Back to leedsth.nhs.ukEMIBank Website
3 General Surgery
3.1 Management of the Acutely Ill Surgical Patient
The majority of acutely surgically ill patient attending the Emergency Dept (ED) have one of the following conditions:
Surgical Category Example
Perforation Perf DU, Perf Diverticulum
Infarction Small bowel ischaemia
Inflammation/infection Pancreatitis, peritonitis
Bleeding AAA rupture, Ectopic pregnancy, DU
Obstruction Small bowel obstruction
History & Examination
• It is essential to take an good history as this will not only help differentiate the above conditions, but also enable medical causes such as AMI, DKA etc to be considered in the differential diagnoses.
• Most patients will present with abdominal pain as one of their symptoms, but the elderly and those with diabetes may present with collapse or "generally unwell".
• Examination should include assessment of impending airway problem and breathing and circulatory compromise as well as general examination of the chest and abdomen including hernial orifices and pulses.
• Always involved a Senior ED doctor for all patients who are physiologically abnormal or who are re-presenting to the ED following recent discharge from ED with a similar complaint..
Investigations:
• All patients who are acutely surgically ill need FBC, U&E, G&S/X match, Amylase, ECG, and a pregnancy test in all women of child bearing age
• It also important to consider the acid/base balance in acutely unwell patients as this will give clues to their oxygenation and perfusion. Blood gases therefore should be taken early and repeated to assess response to resuscitation in appropriate cases.
• X-rays and further investigations should be guided by the possible underlying cause.
• X-rays should not be done to diagnose constipation!
Treatment
Any patient with physiological compromise should have a senior ED Dr involved in their care from an early stage
It is more important that an unwell patient has appropriate resuscitation than definitive diagnoses.
Resuscitation
• High flow O2
• IV crystalloids titrated to response-consider colloids or blood if necessary
• Give antibiotics early if you are considering sepsis having carried out a sepsis screen (culture blood and urine)
• For ruptured AAA the BP should be maintained just enough to for tissue perfusion (systolic~90mmhg) as excessive systolic pressure may worsen bleeding from the rupture.
Monitoring:
All patients should have at least the following:
• Pulse
• BP
• Sats monitoring
• ECG monitor.
• Urinary catheter
It is essential to consider Central Venous Pressure and invasive arterial monitoring if the patient is in a state of collapse and especially if there is co morbid conditions, such as IHD.
Disposal:
Contact the surgical team early. No acutely ill surgical patient should go to the ward without informing the surgical team on call. If the RSO is busy contact the Registrar.
Key Points
• Get senior help early
• Monitor continuously as deterioration may be rapid
• Elderly patients with abdominal symptoms often have significant pathology-beware of making a benign diagnoses and do not send home an elderly patient with abdominal pain without discussing with a senior. Have a low threshold for admission.
3.1.1 Abscesses
History & Examination
An abscess is a collection of pus and the clinical features are a hot, painful, fluctuant mass, which is under tension. Typically the patient finds it difficult to sleep due to te pain
Treatment
• A properly developed abscess cannot be treated with antibiotics and requires surgical drainage.
• In certain situations this can be carried out under local anaesthesia, provided the skin is not very inflamed and the abscess is small. Local anaesthesia is not indicated when the skin is inflamed because injection into such skin may cause infection to spread, and the high blood flow usually renders the anaesthetic ineffective.
• Larger abscesses will invariably need draining under general anaesthetic.
If you drain the abscess under local:-
• This should be done in the major treatment room
• It is important to be aware of the surrounding structures when draining abscesses to avoid damaging vessels or nerves
• A course of oral antibiotics is not necessary unless there is significant surrounding cellulitis. Avoid putting drains into abscesses, but simply leave them incised with a betadine dressing to compress them. Larger abscesses are best treated by giving an im or iv dose of a suitable antibiotic before incision, followed by incision & curretage, followed by primary closure with deep sutures. These can be removed 5 days later.
