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National Teaching Series Prescribing in Surgery Series Surgical Emergencies 2 DATE: TIME: 16/04/24 @ 18:30 Tutor: Dr Hermione Jemmett Prescribing in Surgery Series 2024DISCLAIMER The Prescribing in Surgery for Mind the Bleep has been created by junior doctors who have a passion for teaching, entirely on a voluntary basis. The lecture slides and teaching content are accurate to the best of the tutors’ knowledge. Please note, that neither the tutors nor Mind the bleep take responsibility for any unintentional inaccuracies. Please kindly refer to the full T&C for your reference: https://www.mindthebleep.com/disclaimer/ Prescribing in Surgery Series 2024Surgical prescribing session Provisional date 1: VTE prophylaxis and analgesia 20/02/24 @ 18.30 2: Fluids and electrolyte imbalances 27/02/24 @ 18.30 3: Antibiotics and blood transfusions06/03/24 @ 18.30 4: Prescribing in pre-op 12/03/24 @ 18.30 5: Diabetes medications 19/03/24 @ 18.30 6: Surgical emergencies 1 09/04/24 @ 18.30 7: Surgical emergencies 2 16/04/24 @ 18.30 8: General surgery, colorectal, urology 23/04/24 @ 18.30 9: T+O, ENT, Paediatrics 30/04/24 @ 18.30 10: Surgical questions in PSA 07/05/24 @ 18.30 Prescribing in Surgery Series 2024Case 1 – Part A Case presentation A 72-year-old female is admitted to the general surgery ward with vomiting, indigestion and severe abdominal pain. DECISION OPTIONS Pancreatitis A PMHx include IHD, T1DM, osteoporosis, gastritis and liver cirrhosis. She is known to have alcohol excess. DHx Lower GI bleed B include aspirin, amlodipine, clopidogrel, naproxen, lansoprazole, insulin, colecalciferol, alendronic acid. Norovirus C Obstruction Overnight she becomes increasingly nauseated. She has 2 D episodes of dark coffee ground vomit. Upper GI bleed E Obs RR 17 HR 117 BP 90/78 T 37.4 Question: What do you think the likely cause is here? Prescribing in Surgery Series 2024Case 1 – Part A Case presentation A 72-year-old female is admitted to the general surgery ward with vomiting, indigestion and severe abdominal pain. DECISION OPTIONS Pancreatitis A PMHx include IHD, T1DM, osteoporosis, gastritis and liver cirrhosis. She is known to have alcohol excess. DHx Lower GI bleed B include aspirin, amlodipine, clopidogrel, naproxen, lansoprazole, insulin, colecalciferol, alendronic acid. Norovirus C Obstruction Overnight she becomes increasingly nauseated. She has 2 D episodes of dark coffee ground vomit. Upper GI bleed E Obs RR 17 HR 117 BP 90/78 T 37.4 Question: What do you think the likely cause is here? Prescribing in Surgery Series 2024Case 1 – Part B Case presentation PMHx include IHD, T1DM, osteoporosis, gastritis and liver cirrhosis. She is known to have alcohol excess. . DECISION OPTIONS Aspirin, clopidogrel, naproxen, alendronic Acid DHx include aspirin, amlodipine, clopidogrel, naproxen, lansoprazole, insulin, colecalciferol, alendronic acid. Naproxen B Clopidogrel, aspirin C None of them D Omeprazole, aspirin E Question: Which agents should have been stopped? Prescribing in Surgery Series 2024Case 1 – Part B Case presentation PMHx include IHD, T1DM, osteoporosis, gastritis and liver cirrhosis. She is known to have alcohol excess. DECISION OPTIONS Aspirin, clopidogrel, naproxen, alendronic Acid DHx include aspirin, amlodipine, clopidogrel, naproxen, lansoprazole, insulin, colecalciferol, alendronic acid. Naproxen B Clopidogrel, aspirin C None of them D Omeprazole, aspirin E Question: Which agents should have been stopped? Prescribing in Surgery Series 2024 Medications that increase your risk of bleeding in UGIB Anticoagulants DOACs, warfarin Antiplatelets Clopidogrel, prasugrel, ticagrelor, aspirin Corticosteroids Prednisolone, hydrocortisone NSAIDs Naproxen, ibuprofen Bisphosphonates Alendronic acid SSRIs Sertraline, fluoxetine Aldosterone antagonists Eplerenone, spironolactone [1] Prescribing in Surgery Series 2024Case 1 – Part C Case presentation She is hypotensive, tachycardic and has further episodes of haematemesis. You suspect this is an UGI bleed. You pull the emergency buzzer to get help. You use an ABCDE