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What to Expect From This T utorial • It is impossible to cover all of anaesthetics and surgery in one tutorial. • We will go through anaesthetics, general surgery, and vascular surgery highlighting the key points to know for finals. • Other high-yield surgical specialties for finals include orthopaedics, urology, paediatrics, and breast, however, these are covered in other tutorials. • There will be MCQs throughout. Please vote for the correct answer using the poll function which is anonymous. • These slides will be made available to you after the tutorial. Additional notes as well as explanations for the MCQs are included in the slides.AnaestheticsMCQ 1. A 23-year-old female is brought into A&E after being found on her bedroom floor with empty bottles of oramorph on her bedside table. On examination, she does not open her eyes to voice or pain stimuli. She does not obey any motor commands, however, flexes to withdraw when you squeeze her trapezius muscle. She initially makes some incomprehensible groans, however, after a few minutes this stops, and she only makes snoring sounds. What is the most appropriate next step in the management of this patient?Airway Management – Manoeuvres Head tilt-chin lift • Contraindications include a suspected or confirmed cervical spine injury.Airway Management – Manoeuvres Jaw thrust • More effective than a head tilt-chin lift manoeuvre and may be used if a cervical spine injury is suspected. • Very uncomfortable if awake or semiconscious. • In practice, the head tilt-chin lift and jaw thrust manoeuvres are often performed simultaneously if the level of consciousness allows.Airway Management – Adjuncts Nasopharyngeal airway • Typically, tolerated if awake or semiconscious. • Useful if an oropharyngeal airway cannot be inserted e.g. oral trauma, trismus. • Sized from the tip of the nose to the tragus of the ear. • Contraindications include facial or nasal trauma, nasal lesions, suspected or confirmed basal skull fracture, and coagulopathy.Airway Management – Adjuncts Oropharyngeal airway • May produce a gag reflex if awake or semiconscious. • Rigid structure may cause bleeding if trauma is caused to the oropharyngeal structures on insertion. • Sized from the midpoint of the incisors to the angle of the mandible. Guedel airwayAirway Management – Adjuncts Supraglottic airway • Prevents oral secretions from trickling down the trachea, however, provides incomplete and unreliable protection from aspiration of gastric content. • Contraindications include risk of aspiration I-gel e.g. full stomach, bowel obstruction. Laryngeal mask airwayAirway Management – BVM Ventilation • Provides high flow oxygen. • May be placed over top of nasopharyngeal and oropharyngeal airways. • Connects to supraglottic airways and endotracheal tubes. Mask part must be removed first.Airway Management – Definitive Airway Endotracheal tube • Definitive airway as it transverses the glottic opening and resides in the trachea. • Inflatable cuff provides an excellent seal preventing aspiration of gastric content and blood.Airway Management – Surgical Airway Tracheostomy • Definitive airway. Cricothyroidotomy • Temporary emergency airway. • Not a definitive airway.Airway Management – OSCE • You may need to manage the airway in your A to E OSCE station. • Recognise airway compromise. • Know the key features of the different airway manoeuvres and adjuncts. Most importantly, know the indications and contraindications for each. • Airway manoeuvres and adjuncts may be used simultaneously. • Within reason, multiple airway adjuncts may be used simultaneously. • Demonstrate confidence.WHO Pain Ladder Adjuvants examples: • Local heat. • Antidepressants and anticonvulsants for neuropathic pain e.g. amitriptyline, duloxetine, gabapentin, pregabalin. • Transcutaneous electrical nerve stimulation. • Antispasmodics for intestinal or renal tract colic e.g. hyoscine butylbromide. • Radiotherapy for bone cancer. • Local or regional anaesthesia e.g. lidocaine, regional nerve blocks.General SurgeryAcute Abdomen • The acute abdomen is a key presentation. • There are many potential causes. It is useful to separate them by abdominal region or specialty. • What potential causes of the acute abdomen can you think of?Acute AbdomenMCQ 2. A 50-year-old