Surgical Emergenciesthe
G1Group
B yQ u a h C h e e S i a n
Pa r t h i b a n S .
S H O C KI M M E D I A T EM A N A G E M E N T SS I G N SI N V E S T I G A T I O N SI N F O G R A P H I C S
Introduction..
S U R G I C A L E M E R G E N C I E S
Sign of Shock
• ↑ HR (>100)• ↓ pO2 (< 90%)• ↑ RR (> 20)• SBP < 90 mmHg
Signs of ShockSURGICAL EMERGENCIES
CP presentation
S U R G I C A L E M E R G E N C I E S
Immediate Management
CP presentation
S U R G I C A L E M E R G E N C I E S
Investigations
What specific laboratory studies will help you?
CP presentation
These are the appropiate initial screening tests.
i. FBCii. BUSE/Criii. Blood glucoseiv. Coagulation profilev. Blood grouping/ X
matchingvi. Investigate source of
bleed
IV Fluids
Colloid or Crystalloids?• Theoretical advantage of colloids remains in IV space, smaller volume required
• Risks: Anaphylaxis, Coagulopathy• Evidence: No significance difference in
outcome between 4% albumin & NS
NS or RL?
• NS has strong anion gradient• Cause Hyperchloremic Metabolic acidosis
Worsen Coagulopathy• HyperKalemia after 6 hours
Cannula Size
O2 Delivering
Oxygen
• Target SpO2: 95-99% (Normal pt)• 88-92% (COPD pt)
1.Nasal prong: 2-5L/min (28-35%)2.Simple face mask: 5-15L/min (35-50%)3.Venturi mask: (24-60% based on valve)4.Non-Rebreathing mask (up to 85% in 15L/min)
CP presentation
Thanks
Upper Gastrointestinal Bleeding
SITI NUR AQILAH MOHD AZRYYEE ZHEN AUN
Variceal
Non-variceal:I. Bleeding PUDII. CA gastric, esophagusIII. Drugs?IV. Mallory Weiss tearV. Others: AVM, Dielafoy syndrome
AETIOLOGYUPPER GASTROINTESTINAL BLEEDING
19
PEPTIC ULCER DISEASE
ESOPHAGEAL VARICES
CARCINOMA STOMACH,
ESOPHAGUS
Managementstep-wise management of patients with upper
gastrointestinal bleeding
GENERAL MANAGEMENTUPPER GASTROINTESTINAL BLEEDING
21
In addition…• Stop any aspirin, NSAID, anticoagulant, B-blockers• Tranexamic acid• IV Pantoprazole 80 mg bolus, 8 mg/hour continuous infusion for
72 hours• Suspected oesophageal varices: vasoconstrictors till bleed dealt with
endoscopy, gastric lavage with large (32 F) NG tube for better visualization• IV Terlipressin 2 mg 6th hourly or• S/C sandostatin 50-100 micrograms BD
SPECIFIC MANAGEMENTUPPER GASTROINTESTINAL BLEEDING
22
In acute UGIB: • emergency endoscopy (within 24 hours)
For bleeding PUD; • if Forest grade I, IIa and IIb proceed with endoscopic
therapy, CLO test3 modalities (choose 2):
• Adrenaline (1:10000) 15-30 mlOGDS ELECTROCOAGULATI
ON HEMOCLIP
DEFINITIVE MANAGEMENTUPPER GASTROINTESTINAL BLEEDING
23
If endoscopic therapy fail…Laparotomy and under-running of bleed gastric or duodenal ulcer with silk suture
DEFINITIVE MANAGEMENT
Duodenal ulcer: truncal vagotomy + (pyloroplasty or post. gastrojujenostomy or antrectomy)Gastric ulcer: truncal vagotomy + pyloroplasty, highly selective vagotomy, partial gastrectomy
FOR ESOPHAGEAL VARICESUPPER GASTROINTESTINAL BLEEDING
24
ENDOSCOPIC BAND LIGATION ENDOSCOPIC INJECTION SCLEROTHERAPY
PREFERED IN
EMERGENCY
If EBL and EIS not feasible or fail…UPPER GASTROINTESTINAL BLEEDING
25
SANGSTAKEN BLAKEMOORE TUBE
Open surgery: if bleeding cannot be manage by endoscopy• Emergency open surgery: devascularization• Shunt surgery: porto-caval shunt, spleno-renal shunt• TIPS
Others:• Therapy to prevent or reduce hepatic encephalopathy
Oral neomycin 1 g QIDOral lactulose 100g/day in divided doses, high enemaIV vitamin K 10 mg
26
By Aminurulamirah and Atiqah Zayed
LOWERGASTROINTESTINALBLEEDING BLEEDING
DISTAL TO LIGAMENT OF
TREITZ
27
AETIOLOGY• IBD• Colitis (amoebic colitis, typhoid) Inflammatory
• Benign : Intestinal Polyps• Malignant : Colorectal CANeoplastic
• Iatrogenic : post-endoscopyTraumatic
• Vascular: angiodysplasi, hemorrhoids, ischaemic colitis.• Anal fissure• Diverticulum :bleeding diverticulosis/meckels• Drugs: Anticoagulant• Radiation : Colitis
Misc
28
Lower Gastrointestinal Bleed ClassificationTYPES OF LGIB
WHO WE ARE
BEST SERVICE OF US
GOOD VISION
VERY USEFUL TIMELINE
EXCELLENT DIAGRAM
CONTACT US
Minor Hemorrhage
Major Hemorrhage Occult Bleed
Hemorrhoids Bleeding diverticulosis Polyps
IBD Angiodysplasia Colorectal CAColorectal Polyps Dieulafoy lesion of
intestines
Intussusception Ischaemic cholitis
Meckel’s Diverticulum
29
Schematic Presentation of
approach in LGIBA schematic representation of proper workflow
approach towards lower GI bleed.