DECISION OPTIONS approach. IV lansoprazole A A- patent IV hydrocortisone, IV terlipressin B B- RR 17, O2 97% RA, equal A/E bilaterally C- BP 89/43, HR 121, pulse regular, CRT 4, cool Ciprofloxacin, IV pantoprazole C peripherally, HS I+II+0 IV Terlipressin, IV co-amoxiclav, IV D- BM 6.7, GCS 15/15, PEARL D pantoprazole E- tender abdomen in epigastric region, presence of Lansoprazole, prednisolone E melaena, n0 fresh blood, calves SNT You take bloods including FBC, UEs, coag, LFTs, VBG and G+S. You gain IV access and give her a stat 500ml plasmalyte/ Hartmann’s. Question: What medications would you prescribe? Prescribing in Surgery Series 2024Case 1 – Part C Case presentation She is hypotensive, tachycardic and has further episodes of haematemesis. You suspect this is an UGI bleed. You pull the emergency buzzer to get help. You use an ABCDE DECISION OPTIONS approach. IV lansoprazole A A- patent IV hydrocortisone, IV terlipressin B B- RR 17, O2 97% RA, equal A/E bilaterally C- BP 89/43, HR 121, pulse regular, CRT 4, cool Ciprofloxacin, IV pantoprazole C peripherally, HS I+II+0 IV Terlipressin, IV co-amoxiclav, IV D- BM 6.7, GCS 15/15, PEARL D pantoprazole E- tender abdomen in epigastric region, presence of Lansoprazole, prednisolone E melaena, n0 fresh blood, calves SNT You take bloods including FBC, UEs, coag, LFTs, VBG and G+S. You gain IV access and give her a stat 500ml plasmalyte/ Hartmann’s. Question: What medications would you prescribe? Prescribing in Surgery Series 2024A-E Causes of UGIB A - ensure airway is clear 1. Peptic ulcer (most common) B - check breathing, RR, sats, listen to chest 2. Mallory- Weiss tear • give o2 (nasal cannula if actively vomiting) 3. Oesophageal varices C - HR, BP, heart sounds 1. RF: severe liver disease, ETOH excess - Get IV access, take bloods, give fluid bolus 4. Oesophagitis D - check GCS, BM, PEARL E - check everything else, look for signs of bleeding, Symptoms of UGIB PR, feel calves and abdomen - Haematemesis (red or coffee ground) - Melaena (dark, tarry stool) - Abdominal pain Bloods Symptoms of shock (haemodynamic compromise) 1. FBC – Hb, platelets to advise for transfusions 2. U+Es – urea increased in UGIB - weakness, fatigue - Dizziness 3. Coagulation – INR, need for reversal, coagulopathy - Cool, clammy 4. VBG – lactate - N+V 5. LFTs – liver dysfunction - Reduced urine output 6. G+S and crossmatch – may need blood urgently - Hypotensive, tachycardic [2] Prescribing in Surgery Series 2024 [3] Prescribing in Surgery Series 2024 [3] Prescribing in Surgery Series 2024 [4] [3] Prescribing in Surgery Series 2024[5]Case 1 – Part D Case presentation As the patient is unstable, she is to have an endoscopy immediately after resuscitation. 2 scores need to be DECISION OPTIONS calculated before the endoscopy. These are the Glasgow- Identifies low-risk patient’s not requiring any A Blatchford score and the Rockall score. inpatient intervention (endoscopy, blood) Risk stratification for cause of UGIB being B varices Risk stratification for rebleeding C Identifies patients requiring blood transfusions D before endoscopy Identifies if alcohol was a primary cause of the E UGIB Question: What is the purpose of the Glasgow-Blatchford score? Prescribing in Surgery Series 2024Case 1 – Part D Case presentation As the patient is unstable, she is to have an endoscopy immediately after resuscitation. 2 scores need to be DECISION OPTIONS calculated before the endoscopy. These are the Glasgow- Identifies low-risk patient’s not requiring any A Blatchford score and the Rockall score. inpatient intervention (endoscopy, blood) Risk stratification for cause of UGIB being B varices Risk stratification for rebleeding C Identifies patients requiring blood transfusions D before endoscopy Identifies if alcohol was a primary cause of the E UGIB Question: What is the purpose of the Glasgow-Blatchford score? Prescribing in Surgery Series 2024Glasgow- Blatchford score Rockall score Score <3 good prognosis Score >8 poor prognosis [6] [7][3]Case 2 – Part A Case presentation A 54-year-old female is admitted following a horseriding accident where she