female presents to A&E with acute abdominal pain. She describes episodes of intermittent pain in the right upper quadrant. These episodes last a few hours and tend to come on mostly after dinner. She has also vomited during some of these episodes. Her observations and blood results are within normal range. She has a raised BMI and has been trying to lose weight for some time now, however, has found this difficult. Given the most likely diagnosis, what is the most appropriate definitive management of this patient?Biliary Colic Clinical features • Colicky RUQ pain that may radiate to the back, right shoulder, or right scapula. Worse postprandially, particularly following fatty foods. • Nausea and vomiting. • Apyrexial. Investigations • Normal inflammatory markers. Normal LFTs. • Abdominal USS.Biliary Colic Management • Analgesia +/- IV fluids. • Elective laparoscopic cholecystectomy.MCQ 3. A 48-year-old female presents to A&E with right upper quadrant pain which radiates to the back. She has had a few episodes of vomiting. On examination, she is pyrexial with a temperature of 38.9°C and has a positive Murphy’s sign. Her blood results are shown below. What is the most likely diagnosis? CRP 110 (0-10), WCC 18 (4-11) ALT 35 (3-40), ALP 250 (30-100), bilirubin 10 (3-17) Amylase 150 (40-140)Acute Cholecystitis Clinical features • RUQ pain that may radiate to the back, right shoulder, or right scapula. • Nausea and vomiting. • Pyrexia. • Murphy’s sign. Investigations • Raised inflammatory markers. Raised ALP . • Abdominal USS. • MRCP if no gallstones are found on abdominal USS.Acute Cholecystitis Management • Analgesia +/- IV fluids. • Laparoscopic cholecystectomy, ideally with 48 hours.MCQ 4. A 52-year-old female presents to A&E with right upper quadrant pain which radiates to the back. Her HR is 120, BP is 86/62, and temperature is 39.1°C. Her sclera appear to be yellow in colour. Her blood results are shown below. What is the most appropriate next step in the management of this patient? CRP 280 (0-10), WCC 21 (4-11) ALT 35 (3-40), ALP 250 (30-100), bilirubin 65 (3-17) Amylase 150 (40-140)Ascending Cholangitis Clinical features • Charcot’s triad – RUQ pain, pyrexia, jaundice. • Reynold’s pentad in severe cases – Charcot’s triad, hypotension, reduced consciousness. • May present with severe sepsis. Investigations • Raised inflammatory markers. Raised ALP and bilirubin. • Abdominal USS – bile duct dilatation. • ERCP .Ascending Cholangitis Management • Analgesia. • Fluid resuscitation. • Broad-spectrum IV antibiotics. • ERCP .MCQ 5. A 48-year-old female presents to A&E with severe epigastric pain and vomiting. She is pyrexial with a temperature of 39.2°C. She underwent an ERCP procedure 7-days ago after which she felt well and was discharged home. Her blood results are shown below. What is the most likely diagnosis? CRP 310 (0-10), WCC 22 (4-11) ALT 35 (3-40), ALP 90 (30-100), bilirubin 10 (3-17) Amylase 420 (40-140)MCQ 6. A 48-year-old female presents to A&E with severe epigastric pain and vomiting. She is pyrexial with a temperature of 39.2°C. She underwent an ERCP procedure 7-days ago after which she felt well and was discharged home. Her blood results are shown below. Which parameter would help to establish the severity of the most likely diagnosis? CRP 310 (0-10), WCC 22 (4-11) ALT 35 (3-40), ALP 90 (30-100), bilirubin 10 (3-17) Amylase 420 (40-140)Acute Pancreatitis Clinical features • Severe epigastric pain that may radiate to the back/flanks. • Nausea and vomiting. • Pyrexia. • Cullen’s sign. Grey-Turner’s sign. Purtscher retinopathy. Investigations • Raised inflammatory markers. Raised amylase and lipase. • Abdominal USS. • Contrast CT.Acute Pancreatitis Management • Analgesia. • Aggressive fluid resuscitation. • Nutrition. • Surgical management e.g. early cholecystectomy for gallstones, early ERCP for obstruction of the biliary tree, debridement for necrosis if failing to settle with worsening organ failure, radiological drainage or surgical necrosectomy for infected necrosis.Acute Pancreatitis Glasgow-Imrie CriteriaInguinal Hernias Clinical features • Groin lump – superior and medial to the pubic tubercule, disappears on application of pressure and lying down. • Discomfort – worsened by activity, severe pain is rare. • Incarceration – pain out of