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Teaching series 1: A–E assessment in GI and Surgical Emergency DeliveredDr Alireza Sherafat- SFP doctor- FY1 Kettering General Hospital Delivered: Dr Momna Raja- SFP doctor- FY1 Kettering General HospitalQuick introduction Dr Alireza Sherafat SFP doctor FY1 Kettering General Hospital Dr Momna Raja SFP doctor FY1 Kettering General Hospital isclaimer Disclaimer supervision of junior doctors andts with consultants across the UK. students’ learning but should not replace local guidance or local Medical School teaching material. Overview – Clinical station • Will be given 3 /4 unwell patients • Asked to prioritize the order in which you shall see them. • Use A-E – Be systematic • Always safety net • One long case discussion • Make use of your MDT members • Ask about DNACPR and escalation status • Put out peri-arrest/cardiac arrest earlySurgical Emergencies (General Surgery) Dr Alireza Sherafat SFP doctor- East Midlands FY1 General SurgeryA-E Assessment •Airway •Breathing •Circulation •Disability •ExposureAirway •If patient is able to talk clearly ,airway is clear •Signs of compromised airway:snoring,secretions,aspiration or reduced consciousness •Look inside the mouth and use the suction •Consider airway opening manoeuvres (jaw-thrust or head-tilt chin lift) •Use oropharyngeal/nasopharyngeal airways (depending on consciousness level);estimate the size •Call the anaesthetist to intubate the patient if GCS<8 •Anaesthetist may consider Cricothyroidotomy if intubation is not possibleBreathing •Measure saturation •Check Respiratory Rate •Cyanosis? (peripheral or central) •Respiratory examination:inspection (scars,accessory muscle use, deformities), palpation (equal chest expansion?) •Percussion (Resonance? Dull?) •Auscultation (Equal B/L air entry?) •Examine calves •ABG & CXR •If patient is critically unwell,start 15 L RM oxygen (even for COPD patients,you can titrate the oxygen later) •Treat the cause :Pneumothorax (tension pneumothorax?) PE? COPD/Asthma exacerbation? Pleural effusion?Trauma? (Hemithorax?) ?AtelectasisCirculation •Check capillary refill time <2s (peripherally and centrally) •Check skin temperature •Check HR (rate,rhythm) peripherally;check central pulse (Volume?) •Check BP (previous BP?) •Check temperature (pyrexia? Hypothermia?) •Auscultate the heart sounds (4 areas over valves) ? HS I+II+0? •Listen to base of lungs (fluid overload?) •Check JVP? Check for hepatojugular reflex •Check urine output (Catheter bag? Urine output? Urine colour? ) •Check input/output chart (IV fluids/drink/vomiting/stoma output/fistula/ drain output/etc) •Assess for signs of dehydration (dry oral mucosa/ reduced skin turgor) •Check daily weightsContinued…. •ECG and continuous cardiac monitoring.Treat arrhythmia •Insert two wide-bore IV Cannula (pink or green). •Take bloods ( FBC,U+E,CRP,LFT,Lactate,Coagulation,G+S,Amylase,D-dimer, Troponin) •TakeVBG •Fluid resuscitation .500 ml NaCL stat (15 min) or 250 ml if heart failure background •Elevate their legs •Repeat fluid resuscitation if still low BP up to 2 L •Consider giving blood (Major haemorrhage protocol;RBC,FFP,Plts) •If overloaded give furosemide IV •Monitor U+Es and input/output •Ask for senior review •Manage sepsis (sepsis 6);haemorrhage depending on site (surgeons? Gastro for OGD? Interventional Radiology?) •Escalation to HDU/ITU for inotropes and vasopressors if still hypotensiveDisability •Don’t Ever forget Glucose! (Check BM) •Assess pupils (PEARL?) •Assess GCS (E4V5 M6)/AVPU •Assess for signs of focal neurology deficit •Assess cranial nerves briefly •Assess peripheral nerves briefly •Treat hypoglycaemia urgently (if fully responsive give glucogel/glucose tablet followed by biscuit and repeat until normal glucose,if unresponsive with IV access,give IV dextrose and if no IV access present,Give IM Glucagon •Ask for CT head (if any concerns about unexplained loss of consciousness, neurology deficit or head injury with sinister features such as vomiting more than one episode) •Assess pain and give analgesia (IV paracetamol/ Oral Morph) •Think about causes ;?Seizure ?Stroke ? Intracranial haemorrhageEverything else •Abdominal examination : Inspection (Scars? Stoma? Distension? Drains?) Palpation:Tender abdomen? Rigidity? Guarding? Peritonitis? Rebound tenderness present? Murphy's sign?Abdomen Soft and Non-tender? (Abdo SNT?) Expansile mass? (AAA?) Incarcerated/strangulated hernia? Percussion (free fluids?)Auscultation (Bowel Sounds? Renal bruit?) •Also examine hernia orifices and groin •Examine scrotum in young boys •PR examination to investigate for bleeding (?upper vs lower GI bleed;fresh blood? or