sustains an open book fracture of the pelvis. She has a pelvic binder and undergoes ORIF. DECISION OPTIONS Pneumonia A 1 day post-operatively she becomes breathless. Atelectasis B Obs RR 24 Pulmonary Embolism C O2 sats 90% RA Flash pulmonary oedema HR 120 D STEMI E BP 104/82 T 37.0 ECG is performed showing S1Q3T3 change. Question: What is the most likely cause of this? Prescribing in Surgery Series 2024Case 2 – Part A Case presentation A 54-year-old female is admitted following a horseriding accident where she sustains an open book fracture of the pelvis. She has a pelvic binder and undergoes ORIF. DECISION OPTIONS Pneumonia A 1 day post-operatively she becomes breathless. Atelectasis B Obs RR 24 Pulmonary Embolism C O2 sats 90% RA Flash pulmonary oedema HR 120 D STEMI E BP 104/82 T 37.0 ECG is performed showing S1Q3T3 change. Question: What is the most likely cause of this? Prescribing in Surgery Series 2024Case 2 – Part B Case presentation Her ECG shows evidence of right heart strain, and you suspect she has a PE. DECISION OPTIONS DVT A Dehydration B Coagulopathy C Fat embolus D Septic emboli E Question: What is the most likely cause of the PE? Prescribing in Surgery Series 2024Case 2 – Part B Case presentation Her ECG shows evidence of right heart strain, and you suspect she has a PE. DECISION OPTIONS DVT A Dehydration B Coagulopathy C Fat embolus D Septic emboli E Question: What is the most likely cause of the PE? Prescribing in Surgery Series 2024Case 2 – Part C Case presentation Due to the nature of her injury (large pelvic fracture), you feel a fat embolism is the most likely cause of her PE. You order a CTPA which shows she has a PE. DECISION OPTIONS Heparin infusion A O2 therapy, treatment dose Dalteparin B Aspirin 75mg, clopidogrel 75mg, o2 therapy C Prophylactic Dalteparin, o2 therapy D IVF, o2 therapy E Question: How would you manage her PE? Prescribing in Surgery Series 2024Case 2 – Part C Case presentation Due to the nature of her injury (large pelvic fracture), you feel a fat embolism is the most likely cause of her PE. You order a CTPA which shows she has a PE. DECISION OPTIONS Heparin infusion A O2 therapy, treatment dose Dalteparin B Aspirin 75mg, clopidogrel 75mg, o2 therapy C Prophylactic Dalteparin, o2 therapy D IVF, o2 therapy E Question: How would you manage her PE? Prescribing in Surgery Series 2024[8]Case 3 – Part A Case presentation A 29-year-old man is admitted to the orthopaedic ward following a RTA. He has sustained a right proximal tibial DECISION OPTIONS fracture and multiple broken ribs. He is awaiting an ORIF Blood transfusion, basic analgesia A tomorrow and is placed in a cast and prescribed analgesia. IVF, Cyclizine, macrogol B IVF, O2 therapy, blood transfusion C Paracetamol, oxycodone, Cyclizine, IVF, D macrogol, senna Morphine sulphate, ondansetron E Question: What medications would you prescribe him? Prescribing in Surgery Series 2024Case 3 – Part A Case presentation A 29-year-old man is admitted to the orthopaedic ward following a RTA. He has sustained a right proximal tibial DECISION OPTIONS fracture and multiple broken ribs. He is awaiting an ORIF Blood transfusion, basic analgesia A tomorrow and is placed in a cast and prescribed analgesia. IVF, Cyclizine, macrogol B IVF, O2 therapy, blood transfusion C Paracetamol, oxycodone, Cyclizine, IVF, D macrogol, senna Morphine sulphate, ondansetron E Question: What medications would you prescribe him? Prescribing in Surgery Series 2024Case 3 – Part B Case presentation That evening, you are asked to review him for ongoing pain. DECISION OPTIONS O/E Contact neurology A RR 22 HR 121 Call senior for review of compartment B BP 124/78 Alert Contact pain team for review C Apyrexial Switch oxy to morphine D Increase dose of oxy E The right foot has reduced sensation on the dorsum, is very swollen and tender. Question: How would you manage this patient? Prescribing in Surgery Series 2024Case 3 – Part B Case presentation That evening, you are asked to review him for ongoing pain. DECISION OPTIONS O/E Contact neurology A RR 22 HR 121 Call senior for review of compartment B BP 124/78 