proportion, tenderness, erythema. • Strangulation – pain out of proportion, firm groin lump, discolouration. • Bowel obstruction.Inguinal Hernias Investigations • Clinical diagnosis. • USS if there is uncertainty. • CT if incarceration, strangulation, or bowel obstruction are suspected.Inguinal Hernias Direct Indirect Bowel enters the inguinal canal Bowel enters the inguinal canal through a weakness in the posterior through the deep inguinal ring. wall. Medial to the inferior epigastric Lateral to the inferior epigastric vessels. vessels. Older patients. Younger patients. Due to an acquired weakness in the Due to incomplete closure of the abdominal wall. processus vaginalis.Inguinal Hernias Direct inguinal hernia Indirect inguinal hernia • This is of no relevance to the management.Inguinal Hernias Management • Mesh repair for both direct and indirect inguinal hernias. Open approach is typically used if unilateral. Laparoscopic approach is typically used if bilateral and recurrent.MCQ 7. A 24-year-old male presents to A&E with acute central abdominal pain which radiates to the right iliac fossa. He has vomited several times since the pain began. His HR is 101 and temperature is 38.2°C. On abdominal palpation, he shows guarding and a positive Rovsing’s sign. His blood results are shown below. What is the most likely diagnosis? CRP 250 (0-10), WCC 18 (4-11) ALT 20 (3-40), ALP 75 (30-100), bilirubin 5 (3-17) K+ 3.7 (3.5-7), Na+ 137 (135-145) Creatinine 70 (55-120), urea 6 (2-7)MCQ 8. A 24-year-old male presents to A&E with acute central abdominal pain which radiates to the right iliac fossa. He has vomited several times since the pain began. His HR is 101 and temperature is 38.2°C. On abdominal palpation, he shows guarding and a positive Rovsing’s sign. His blood results are shown below. What is the most appropriate next step in the management of this patient? CRP 250 (0-10), WCC 18 (4-11) ALT 20 (3-40), ALP 75 (30-100), bilirubin 5 (3-17) K+ 3.7 (3.5-7), Na+ 137 (135-145) Creatinine 70 (55-120), urea 6 (2-7)Acute Appendicitis Clinical features • Abdominal pain – periumbilical radiating to RIF, worsened by coughing or moving, children are typically unable to hop on the right leg. • Nausea and vomiting. • Anorexia. Diarrhoea. • Mild pyrexia. • Rovsing’s sign. McBurney’s sign. • Rebound tenderness. Percussion tenderness. Guarding. Rigidity.Acute Appendicitis Investigations • Raised inflammatory markers. Neutrophil-predominant leucocytosis. • Urinalysis. • Abdominal USS. Management • Analgesia. • IV fluids. Prophylactic IV antibiotics. • Open or laparoscopic appendicectomy. • Copious abdominal lavage if perforated.MCQ 9. A 72-year-old male presents to A&E with abdominal pain and bloating. He is constipated and has not opened his bowels for the past 4 days. He has had a few episodes of vomiting which were green in colour. He is usually fit and well, however, underwent a bowel resection 12 years ago due to a colorectal malignancy. His AXR is shown on the right. What is the most likely diagnosis?Small Bowel Obstruction Clinical features • Abdominal pain – diffuse, central. • Nausea and vomiting – typically bilious vomiting. • Constipation and lack of flatulence in complete obstruction. • Abdominal distension. Tinkling bowel sounds. Investigations • AXR – distended small bowel loops with fluid level. • CT – definitive investigation.Bowel Obstruction On AXR Small bowel obstruction Large bowel obstructionSmall Bowel Obstruction Management • NBM. IV fluids. NG tube. Analgesia. • Urgent surgical management if complete obstruction, peritonitis, or strangulated hernia are present. • Conservative management may be sufficient if incomplete obstruction is present.Large Bowel Obstruction Clinical features • Symptoms of underlying cause e.g. colorectal malignancy. • Abdominal pain. • Nausea and vomiting – late sign. • Constipation and lack of flatulence. • Abdominal distention. Tinkling bowel sounds. Investigations • AXR – distended large bowel loops. • CT – definitive investigation, useful for identifying underlying cause.Large Bowel Obstruction Management • NBM. IV fluids. NG tube. Analgesia. • Urgent surgical management if peritonitis or perforation are present. • Trial of conservative management for up to 72 hours if urgent surgical management is not indicated, however, most cases will require surgical management.MCQ 