Surgery for the on-call SHO Matt Dunstan, ST4 Vanessa Brown, ST7

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

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.

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

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

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

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

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

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

Head Injury

Head injury – NICE guidelines

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

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

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

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

Vascular history Arterial questions – Claudication – Night pain – Rest pain – Ulcers Venous questions – Aching – Oedema – Itching – Bleeding – Ulcers

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

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

Consent

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

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

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

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!

Any questions?