Alert Contact pain team for review C Apyrexial Switch oxy to morphine D Increase dose of oxy E The right foot has reduced sensation on the dorsum, is very swollen and tender. Question: How would you manage this patient? Prescribing in Surgery Series 2024 Compartment Syndrome Symptoms – 5 P’s - Pain - Pallor ( pale skin tone) - Paraesthesia (numbness) - Pulselessness (faint pulse) - Paralysis (weakness in movements) Risk Factors - Crush injuries - Large bone fractures (tibia) - restrictive casts Types of Leg compartment syndrome èAnterior èPosterior èLateral [9]Case 3 – Part C Case presentation Your senior comes to review the patient as you are concerned about compartment syndrome. DECISION OPTIONS Compression stockings A Compartment monitor B Emergency ORIF C Emergency Fasciotomy D Oxycodone E Question: What is the definitive treatment for compartment syndrome? Prescribing in Surgery Series 2024Case 3 – Part C Case presentation Your senior comes to review the patient as you are concerned about compartment syndrome. DECISION OPTIONS Compression stockings A Compartment monitor B Emergency ORIF C Emergency Fasciotomy D Oxycodone E Question: What is the definitive treatment for compartment syndrome? Prescribing in Surgery Series 2024Case 4 – Part A Case presentation A 68-year-old female is 6 hours post-op following a Whipple’s procedure. She has increased pain which is not being well managed and believes she is hallucinating. You DECISION OPTIONS review her current meds: Switch Morphine to oxycodone A Regular meds: Increase morphine sulphate 5mg to 10mg QDS B Fortisip Zopiclone 3.75mg ON Switch Cyclizine to ondansetron C Increase Morphine PRN to 5mg Meds started in hospital: D Add in anti-psychotic E Paracetamol 1g QDS Cyclizine 50mg PRN TDS Macrogol 1 sachet BD Morphine sulphate 5mg QDS Morphine sulphate 2.5mg PRN (max 6x in 24 hrs) Question: What would you change in the prescription? Prescribing in Surgery Series 2024Case 4 – Part A Case presentation A 68-year-old female is 6 hours post-op following a Whipple’s procedure. She has increased pain which is not being well managed and believes she is hallucinating. You DECISION OPTIONS review her current meds: Switch Morphine to oxycodone A Regular meds: Increase morphine sulphate 5mg to 10mg QDS B Fortisip Zopiclone 3.75mg ON Switch Cyclizine to ondansetron C Increase Morphine PRN to 5mg Meds started in hospital: D Add in anti-psychotic E Paracetamol 1g QDS Cyclizine 50mg PRN TDS Macrogol 1 sachet BD Morphine sulphate 5mg QDS Morphine sulphate 2.5mg PRN (max 6x in 24 hrs) Question: What would you change in the prescription? Prescribing in Surgery Series 2024Case 4 – Part B Case presentation You re-review 2 hours later and she is no longer complaining of pain. DECISION OPTIONS O/E Intra-operative blood loss A RR 7 O2 94% RA Hypoglycaemia B HR 78 BP 110/65 Sepsis C Apyrexial Stroke GCS 13/15 D Opiate toxicity E PEARL, pinpoint Question: What is the likely cause of her reduced GCS? Prescribing in Surgery Series 2024Case 4 – Part B Case presentation You re-review 2 hours later and she is no longer complaining of pain. DECISION OPTIONS O/E Intra-operative blood loss A RR 7 O2 94% RA Hypoglycaemia B HR 78 BP 110/65 Sepsis C Apyrexial Stroke GCS 13/15 D Opiate toxicity E PEARL, pinpoint Question: What is the likely cause of her reduced GCS? Prescribing in Surgery Series 2024Case 4 – Part C Case presentation She has reduced respiratory effort, reduced consciousness and pinpoint pupils. You are concerned she is opiate toxic. DECISION OPTIONS Digoxin A Glucagon B Naloxone C Flumazenil D Salbutamol E Question: How do you manage this emergency acutely? Prescribing in Surgery Series 2024Case 4 – Part C Case presentation She has reduced respiratory effort, reduced consciousness and pinpoint pupils. You are concerned she is opiate toxic. DECISION OPTIONS Digoxin A Glucagon B Naloxone C Flumazenil D Salbutamol E Question: How do you manage this emergency acutely? Prescribing in Surgery Series 2024Management - Naloxone - Suspend all opioids [10][11]Case 5 – Part A Case presentation A 71-year-old male is admitted with necrotizing