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Hello, welcome everyone. Um My name's Doctor Isha Miser. I'm one of the co leads in the prescribing and surgery series. Uh and welcome to our sixth session on surgical emergencies. Part one. So just a disclaimer. Uh the prescribing surgery series uh has been created by junior doctors. Uh We will have a passion for learning and teaching and it's entirely on a voluntary basis. Um The li slides and the teaching content are accurate to the best of our knowledge. Um and neither the teachers nor mine. The people take responsibility for any unintentional inaccuracies. So, yeah, today's the sixth session on surgical emergencies. Part one and next week, uh Doctor Gemme will deliver the surgical emergencies, part two session. So let's go straight into the first case. So case one, a 56 year old female presents with fever, nausea and vomiting on examination of her abdomen. Uh there's a palpable tender gallbladder and Murphy sign is positive. Uh So, Murphy sign positive, that means there's pain and sudden cessation of inspiration when the gallbladder is palpated. Uh ultrasound abdomen shows no stone in the gallbladder. She's admitted to the General Surgical ward for management of acute cholecystitis in terms of her past medical history, she's got depression and she, uh, for which she takes sertraline. She has no known drug allergies. She's on the list for, uh, cholecystectomy and she requires antibiotics in the meantime. So, which antibiotic will you prescribe for her acute cholecystitis? So I'm just gonna load the f first pore. Ok. Ok. Someone says amoxicillin just give you a few more seconds. Ok. Uh, ok. It seems like amoxicillin is the most popular option, followed by Coamoxiclav and then Vancomycin. OK. So the correct answer is actually Coamoxiclav of 1.2 g. I VTD. S. Um So just if I talk through, why isn't the other options? So, Vancomycin uh 100 and 25 mg per oral Q DS is what we use to treat C difficile. Uh rifAXIMin 550 mg. BD is how we treat um hepatic uh encephalopathy. And we also use it for prophylaxis. Uh It's not D amoxicillin um because we tend to uh so in my trust, we use it for community acquired pneumonia. Um And it's not e cefTRIAXone um because it's used for epiglottitis again, according to my local trust. Uh so when it comes to antibiotic, prescriptions also always follow your local trust guidelines. Uh So if you see over here, the East Kent guidelines for acute cholecystitis first line in a patient who's not penicillin allergic is coamoxiclav 1.2 g. I VTD S. Um I hope that makes sense. Ok? But um I'm just gonna move on to the next case if there's any questions. Ok. Um So case two. So during uh her admission following the same patient whilst waiting for her cholecystectomy, the nurse reports that she looks more unwell and asks for her to be reviewed. So, on examination, she's alert respirate is 16. Her oxygen starts to 98% on room air temperature is 38 BP. 100/70 heart rate is 100 and 35 BPM. Heart sounds one and two present with no added heart sounds. Her chest is clear. Her cap refill is three seconds and her urine dip is clear. So the question is, how would you manage her? Currently, I'm just gonna release the pole. So, so far everyone's going for b any other responses. OK. So it seems like B is the most popular choice followed by uh A. OK. So the correct answer is B um So this patient has sepsis secondary to acute cholecystitis. So we need to do the sepsis six. So this patient doesn't require oxygen because oxygen sats are maintained on room air. So that uh means C or D is not correct. Um A&E A&E are partially correct whereas B gives us the full kind of sepsis six. So taking bloods, including blood cultures and lactate, catheterizing the patient giving IV fluids and also IV antibiotics. OK. Uh Any questions for this uh about this case. OK. We can move on to our third case. Uh Before that, um I think I just included this slide just to show you um the sepsis trust. So, uh again, it just shows you sepsis six. So administer oxygen, take blood cultures, um giving IV antibiotics, IV fluids, um taking lactate level and measuring urine output. Um but only administering oxygen if SATS aren't maintained on Roma. OK. So moving on to case three, a 39 year old female presents to the surgical emergency assessment unit with right iliac fossa, pain, fever and nausea and vomiting on examination. Mcburney's sign is pos positive and rosing sign is positive. Um So mcburney sign is when you have uh right iliac fossa tenderness and it's around a third of the distance from the ass to the umbilicus and rossing sign is when you palpate the left iliac fossa and it causes pain in the right iliac fossa. Um So past medical history is uh negative. Not uh so doesn't have any medical conditions, not on any regular medications is allergic to penicillin and has a anaphylaxis reaction to penicillin. Uh She undergoes a laparoscopic appendectomy and receives two days of antibiotics. She's now apyrexial and her inflammatory markers are improving. The surgical consultant asks you to convert her current antibiotics to an oral equivalent. So, current antibiotic, she's on IV, Vancomycin, IV, Gentamicin, uh IV uh metroNIDAZOLE, metroNIDAZOLE, 500 mg T DS. So which antibiotics. Will you prescribe for an IV to oral