Follow up
If there is significant cellulitis bring the patient back to returns clinic at 3-4 days. If not then patient can be followed up by the practice nurse.
3.1.2 Bites
Animal bites (the worst of which is the human bite) can result in quite severe soft tissue infections.
Bacterial infection is particularly likely if:
• Puncture wound(cat/human)
• Hand wounds >24 hr old
• Wounds in alcoholics diabetics and immuno-compromised
Management
Establish the biting animal and the time since injury
Obtain X-rays if FB, Fracture or joint involvement is suspected
Treatment
• Human bites involving a joint (classically over the MCP) should be referred to Hands on call for exploration and debridement and given IV antibiotics (Augmentin) prior to transfer.
• Explore fresh wounds under appropriate anaesthetic.
• Debride and clean thoroughly with copious saline
• Refer complicated wounds ( those that are too difficult to clean, those involving tendons, ? joints, ? nerves) to a specialist
• give antibiotics if the wounds are penetrating (not necessary with superficial wounds) and bring the patient back at 48 hours for consideration of delayed primary suture
• The only exception to this is if the wounds are on the face, in which case they should be thoroughly cleaned and sutured under antibiotic cover. Use Augmentin.
DO NOT SUTURE OR STERISTRIP WOUNDS ELSEWHERE ON THE BODY.
Special considerations
• Be on the lookout for puncture wounds over the knuckles, which patients are reluctant to admit are due to bites, but are usually caused by the victim's teeth.
• Such wounds often penetrate the metacarpo-phalangeal joint capsule.
• If they present >24 hrs after injury they are often already infected with sepsis within the joint. Refer theses patients to hands on call.
• If the wound has likely penetrated into the joint refer to Hands on Call. Treatment then involves thorough exploration of the wound and if the joint is involved other structures such as tendons may also be damaged Otherwise thoroughly irrigate the wound. If there is no chance of joint involvement, still treat human bites aggressively. Admission for 6 hrs for 2 doses of IV Augmentin is recommended with follow up in A&E clinic at 2-3 days
Some animal scratches, especially cats, can result in very severe infections. Penicillin and metronidazole are the drugs of choice.
Insect bites can be very troublesome, especially continental varieties! Treat with oral anti-histamines, antibiotics, and a high arm sling if appropriate. Be patient, they are slow to resolve. (See also under stings and soft tissue infection).
3.1.3 Burns
There different causes of burns e.g. thermal electrical chemical and radiation.
The treatment is based on the depth and extent of injury.
History
The important questions regarding the history are:
• Was there an explosion or fall( risk of other injuries)?
• What was the burning material?
• Was the fire in an enclosed space (risk of CO poisoning)?
• How long was patient exposed to fire and smoke?(confined space).
• Was there loss of consciousness?
• Was there any first aid?
• What is the past medical history and tetanus status?
• Always consider the risk of NAI in a child.
Treatment
A: Airway may be at risk from burns to the mouth and nose and CO inhalation. Airway burns are suggested by hoarseness, stridor, carbanaceous sputum, singing of nasal hairs. The airway may be at risk, oedema and obstruction can develop rapidly. If in ANY doubt call for help from a senior.
B: this my be impaired due to contracted chest burns but is not usually a problem in the emergency room.O2 should be administered to all patients and CO measures taken to determine treatment of this
C: Hypovolemic shock in a patient with burns is usually not due to the burn within the first 6 hours. Consider trauma from blast or fall and manage appropriately.
Assess the percentage of burn.
The patient's palm represents 1% surface area. Use the Lund & Browder charts. There are separate ones for adults and children. It is important to get an accurate picture of the percentage as this will allow accurate calculation of fluids, disposal and prognosis.
