1. Surgical Emergency Tsung-Chien Lu, MD
Core Lecture
Surgical Emergency
Tsung-Chien Lu, MD

2. GOAL emergencies 2. Learn a correct notion
1. Recognize different surgical
emergencies
2. Learn a correct notion
3. Decrease delayed diagnosis
4. Prevent secondary injury

3. GUIDELINES 1. Surgical emergencies 2. Pediatric surgery emergencies
3. Urological emergencies
4. ENT emergencies
5. Ophthalmic emergencies
6. Gynecologic emergencies

4. PRINCIPLES OF MANAGEMENT
1. Life-saving
a. Identify life-threatening injury
b. Appropriate resuscitation
2. Maintain vital status
a. Detailed physical examination
b. Continuous resuscitation
3. Further evaluation and management
a. Laboratory examination
b. Consultation

5. TRAUMA 1. The 5th leading causes of death of Taiwanese
2. The 1st leading cause of death of
young adults
3. Approximately 8,000 patients died
from trauma annually

6. WOUND CARE 1. Copious irrigation 2. Remove foreign body
3. Antiseptic solution
4. Adequate debridement
5. Primary / Delayed suture

7. PRIMARY SURVEY A. Airway and C-spine control
B. Breathing and ventilation
C. Circulation and hemorrhage control
D. Disability
E. Exposure
M. Monitor (Foley: indication and contraindication)

8. AIRWAY ASSESSMENT
Stridor
Debris in oropharynx
Airway obstruction

9. AIRWAY INTERVENTIONS Jaw thrust
AVOID HYPEREXTENSION OR FLEXION OF THE NECK
Log roll to side for emesis

10. CERVICAL SPINE STABILIZATION
Place hands on either side of the head
Maintain neck midline

11. BREATHING ASSESSMENT Look, listen, and feel Observe chest symmetry
Note work of breathing
Jugular vein distention
Tracheal deviation

12. BREATHING INTERVENTIONS
If breathing is absent, begin mouth to mask ventilations
If breathing is shallow or labored, maintain airway control

13. CIRCULATORY ASSESSMENT
Level of consciousness
Carotid pulse (absent or present)
Capillary refill
Skin color
Skin temperature
Sites of bleeding

14. CIRCULATORY INTERVENTIONS
If pulse is absent, begin CPR
Apply direct pressure to open wounds

15. SECURE AIRWAY Assist airway Oral airway, nasal airway, LMA
Endotracheal intubation
Oral, nasal
Surgical airway
Cricothyroidotomy
Tracheostomy

16. LMA and Intubating LMA

18. Intubating LMA

20. Contraindication: < 11y/o

21. Needle Cricothyroidotomy

22. NEUROLOGICAL ASSESSMENT
Level of consciousness
AVPU scale
Awake
Verbal response
Pain response
Unresponsive

24. LIFE-THREATENING HEAD INJURY
Intracranial hemorrhage
Epidural hematoma, subdural hematoma,
intracerebral hematoma, subarachnoid
hematoma
Diffuse axonal injury
Management
a. Evacuation of hematoma
b. Decrease IICP and mass effect
c. Maintain cerebral perfusion

25. Traumatic SAH Most common: 30-40%
Blood within the CSF and subarachnoid (SA) space
Tearing of small SA vessels
Blood often seen in the basilar
cisterns, interhemispheric fissures
and sulci

26. Epidural Hematoma (EDH)
0.5-1% of head injuries
Blood between the skull and dura
Middle meningeal artery (MMA) > dural sinuses, veins, fracture line
“Classic” LOC then ‘lucid’ (30%)
80% associated with skull #

27. Acute Subdural Hematoma (SDH)
30% of head injuries
Forceful acceleration-deceleration injuries
Blood between the dura and brain
Hyperdense, crescent shaped, extend beyond suture lines
Quick clinical course
Prognosis: 60-80% mortality

28. I I C P Symptoms Headache, vomiting, cons change Signs
Increase BP, decrease HR & PR
papilledema
Neurological findings
Focal sign, pupil size and light reflex
Cushing's triad: hypertension, bradycardia, and Cheyne-Stokes respiration (irregular breathing)
Increased BP
Slow Pulse
Altered Breathing

29. BATTLE’S SIGN

30. RACCOON EYES

31. Brain Concussion Temporary disturbance in brain function
Probably due to brain being “rattled” inside the skull by a blow to the head
Usually confused or unconscious
Retrograde amnesia--“What happened?”
Effects clear without residual effects

32. OBSERVATION OF HEAD INJURY
Progressive headache
Vomiting
Consciousness
Dyspnea
Extremity weakness
Seizure

33. LIFE-THREATENING CHEST INJURY
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Massive hemothorax
5. Pericardiac tamponade
6. Flail chest combined pulmonary
contusion