switch? Just gonna release the pole now? OK. I'm just gonna give you a few more seconds. OK. So it seems like D which is Doxy Doxycycline and metroNIDAZOLE is the most popular option followed by B which is amoxicillin and Clarithromycin. OK. The correct answer is A. So, Ciprofloxacin and metroNIDAZOLE. So if we go through why it isn't the other options. So, um it wouldn't be b um, so amoxicillin and Clarithromycin is commonly given to patients who have community acquired pneumonia. Um Usually when that her 65 scores around a score of two. you wouldn't give c um because he's penicin allergic. So you wouldn't give him the Coamoxiclav. Um And usually we only give oral camox ala once the patients on IV Coamoxiclav, uh it's not d because Doxycycline and metroNIDAZOLE is usually treated. Uh, it's a treatment for animal bites for patients that are penicillin allergic and it wouldn't be flu uh flucloxacillin because that's usually used for skin infections like cellulitis. Um So this is just showing you, um my local trust guidelines which shows that uh in the case of um intraabdominal infections, appendicitis, diverticulitis and peritonitis. Uh if a patient is prescribed Vancomycin, Gentamicin and metroNIDAZOLE and um, you know, they're clinically improving their bloods are improving, you would switch to oral metroNIDAZOLE, uh, as well as uh oral ciprofloxacin. Yeah, I hope that makes sense. Ok. Um, we'll move on to the next case, if there's no questions for the previous case. Ok. Um, so case four, a 40 year old male presents with severe epigastric pain radiating to the back, which is worse on lying down alongside, uh, nausea and vomiting. He's being managed on a surgical ward with IV, fluids, painkillers and antiemetics. Um, sorry if they weren't penicin allergic, what would you do? Uh Sorry, let me just go back. So, um, essentially, if the patient wasn't person allergic, they would be put on, uh they would be on IV Comox ala to begin with. And once they clinically improved, you would switch to oral coamoxiclav. So you'd give them 625 mg, oral coamoxiclav, uh T DS for a duration of seven days and I hope that helps. Ok. Sorry. Um So case four, a 40 year old male presents with severe epigastric pain radiating to the back, which is worse on lying down alongside, nausea and vomiting. He's being managed on a surgical ward with IV fluids, painkillers and antiemetics. And he's awaiting a cholecystectomy uh because his pancreatitis is secondary to gallstones and the CT is suggestive of pancreatic necrosis. Uh and he has no known drug allergies on examination. He's alert. His respirate is 18. His oxygen starts on 97% on room air. His temperature is 38.2. His BP is 100 and 10/70 his heart rate is 100 and 40 BPM. The surgical consultant suspects that he's developed sepsis and asks you to start antibiotics. Um, which antibiotics were you prescribed for his acute necrotizing pancreatitis? So I'm just gonna start the p ok. Mhm. Ok. Someone's come for a yes. Ok. Someone's come for a pee as well. Ok. So it is the most popular option. Uh, and 20% of people going for B and D. Ok. Then, ok, I'll go through and show the answer now, then. So the answers. B So if we quickly talk to you, why it isn't the other options? So, a amoxicillin, Clathromycin and omeprazole. So that's the triple therapy used to treat H pylori infection. Um If we go through white, not C So cefTRIAXone, 2 g. IV BD is the treatment for meningitis. Uh If we go through why it's not D So, Ciprofloxacin and metroNIDAZOLE um is first line for patients with acute necrotizing pancreatitis who are allergic to penicillin. Uh This patient isn't allergic to penicillin. So this wouldn't be first line. Uh E is amoxicillin. Um 500 mg per oral T DS. So, uh it's not e because this is used for patients with a community acquired pneumonia. So, if I show you uh my local trust guidelines for acute necrotizing pancreatitis. So first line is cephalexin, uh plus metroNIDAZOLE and only if the patient was pe penicillin allergic. Would you give Ciprofloxacin and metroNIDAZOLE? Um Just to let you know in cases of acute pancreatitis. We don't routinely give antibiotics but in this patient, sorry, in this case, because this patient has acute necrotizing pancreatitis with suspicion of infection. We would start antibiotic treatment. Um I hope that makes sense. Uh Any questions for this case? Ok. If not, I'll move on to the next one. So case five, a 63 year old male presents with colicky generalized abdominal pain, vomiting and constipation. Ct scans show small bowel obstruction, secondary to adhesions. Um NG tube has been inserted and been catheterized and prescribed analgesia and antiemetics. Um Some bloods have been taken. Um His sodium's uh 140 within normal range. His potassium is 2.2. Uh It's very low. Um His urea is 5.8 which is within normal range and his creatinine is 62 which is within normal range. So write a prescription for one IV fluid that is most appropriate to treat the patient's hypokalemia. OK. I am just gonna start the pool now. Um So it seems like B and E are the two popular options. OK. OK. Um So 83% of people have gone for E and 16% of people have gone for B. So the correct answer is uh C OK. So if I talk to you, why it isn't the other options? So, a which is calcium chloride, 10% IV 10 mL over five