The Depth of burn
This can be quite tricky, use a chart and record the following:-
1. Erythema
In calculating the percentage burn simple erythema will rarely need fluid resuscitation and should not be included in your calculations
2. Partial thickness
These are very painful. The appearance range from blistering, to a loss of the majority of the dermal elements leaving a raw surface. Blistering can take a while to develop. Any suggestion of blistering should be regarded as a burn and measured as part of the burn surface.
3. Full thickness
These may be white brown or black in colour and appear leathery; they do not blister and are insensate and must be measured as part of the burn surface.
Treatment
• This depends on the percentage burn and the presence of other injuries
• Give O2 to all patients
• After consideration of the A, B, C the patient should have their pain controlled with IV morphine, titrated against the pain.
• Replace fluid by giving 2-4ml of electrolyte solution per Kg per 1% burn surface area in the first 24 hours following the burn, giving half of this total in the first 8 hours.
• Burns >10% and burns in specialist areas e.g. face and genitalia need admission to a burns unit
• Before transfer you must ensure that satisfactory analgesia, fluid replacement therapy (with good IV access and after discussion with the ED Senior) and simple sterile covering of the wounds are established.
Borderline burns
• (i.e. 5-10% in a child or 10-15% in an adult) may be admitted under the Paediatric/General Surgeon of the day after discussion with the A&E Senior.
• Outpatient burns are treated either by a standard jelonet "burns dressing”.
• Burnt hands can be treated with "Flamazine" and put into plastic gloves, but this interferes with the assessment of depth at the next clinic visit, and we would prefer jelonet dressings initially.
• Faces are treated with bland E45 cream applied repeatedly until a scab forms. Bring the patient back on the second day for inspection and dressing change. The next visit is approximately four days later.
• Superficial burns usually heal within two weeks. Deep dermal and full thickness burns may take considerably longer.
• Advice sheets are available for parents of a burnt child.
3.1.4 Head injury
Reviewed by: TB Hassan
Date: July 2005
Background
Head injury encompasses a broad spectrum of clinical problems frequently seen in the ED. Ironically it is those at the less severe end of the spectrum that often pose the greatest difficulty in management.
The questions generally posed are:
• Who needs admitting?
• Who can I safely discharge?
• Who needs radiological investigations and what type of imaging?
Using the Scottish Intercollegiate Guidelines Network document ‘Early Management of Patients with a Head Injury’ and a recent paper ‘The Canadian CT Head Rule for patients with minor head injury’* this guideline hopes to answer these questions.
*Stiell I, Wells G et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357:1391-96
Assessment
• Airway (with C Spine control)
• Breathing (with oxygen)
• Circulation (with IV access/haemorrhage control)
• Disability (GCS)
• Expose/environment
• (don’t forget to measure Glucose in any patient with altered consciousness, start with a BM stick)
Follow ATLS approach and guidelines (Primary survey, Resuscitation phase, Secondary Survey)
Resuscitate with IV fluids, Oxygen.
Analgesia (pain increases ICP as does vomiting and being combatative)
Anaesthetic input early (all patients with a GCS <8/15 require an anaesthetist)
Monitor ETCO2 and ventilate to normocapnoea
The aim of this approach providing adequate oxygenation and tissue/brain perfusion using fluids and high flow oxygen is to minimize the prospect of further (secondary) injury.
In head injury there is a loss of auto regulation of brain perfusion and hence perfusion is related to:
Mean arterial pressure (MAP) – Intracranial pressure (ICP)
Once stable further assessment is required:
1. Mechanism of injury
2. Loss of Consciousness (duration)
3. Seizures
4. Memory of incident and posttraumatic amnesia (PTA).
5. Nausea / Vomiting (duration)
6. Headache
7. Weakness / visual problems / paraesthesia / dizziness /poor coordination
8. Alcohol / Drugs
9. Medicines esp. anticoagulant therapy
10. Examination for focal neurological signs including GAIT & FUNDOSCOPY.
11. Examination for clinical signs of skull fracture i.e. nose/ears for signs of blood or CSF, for signs of periorbital haematoma, subconjunctival haemorrhage with posterior border not seen, bruising posterior to mastoid process, boggy scalp haematoma
REMEMBER IF THERE IS SUFFICIENT TRAUMA TO PRODUCE HEAD INJURY THE CERVICAL SPINE IS ALSO LIKELY TO HAVE SUFFERED TRAUMA.