34. Pericardial Effusion

35. Pneumothorax

36. BECK’S TRIAD 2. Distended neck vein 3. Distant or muffled heart sounds
1. Decrease blood pressure
2. Distended neck vein
3. Distant or muffled heart
sounds

37. Pulsus Paradoxicus
The inspiratory diminution in systolic arterial pressure exceeds 10 mmHg.
To measure pulsus paradoxus, a sphygmomanometer sphygmomanometer is employed for blood pressure measurement in the standard fashion except that the cuff is deflated more slowly than usual. During deflation, the first Korotkoff sounds are audible only during expiration, but with further deflation, Korotkoff sounds are heard throughout the respiratory cycle. The difference between the systolic pressure at which the first Korotkoff sounds are heard during expiration and the pressure at which they are heard throughout the respiratory cycle quantifies pulsus paradoxus.

38. LIFE-THREATENING ABDOMINAL INJURY
1. Liver laceration
2. Spleen laceration
3. Large vessel injury
4. Pelvic fracture

39. PELVIS Apply pressure on pelvis to determine its stability
Perform genitalia exam at one’s discretion

40. EXTREMITIES Observe for deformities, impaled objects, open wounds
Palpate for pulses, crepitus, or swelling
Determine capillary refill, skin color, temperature
Assess for pain/tenderness

41. INSPECT THE BACK Log roll student with assistance
School nurse must maintain cervical spine control
Inspect and palpate the back for bruising, impaled objects, pain and tenderness

42. TRAUMATIC SHOCK 1. Hypovolemic shock 2. Neurogenic shock
3. Cardiogenic shock
4. Septic shock

43. Neurogenic shock
Spinal cord injury may produce hypotension due to loss of sympathetic tone.
Hypotension without tachycardia or cutaneous vasoconstriction.

44. FLUID RESUSCITATION 1. Access Two large bore IV catheter 2. Fluid
Crystalloid, colloid, blood component
3. Amount
a. Bolus: 2 liter for adults
20 ml/ kg for child
b. maintain amount based on urine output

45. DIFFICULT CATHETERIZATION
1. Venous cut down
2. Intraosseous infusion (<6 y/o)
3. Central venous puncture

46. THERMAL INJURY 1. Major burn 2. High-voltage electric injury
3. Inhalation injury
4. Chemical burn

47. ACUTE ABDOMEN Differential diagnosis
Surgical abdomen / medical abdomen
Pain history
Onset, location, intensity, duration,
radiation, quality, associated symptoms
Symptoms sequence

48. SEVERE ABDOMINAL PAIN 1. Hollow organ perforation
2. Acute pancreatitis
3. Colic pain
a. Biliary system
b. Renal system
4. Ischemia pain
5. Others

49. COMMON DISEASES 1. Acute cholecystitis 2. (Perforated) Peptic ulcer
3. Acute appendicitis
4. Acute pancreatitis
5. Small bowel obstruction
6. Colon obstruction
7. Vascular occlusion
8. Others

50. PEDIATRIC SURGERY EMERGENCY
1. Respiratory distress
* Esophageal atresia
* Diaphragmatic hernia
2. Skin defect
* Gastroschisis
* Omplalocele
* Menigocele

51. PEDIATRIC SURGERY EMERGENCY
3. Bowel obstruction
Pyloric stenosis, intussusception
Adhesion, incarcerated hernia,
Malroatation
4. Abdominal pain
*Acute gastroenteritis
*Acute appendicitis
*Mesenteric lymphadenitis

52. GYNECOLOGIC EMERGENCY
Vaginal bleeding
1. Dysfunctional uterine bleeding
2. Uterine myoma
3. Hypermenorrhea
4. Abortion
5. Atony uterus

53. GYNECOLOGIC EMERGENCY
Ectopic pregnancy
* Missed period
* Vaginal spotting
* Abdominal pain

54. GYNECOLOGIC EMERGENCY
Abdominal pain
* Pelvic inflammatory disease
* Acute appendicitis
* Ovarian cyst (torsion)
* Ileus
* Menstruction

55. Urological Emergency Painful conditions Bleeding conditions
Trauma conditions
Others

56. ENT Emergency
Foreign body
Epistaxis
Deep neck infection
Others

57. Ophthologic Emergency
Red eye
Foreign body
Blurred vision
Others

58. REEVALUATION Time interval Same personnel Vital signs
Laboratory examination
Early suspicion
Early consultation

59. MEDICAL ETHICS Treat a person not a disease
Treat a patient as your family
Be patient to a patient’s complaint
Be kind and more smile
Careful explanation

60. Suggestive Readings
Advanced Trauma Life Support (ATLS) for Doctors (American College of Surgeons Committee on Trauma, 1997)
外傷及外科重症醫學 (中華民國急救加護醫學會, 金名圖書, 1999)

61. Questions?