fasciitis. He undergoes an extensive emergency surgical debridement. You complete a post-op review. DECISION OPTIONS Urine dip A Bloods Hb 121 (115-165) ECG B Wcc 23.1(4-11) CRP 274 (<4) BP C Urea 25 ( 1-7) CXR Creat 217 (30-70) D Magnesium level E Na 122 (125-135) K 6.6 (3.5-5.5) Question: What investigation is required to determine treatment? Prescribing in Surgery Series 2024Case 5 – Part A Case presentation A 71-year-old male is admitted with necrotizing fasciitis. He undergoes an extensive emergency surgical debridement. You complete a post-op review. DECISION OPTIONS Urine dip A Bloods Hb 121 (115-165) ECG B Wcc 23.1(4-11) CRP 274 (<4) BP C Urea 25 ( 1-7) CXR Creat 217 (30-70) D Magnesium level E Na 122 (125-135) K 6.6 (3.5-5.5) Question: What investigation is required to determine treatment? Prescribing in Surgery Series 2024Case 5 – Part B Case presentation An ECG is performed which shows elevated T waves. He has a severe AKI and hyperkalemia. DECISION OPTIONS He feels SOB and has palpitations and nausea. IV Calcium gluconate, IV insulin-glucose A infusion, salbutamol nebs IV Sodium bicarbonate B Calcium resonium C IV dextrose with insulin, salbutamol nebs D IV plasmalyte E Question: What is your immediate management? Prescribing in Surgery Series 2024Case 5 – Part B Case presentation An ECG is performed which shows elevated T waves. He has a severe AKI and hyperkalemia. DECISION OPTIONS He feels SOB and has palpitations and nausea. IV Calcium gluconate, IV insulin-glucose A infusion, salbutamol nebs IV Sodium bicarbonate B Calcium resonium C IV dextrose with insulin, salbutamol nebs D IV plasmalyte E Question: What is your immediate management? Prescribing in Surgery Series 2024[12][13]References [1] John R. Horn, P. andPhilip D. Hansten, P. (2021) Gastrointestinal bleedingdue to drug-drug interactions, Pharmacy Times. Available at: https://www.pharmacytimes.com/view/gastrointestinal-bleeding-due-to-drugdrug-interactions (Accessed: 10 April 2024). [2] Gastrointestinal bleeding (2023) Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/gastrointestinal-bleeding/symptoms-causes/syc-20372729 (Accessed: 10 April 2024). [3] Recommendations: Acute upper gastrointestinal bleedingin over 16s: Management: Guidance (no date) NICE. Available at: https://www.nice.org.uk/guidance/CG141/chapter/Recommendations#management-of-variceal-bleeding (Accessed: 10 April 2024). [4] BNFis only available in the UK(no date a) NICE. Available at: https://bnf.nice.org.uk/drugs/omeprazole/ (Accessed: 10 April 2024). [5] Acute upper GI bleed(Guidelines) (no date) NHS choices. Available at: https://rightdecisions.scot.nhs.uk/tam-treatments-and-medicines-nhs-highland/therapeutic-guidelines/gastro- intestinal/upper-gastro-intestinal/acute-upper-gi-bleed-guidelines/ (Accessed: 10 April 2024). [6] Glasgow-BlatchfordScore Assessment Criteria| Downloadtable. Available at: https://www.researchgate.net/figure/Glasgow-Blatchford-score-assessment-criteria_tbl1_221734465(Accessed: 10 April 2024). [7] Risk assessment in patients withgastrointestinal bleeding.. Available at: https://pulmonarychronicles.com/index.php/pulmonarychronicles/article/download/90/178?inline=1 (Accessed: 10 April 2024). [8] BNFis only available in the UK(no date a) NICE. Available at: https://bnf.nice.org.uk/drugs/dalteparin-sodium/ (Accessed: 10 April 2024). [9] Compartment syndrome (2022) MOTUS Physical Therapy. Available at: https://motusspt.com/compartment-syndrome/ (Accessed: 10 April 2024). [10] Opioidoverdose: Howto respond&prevent death, ClevelandClinic. Available at: https://my.clevelandclinic.org/health/diseases/24583-opioid-overdose (Accessed: 10 April 2024). [11] BNFis only available in the UK(no date) NICE. Available at: https://bnf.nice.org.uk/drugs/naloxone-hydrochloride/ (Accessed: 10 April 2024). [12] Buttner, R., Burns, E. andBurns, R.B. andE. (2022) Hyperkalaemia, Life in the Fast Lane • LITFL. Available at: https://litfl.com/hyperkalaemia-ecg-library/ (Accessed: 10 April 2024). [13] Varma, R., Patrick, J. andKorn, N. (2023) AClinical Guideline for the Management of Hyperkalaemiain Adults