10.An 86-year-old male presents to A&E with abdominal pain and bloating. He is constipated and has not opened his bowels for the past 4 days. He often suffers with constipation despite regular laxatives. He feels nauseated and has had a few episodes of vomiting. His AXR is shown on the right. What is the most likely diagnosis?Volvulus Sigmoid volvulus (80% of cases) • Large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon. Associated with older age, chronic constipation, neurological conditions, and psychiatric conditions. Caecal volvulus (20% of cases) • Normally, the caecum is retroperitoneal there is therefore no risk of twisting. In the minority, there is a risk of twisting due to developmental failure of peritoneal fixation of the proximal bowel. Associated with all ages, adhesions, pregnancy.Volvulus Clinical features • Abdominal pain. • Nausea and vomiting. • Constipation. • Abdominal distention. Investigations • AXR. • Sigmoid volvulus – large bowel obstruction, coffee bean sign. • Caecal volvulus – small bowel obstruction may be seen.Volvulus Management • Sigmoid volvulus – rigid sigmoidoscopy with rectal tube insertion. • Caecal volvulus – right hemicolectomy is often required.Vascular SurgeryMCQ 11.A 65-year-old male attends screening and is found to have an abdominal aortic aneurysm which is 4cm in diameter. He has a repeat abdominal USS a year later which finds that the aneurysm has increased in diameter to 4.7cm. He is asymptomatic with no other co- morbidities. What is the most appropriate next step in the management of this patient?AAA Clinical features • Mostly asymptomatic and found incidentally through screening. • Abdominal/back/loin pain. • Limb ischaemia from embolisation. • Pulsatile abdominal mass. • Collapse, hypovolaemic shock, and severe abdominal/back/loin pain if leaking or ruptured.AAA Investigations • Abdominal USS – normal aorta is 2cm in diameter, >3cm is AAA. • Contrast CT angiogram. Management • Surveillance if <5.5cm. • Medical management including BP control, statin, and antiplatelets. • Surgical management if symptomatic, >5.5cm, or increasing at >1cm per year. Open or endovascular repair.AAA Screening programme • Single abdominal USS for males aged 65 years. • <3cm = normal, no further action. • 3-4.4cm = small, re-scan every 12 months. • 4.5-5.4cm = medium, re-scan every 3 months. • >5.5cm = large, high risk of rupture, refer to vascular surgery within 2 weeks for probable surgical management. • Rapidly enlarging at >1cm per year = high risk of rupture, refer to vascular surgery within 2 weeks for probable surgical management.MCQ 12.A 54-year-old female presents to A&E with central chest pain that is tearing in nature. Her HR is 112, BP is 176/98, and RR is 21. Her observations are within normal range otherwise. She has a history of poorly-controlled hypertension. She undergoes a contrast CT angiogram which is shown below. What is the most likely diagnosis?Aortic Dissection Clinical features • Severe ‘sharp’ or ‘tearing’ chest/back pain. • Pulse deficit. • Aortic regurgitation. • Hypertension. • Involvement of specific arteries e.g. coronary arteries causing angina, spinal arteries causing paraplegia, distal aorta causing limb ischaemia.Aortic Dissection Investigations • Contrast CT angiogram – investigation of choice, suitable for stable patients and surgical planning, false lumen is the key diagnostic finding. • CXR – widened mediastinum. • Transoesophageal echo – more suitable for unstable patients where the risk of placing the patient in the CT scanner is too high.Aortic DissectionAortic Dissection Management • Based on the Stanford classification. • Type A – surgical management, control BP to a target systolic of 100- 120mmHg whilst waiting. • Type B – conservative management, bed rest, reduce BP with IV labetalol to prevent progression.General Advice • You know much more than you think you do. You have made it to this stage of medical school for a reason. • Know the main clinical features, investigations, and management steps for the main conditions within each specialty. • Know what would be expected of a generalist. • It is all about pattern recognition. • PassMedicine, Oxford Handbook of Clinical Medicine, and Oxford Handbook of Clinical Specialties are all that you need.Thank You • magdalena.markiewicz@nhs.net