CP Presentation 30
•Most of LGIB are chronic cases.
•Acute LGIB : 20% of GI bleed cases
Management of Acute LGIB
Resuscitation and initial assessment
Localization of the bleeding site
Therapeutic intervention to stop bleeding at
the site
CP Presentation 31
Immediate Mxi.02, NG tube, IV fluids, CBD, CVPii.Correct metabolic acidosisiii.Blood transfusioan
(p.RBC,platelets, FFP)iv.Administer hemostatic adjunctv.IVG : all baseline IVG
ABC Protocol
32
Usually LGIB source difficult to identify
Localizationof the cause
• 99mTC radionuclide/ scintigraphy• Digital Subtraction Angiogram• Arteriogram of I.M.A • Emergency colonoscopy • Unstable patient subjected to urgent
laparotomy
If actively bleed vessel is identified:
Therapeutic interventions to stop bleeding at the site
Vasopressin injected = vasospasm
Injection of 1:20000 adrenaline into 4 quadrants of bleeding (bleeding diverticulum)Laparotomy
Embolization with metal microcoil or PVA. (life-saving but need interventional radiologist)
34
Management for Non-urgent Cases
Baseline blood
IVGStools for
occult blood
Endoscopy
ImagingDouble contract barium enema, CT, angiography
35
referencesI. Website: gi.org/wp-content/uploads/2016/03/ACGGuideline-Acute-
Lower-GI-Bleeding-03012016.pdf
II. Website: emedicine.medscape.com/article/188478-treatment#d14
III. Manipal Manualof Surgery
IV. Clinical Companion in Surgery
Causes & managementHAEMATURIA
Lili syafinaz & Teo pei shin
MICROSCOPIC●Can be detected on
dipstick or FEME●Red Blood Cell
(RBC): >3 /hpf
Non-visible haematuria / dipstick-positive
HAEMATURIACLASSIFICATIONS
MACROSCOPICVisible haematuria or gross haematuria
38
aetiologyCAUSES OF HAEMATURIA
CONGENITALPOLICYSTIC KIDNEY DISEASE
Infective: Urinary infection
Non-infective: Interstitial cystitis, glomerulonephritis, pyelonephritis
Direct: Blunt/ penetrating trauma
Iatrogenic: Instrumentation/ catheterisation
ACQUIRED
Benign: Benign prostatic hyperplasia Malignant: Renal cell carcinoma, transitional cell
carcinoma of renal pelvis, ureter and bladder, carcinoma of prostate
INFLAMMATORY
TRAUMATIC
NEOPLASTIC
MISCELLANEOUS
BLEEDING DISORDER
Urinary calculi Strenous exercise, Haemoglobinuria
Autoimmune (SLE) Anticoagulant (Warfarin), blood thinner (Aspirin)
39HAEMATURIA
40
• HistoryPainBlood at which stage of micturationAbility to pass urineClots?Symptoms of UTIBleeding disorder/ on anti-coagulantHistory of traumaOther causes of discoloured urine: beetroot, Nitrofurantoin
ManagementIn Emergency Department:
• Resuscitate:Volume replacementCorrect coagulopathyHemostasis
41
• Baseline investigationsBlood: FBC, BUSE, coagulation profile, Bloog grouping & crossmatchUrine: Dipstick, C&SImaging: X-ray KUB
ManagementIn Emergency Department:
• Indications for admission:Clot retentionHeavy hematuriaCVS instabilityUncontrolled pain
SepsisAcute renal failureCoagulopathySevere comorbidities
42Subsequent managementIn Ward
LABORATORY• Urine FEME
IMAGINGUSG KUBIntravenous urogramCT scanMRI scan Radioactive scan
OTHERS• Cystoscopy— biospy and HPE• Ureterorenoscopy— Brushing
and cytology
General Treatment of Haematuria
Continuous Bladder IrrigationExcept in a case of haematuria
following instrumentation…
44Management of renal stoneConsist of two main components
Medical expulsive therapy (MET)•Drink lots of fluids (>1.2 L)•Diuretic•Antispasmotic, alpha blocker, CCB
