynae emergency) • UTI

8. Other causes of abdo pain • Bowel obstruction • Adhesions? Hernia? Cancer? Diverticular abscess? • Drip, suck, catheter, ?conservative, ?theatre, ?gastrograffin • Volvulus/pseudoobstruction - ?flexi/flatus tube/correct electrolytes • ?theatre for caecal volvulus • Ischaemic bowel • Lactate? AF? Serial examinations and blood tests • Early CT scan, write “?ischaemic gut” on request! – needs correct phase • Constipation

9. Abdominal Trauma • Splenic injury • Liver injury • Primary survey, secondary survey, AMPLE history • Allergies, medications, PMH, last meal, events • Full body CT (depending on mechanism, and ?high velocity injuries) • “Is this patient in the right hospital?” – polytrauma, cardiothoracics etc. • 2x cannulas, XM, NBM, ?theatre

10. Head Injury

11. Head injury – NICE guidelines

12. Head injury – NICE guidelines

13. Head injury ALWAYS THINK C SPINE - ?image Get advice from regional neurosurgeons ?period of observation if on anticoagulants

14. Head injury advice Headache Vomiting Double vision Concern Home with responsible adult

15. Abscesses Axillary, Pilonidal, Perianal, Buttock ?Limb abscesses to orthopaedics? ?Neck abscesses to ENT? Always check BM (?diabetes) Recurrent abscesses? (?perianal fistula/IBD/hidradenitis) Abx+/- theatre

16. PR bleeding • Causes • Haemorrhoids • Cancer • Fissure • Diverticulitis • UC / Crohns • UGI bleed (?urea) – varices/ulcer • Reasons for admission • Haemodynamically unstable • Hb drop • Significant bleeding <24hours – how much, how many times, fresh or dark? • Coagulopathy eg warfarin • 2 cannulas, XM, correct clotting, OGD/Colon/CTA, ?tranexamic acid

17. Vascular history • Arterial questions • Claudication • Night pain • Rest pain • Ulcers • Venous questions • Aching • Oedema • Itching • Bleeding • Ulcers

18. Ischaemia • Acute – 6 Ps • History, examination, ECG (?AF), ?INR level • ?endocarditis, prox aneurysm, autoimmune, undiagnosed AF? • Chronic / ULCERS • Vascular risk factors, DIABETES • If in doubt, urgent duplex or CTA +/- anticoagulate, NBM, call vascular • TVN/district nurses/podiatry/footwear/diabetic team

20. Breast • Abscess • Breast abscess pathway (USS aspiration) • Needle aspiration if confident -> MC&S • Abx (coamox) • Don’t rush to I&D in theatre! • Post op infection • As above • Is there an implant present!? - ?admit for IVAbxs • Drains • Breast care nurses, or call consultant

21. Consent

22. I&D • Infection • Bleeding • Anaesthetic • Scar • Neurovascular damage • Wound left open/dressings • Recurrence • Fistulae • Need for further procedures

23. Appendicectomy consent Laparoscopic appendicectomy +/- proceed +/- open procedure Specific Negative appendicectomy Open procedure Gynae procedure Proceed (?bowel resection) Pelvic collection General • Infection • Bleeding • Scar • Shoulder tip pain • Anaesthetic • DVT/PE • Damage to surrounding structures

24. All patients for theatre NBM G&S x2 INR Book, mark, consent Tell your registrar first!

25. Final words • Always notify your Registrar of: • Any suspected splenic/liver trauma • AAA • Ischaemic gut • Perforation • Ischaemic limb • Anyone for theatre • Beware the very young and very old! • Never forget HCG or amylase!

26. Any questions?