WHO NEEDS A CT SCAN?
(We are not yet in a position to adopt the NICE guidelines for CT imaging)
Indications for Immediate CT Scanning (ie after resuscitation)
1. All patient with head injury and GCS < 9/15.
2. All patients with a deteriorating level of consciousness (a 2 point fall in their GCS) or progressive focal neurological signs.
Indications for Urgent CT Scan (ie within 4 hours of assessment)
1. GCS between 9-12.
2. Clinical or Radiological evidence/suspicion of skull fracture
3. New Focal neurological signs which are not progressive.
4. GCS 15/15 with
i) Persisting amnesia / short term memory deficit (amnesia for >30 min prior to injury)
ii) Severe persistent headache despite simple analgesia
iii) Continuing nausea and vomiting (vomiting twice or more)
iv) Seizure
v) Altered behaviour / irritability
WHO NEEDS A SKULL X-RAY?
Those not requiring a CT Scan who:
1. GCS 13 or 14 prior to being observed – although anybody with a persisting GCS of 13-14 should be considered for CT. Involve a senior to make that decision..
2. GCS 15/15 in whom:
i) Non trivial mechanism of injury i.e. fall from half own height or more
ii) Patient amnesic, vomited
iii) Inadequate history i.e. if alcohol/drug use suspected
iv) Full thickness scalp laceration / boggy scalp haematoma
v) Loss of consciousness
Do NOT SXR patients with:
Simple lacerations (ie not full thickness)
Simple bruises
Patients in whom CT is required where depressed skull fracture is not suspected
'Because we always SXR patients admitted to Ward 1 / CDU'
'Because we always SXR head injured patients'
WHO NEEDS OBSERVATION?
All head injured patients require observation until they are alert, orientated and deemed safe to go home by medical and nursing staff. If they remain symptomatic after a period of observation, eg persistent headache, nausea or dizziness then a CT is indicated.
Admission to Hospital is indicated if:
Level of consciousness is impaired (GCS <15/15)
If fully conscious (GCS 15/15) but any of following risk factors:
o Amnesia persisting for at least five minutes after injury occurred.
o Continuing nausea/vomiting
o 1/more seizures post injury
o Focal neurological signs
o Irritability or abnormal behaviour
o Clinical or radiological evidence of skull fracture or abnormal CT Scan
o Severe headache or other neurological symptoms
Patient has significant medical problems e.g. anticoagulant use – if on Warfarin and has suffered anything more than a ‘minor head injury’ consider a CT scan. Discuss all such patients with a senior doctor.
Concurrent alcohol/drug use makes assessment difficult.
Cannot be supervised by an adult on discharge.
When to discharge after observation
1. Full recovery of consciousness, which is sustained for >4hours.
2. Eating normally with no vomiting
3. Neurological symptoms/signs fully resolved or are minor and amenable to simple treatment e.g. simple analgesia for headache.
4. Radiologist has reviewed results of imaging and no further investigation/treatment is required.
5. Other injuries all treated.
6. If less than 24-hour stay then need adult supervision (and written head injury instructions) on discharge for at least further 24 hours.
If being discharged: Oral advice and reinforce this with a written head injury advice sheet.
KEY POINTS
PREVENT SECONDARY BRAIN INJURY BY PROPER FLUID RESUSCITATION OXYGENATION and EARLY SENIOR/EXPERT ADVICE
LOOK FOR AND BE AWARE OF OTHER INJURIES
DON’T ASSUME ALCOHOL IS TO BLAME
IF IN DOUBT ASK ADVICE AND/OR OBSERVE until neurologically intact.