melaena?) •Exposure (full exposure,protect dignity,check bedside,look for rash,bleeding, check IV lines,surgical drains,assess catheter and stoma bags) •If suspecting ectopic pregnancy ;add urine b-HCG •FAST abdomen scan (FocusedAbdominal Sonography inTrauma) to look for free fluid (blood)Important points • Always treat causes of abnormal findings before going to next part of assessment • Always go back and re-assess! • Inform your senior • Inform outreach team, HDU and ITU • If suspecting sepsis; check for sources of infection (Blood culture, Urine MCS, Stool culture, CXR, Wound swab, sample from drains, etc) . Start Sepsis six give oxygen, IV fluids, IV Antibiotics; take urine output, lactate and blood culture)Surgical Complications •Immediate Complications. Hours (bleeding, Pain) •Early Complications. 0-4 days (Atelectasis, DVT/PE, Ileus) •Delayed Complications. 5-10 days (Anastomotic leak, wound infection, Pneumonia) •Late Complications . Weeks to months (collection, adhesions)Case 1 •FY1 On Call •79-year-old female patient day 2 post Hartmann's procedure develops cough, low grade temperature (37.9 C), tachycardia (HR 107) and RR:23 with Sats 93% on Room Air •Nurse bleeps your SHO to assess the patient. He is busy in ED seeing patients. He calls you and asks you to see the patient. •O/E patient has SOB and on chest auscultation he she has reduced breath sounds in the lower zones bilaterally •You notice the patient is in a lot of pain op tDiscussion •Ask for further information •Consider their surgical and medical history •Check observations again (or ask the nurse to kindly repeat) •Take history from patieAsk if they have SOB? Chest pain? Any respiratory conditions? Cough? Sputum?) •Assess the patient A-E ( CardioResp examination, examine sputum pot, Check if they have had chest physio) •Review medications (Abx?) •Request CXR (Portable?) •Further investigations (Bloods including FBC, U+Es and CRP, Blood Cultures) •Sepsis screen (Could this be sepsis?) •Look out for other places prone to infection (Urine?) •Monitor Observations, give IV Abx, Oxygen and fluids •Monitor Input/Output (risk of pulmonary oedema secondary to fluid overload?)Atelectasis • Lung collapses partially or completely • Can make the patient severelyunwell • Pain control, breathing exercises, Oxygen, ? Abx (not routine)and fluids • Early pneumonia? Atelectasis? an be challenging to differentiateCXR Figure 1) B/L Atelectasis in a 35-year-old gentleman 1 week post splenectomy with left chest pain (Murphy, 2016).Case 2 • FY 1 on Call and receive a bleep at 6:45 pm • 76-year-old gentleman complains of nausea, vomiting, bloating and distended abdomen 3 days post laparoscopic R Hemicolectomy which wasperformed to resect a malignant tumour • His HR is 99 and BP is 110/67 mmHg. He does not have a temperature and his sats is 95% on RA. • He has not been able to pass wind since yesterday • Stoma output is less than expected amountDiscussion • Ask for further information • Consider their surgical and medical history • Check observations again (or ask the nurse to kindly repeat) • Take history from pati( nt if they have Abdominal pain? Passing wind? Vomiting? Eating and Drinking? • Assess the patient A-E ( Abdominal examination, examine stoma and drains, check input/output) • Review medications • Request CT AP with Contrast • Further investigations (Bloods including FBC, U+Es, Lactate and CRP) • The main diagnosis to consider with this presentation is ileus • NG tube (Rylestube) for drainage and IV fluids (Drip and suck), Keep NBM • Be aware of risk of aspiration pneumonia • Monitor Observations and red flags for complete bowel obstruction • Monitor Input/Output and U+EsCase 3 • FY1 doctor on nights • Nurse bleeps you concerned about a 73-year-old patient who is day 6 post R hemicolectomy and has developed fever (38.7 C), Tachycardia (HR 121), Low BP (86/56 mmHg) and is complaining of new-onset abdominal pain (pt already on PCA morphine) • He also has complaining of nausea and vomiting. • Urine output is minimal. • O/E Abdomen is tender, rigid with positive rebound tenderness.Discussion •Ask for further information •Consider their surgical and medical history (bowel anastomosis?) •Check observations again (or ask the nurse to kindly repeat) •Take history from patieAsk if they have Abdominal pain? Passing wind? Vomiting? Eating and Drinking? Confused?) •Assess the patient A-E ( Abdominal examination, examine stoma and drains, check input/output) •Start Sepsis six (give three :Abx, Fluids, Oxygen ; Take three : Lactate, Blood culture, Urine Output) •Review medications •Request CT AP with Contrast urgently •Further investigations (Bloods including