— Relax ureteric smooth muscles
Surgical•Upper 1/3: Push and bang method
I. Cystoscopy—> pass a stent (Pigtail/ Double J stent)—> ESWL
II. Prevent damage to bones.•Middle 1/3 & Lower 1/3:
I. By dormia basket or lithotripsy
45
Lithotripsy Pigtail stent Dormia basket Double J stentESWL
Must know (Extra)
46Bladder stone
Urethral stone●Urethroscopy + lithotrypsy●Surgery (urethrolithotomy)
Lithotrite instrument (hendrickson lithotrite)
●ESWL●Cystoscopy and lithotrite (instrument
used to crush stone)●Cystoscopy and lithotripsy
(electrohydraulic/ laser lithotrypsy)
Benign Prostatic HyperplasiaMedical•Alpha blocker (Prazosin, Terazosin, Doxazosin
5mg ON): relax smooth muscle of bladder neck and prostate
•5-alpha reductase inhibitor (Finasteride 5 mg): reduce epithelial layer in prostate glands
Surgery
•TURP (gold standard)
Bladder carcinoma•Depends on staging•Cancer not involving muscle Transurethral resection of tumour+ post-op
intravesical chemotherapy (Thiotepa/ Adriamycin/ Mitomycin)•T2-T4 Radical cystectomy •Any nodes/ metastasis systemic radiation •Small lesion: Partial cystectomy + intravesical
chemotherapy.
Renal Cell Carcinoma•Mainly surgery, respond poorly to
chemotherapy or radiotherapy. •Surgery
I. Nephron sparing surgery (T1)II. Radical nephrectomy
•Targeted therapyI. VEGF inhibitorII. ImmunotherapyIII. Interleukin-2
50 of 47
HemoptysisEtiology
Specific Management
51 of 47
Etiology
Haemoptysis is the coughing of blood from a source below the glottis. [1]
Common causes: 1. Tuberculosis (most common in southeast Asia)2. ****Lung cancer - most common in age > 60 years.old ( bronchogenic ca)3. Pneumonia,4. Acute and chronic bronchitis 5. Bronchiectasis.
massive bleeding with life-threatening consequences
Small amount of blood-streaked sputum
52 of 47
Approach to Hemoptysis
To differentiate haemetemesis /pseudo-hemoptysis /haemoptysis
Volume (in 24 hours) ● mild (15-30ml ) ● frank (>15 <600 ml) ● massive (>600 ml)
History and examination
53 of 47
Specific for Lung Cancer ...
Chest x ray - to locate site of bleeding
Investigations for diagnosis: doubt ?
Flexible Bronchoscopy (4% to 22% discovered bronchogenic ca) 86% can detect site of bleeding with/ without CT thorax
Bronchoscopy sampling procedures involved several techniques including bronchial washing (BW), bronchial brushing (BB), broncho-alveolar lavage (BAL), transbronchial biopsy (TBB) and endobronchial biopsy (EBB).* visible tumours. : BW > EBB > BB* not visible by bronchoscopy : BAL > BB > followed by TBB.
54 of 47
ManagementSTAGE MANAGEMENT Clinical stage I or II non-small cell lung cancer (NSCLC) Curative Surgical Resection
Stage IIIA NSCLC , T1-3 primary tumors Combined modality treatment approach
Unresectable stage IIIB NSCLC due to T4 primary tumours, N2-3
Platinum-based doublet chemotherapy (gemcitabine, paclitaxel, or vinorelbine) + - Radiotherapy
Stage IIIB disease due to the presence of a malignant pleural or pericardial effusion
Platinum-based doublet chemotherapy alone
Stage IV disease - good performance status - Poor performance
Platinum-based doublet chemotherapy or single agent chemotherapy
Supportive care
55 of 47
Thank you
Reference:The causes of haemoptysis in Malaysian patients aged over 60 and the diagnostic yield of different investigations - Published article by Catherine Mee-Ming WONG,Kim Hatt LIM,Chong-Kin LIAM