FBC, U+Es, Lactate and CRP) •The main diagnosis to consider with this presentation is anastomotic leak •NG tube (Ryles tube) for drainage and IV fluids , Keep NBM •Talk to SHO/SpR and escalate •Talk to Outreach teamAlways think about 5 Ws •Wind (?Atelectasis, ? Pneumonia) •Water (?UTI, ?Retention, ?AKI) •Walk (?DVT/PE) •Wound (?Wound dehiscence, ?Wound infection) •Wonder drugs!! (?Nausea, ?Constipation, ?Anaesthetic drugs) Medical Emergencies (Gastroenterology edition) Dr Momna Raja SFP doctor- East Midlands FY1 Gastroenterology Case 1 • You have been called to see-ye50 -old patient who has just vomited 200ml of coffee-ground vomit all over his sheets. Background of HTN, and alcohol excess • His NEWS = 8 (Alert, BP = 79/42, HR = 105bpm, RR=26bpm, Sats = 94% on air) • Always look at patient from the end of bed! Airway • Patient speaking in full sentences • No additional sounds • Check for any vomit/blood in mouth • Consider suction • Intervention: • Sit patient up straight/45 degrees • If not possible, recovery position Breathing • Observations: • RR= 26bpm Sats= 94% on air • Examination: • Trachea central, chest expansion equal and symmetrical, normal breathing sounds • Intervention • Consider oxygen if desaturating Circulation • Observations: • HR= 105bpm BP= 79/42 • Examination: Examination: CRT = 5 seconds, HS I+II+0 • Intervention • 2 large wide borne cannulas – one for giving and one for taking. • Raise legs • Give fluids -> >30% blood loss: Activate the Major Hemorrhagic Protocol • Investigations • Bloods: VBG, FBC, U&Es, LFTs, Group and save, cross-match, clotting. • Scoring systems • Glasgow-Blatchford matching score – Hb, urea, Initial BP, HR, risk factors Disability • Alert • Pupils equal and reactive to light • Blood glucose = 11mmol/L • Temperature = 37.1*C Everything else • Abdominal examination • Look for peritonitis • Ascites/ peripheral oedema • any signs of cirrhosis • PR exam (?melena) Management • Nil by mouth • If massive hemorrhage, activate the major hemorrhage protocol, consider transfusion ORh- negative blood until crossmatch arrives. • Correct coagulopathies • Gastroenterology referral – urgent endoscopy if severe bleeding • If suspecting varices: Use first 24-hour Liver Cirrhosis Care BundleFigure 2: Decompensated Cirrhosis Care Bundle [BSG 2019] (2) Upper GI bleed • 5 common causes to consider: • Peptic ulcer • Endoclips, inject dilute adrenaline, thermal therapy • Varices • Blanding (esophageal), Injection sclerotherapy (gastric) • 2 line: TIPS + lactulose, Sengstaken Blakemore tube • PPI cover for 72 hours • Duodenal erosion • Oesophagitis • Mallory-Weiss tear • Calculate Rockallscore for progression Case 2 • You are the nightsoncall. You are asked to see a 65-year-old patient complaining of severe abdominal pain and acute diarrhea (6 stools in past 3 hours). BG of HTN, UC, OA. • NEWS = 6 (HR= 115,bpm BP= 107/77, temperature =38.4*C, Alert) • Ask what the patient is currently being treated for in hospital. • Treated for CA– on IV co-amoxiclav Airway • Patent– but dry mucosal membranes • Patient speaking in full sentences • No additional sounds Breathing • Observations: • RR= 19bpm Sats= 94% on air • Examination: • Trachea central, chest expansion equal and symmetrical, normal breathing sounds • Intervention • Consider oxygen if desaturating • Investigation • VBG, CXR Circulation • Observations: • HR= 115 bpm BP= 107/77 • Examination: CRT = 3 seconds, HS I+II+0 • Intervention • 2 large wide borne cannulas – one for giving and one for taking. • Give fluids – consider slow hydration • Investigations • Bloods: VBG, FBC, U&Es, LFTs, clotting,, Lactate, Blood cultures • ECG Disability • Alert • Pupils equal and reactive to light • Blood glucose = 6.5mmol/L • Temperature = 38.4*C • Consider sepsis protocol (BUFFALO) Everything else • Examination • Abdominal examination • Look for peritonitis • PR exam (?fresh blood/melena) • Extra-intestinal features of IBD • Investigations • CXR/ AXR/ CT Abdomen • Send off stool cultures – ?Clostridium difficile • Stool chart • Intervention: VTE thromboprophylaxis Management • Encourage oral hydration • Correct electrolyte disturbances • IV steroids + IV Fluids • Monitor for 72 hours • Consider surgical referralReferences 1-Murphy, A. (2016). Bilateral atelectasis. Radiopaedia. https://radiopaedia.org/cases/bilatera-atelectasis?lang=gb (accessed 21 Oct 2022) 2. Decompensated Cirrhosis Care Bundle (2019) - First 24 Hours. British Society of Gastroenterology. https://www.bsg.org.uk/wp -content/uploads/2019/12/BSG - BASL-Decompensated-Cirrhosis-Care-Bundle-First-24- Hours.pdf (Accessed on 21 Oct 2022)FOR FEEDBACK AND QUERIES: Email @ info@bidasw.com