minutes is what we prescribe initially for patients with severe hyperkalemia. So, when the potassium levels are very high. Um And this is to protect the heart. Uh It's not b because B uh which is glucose, 20% I va 100 mL over 15 minutes is what we prescribe to patients that have severe hypoglycemia. Um It's not d because um D which is calcium gluconate, 10% IV, 20 mL over 10 minutes is what we prescribe to patients that have severe hypocalcemia or patients that have severe hyperkalemia. So, when the potassium levels are high, um and it's not e because um if you um see the BNF and the nice guidelines, um they say that initial potassium replacement should not involve glucose infusions because glucose may cause a further decrease in the plasma potassium concentration. So the correct answer is c in this case. Uh So just to show you um in the B NF, it says that first line for severe hypokalemia is potassium chloride with sodium uh chloride. And again, they said initial potassium replacement should not involve glucose infusions because glucose may cause a further decrease in the plasma potassium concentration. Um So the maximum rate that you can give uh potassium without ECG monitoring is 10 millimoles per hour. Um And the potassium 0.3% by contains 40 millimoles of potassium. So the quickest you can give potassium without ECG monitoring is over four hours, which is why the correct answer is sodium chloride, 0.9% potassium chloride, 0.3% solution I va 1000 mL over four hours, which is option C OK. Any, any questions for this case? OK. If not, we'll move on to the next case. Uh And, and, and don't worry, um the, the slides will be available after the talk as well. So you can go through things. Uh you can go through the recording and uh go through the slides at your own pace as well. Uh OK. So case six, a 48 year old man presents to A&E with a wound on his right lower limb. He reports severe pain, swelling and has noticed worsening black discoloration around his wound. He also reports having a fever tiredness and his wife noticed that he's become acutely confused. Uh in terms of his past medical history, he's diagnosed with type two diabetes for which he takes Metformin 500 mg uh per oral and he has no known drug allergies. He's referred to the orthopedics and they diagnose him clinically with necrotizing fasciitis and he's put on the list for urgent surgical debridement. Um And in the meantime, the orthopedic surgeons ask you to prescribe him antibiotics. So the question is, which antibiotics were you prescribed for his necrotizing fasciitis? I'm just gonna raise the bone now. So, so far everyone's going for a OK. Give you a few more seconds. Ok. Yeah. Ok. So, so far, uh everyone's gone for 100% of people gone for a uh which is the correct answer. Um I'm just going to quickly talk to you why? It's not the other options. So, b uh it's not B because Clindamycin 300 mgs per oral Q DS is um used for treatment of facial cellulitis uh with no intracranial involvement in patients that are penicin allergic. Um And it's not C because Levofloxacin 500 mg, IV BD is used for uh facial citti with intracranial involvement in penicillin allergic patients. And this is uh according to my local trust guidelines, uh it's not d because nitro uh 50 GQ DS is used for patients with UTI whose eg fr is more than 45. Um and it's not chlorophenol 1% eye ointment um because this is treatment for conjunctivitis. So, yeah, so like everyone's said correctly, um You'd give Clindamycin and meropenem and the patient would require urgent surgical review. Um So just to, I just wanted to mention a bit more about a necrotizing fasciitis. So it's a life threatening condition. Um It's commonly caused by group a streptococcus bacteria and it tends to enter the body via breaking the skin. Um It's a kind of a rapidly progressive infection and it tends to involve the deep subcutaneous tissue and fascia and it tends to cause extensive necrosis. Um which is why if we just quickly go back to the uh to the case, the patient's having worsening black discoloration around his wound. Um It can present similarly at cellulitis. So with swelling and erythema, but it tends to be caused by cellulitis. Um patients tend to present with this intense pain out of proportion to the injury. Um and sometimes the patients can have pus discharge and blistering around the co a wound bite or a burn. Uh patients also have uh uh systemic uh symptoms like this patient who had fever and was acutely confused and risk factors is being immunocompromised. So, in this case, the patient has type two diabetes. Um and this is a, you know, a fatal condition. It can cause septic shock, organ failure. Uh and um it can potentially lead to death. So, if suspected uh in your clinical practice, do escalate urgently um and to your seniors and refer to the orthopedics team as well. Ok. So we're just gonna move on to case seven if there were no questions um about the previous case. Ok. So case seven, an 80 year old female presents to a knee with pain in her left knee and she presents also with a fever or examination, her left knee of her left knee, uh it's red tender, it's painful, um warm and swollen and there's also a reduced range of motion. So, in terms of her past medical history, she's got cirrhosis uh for which she takes rifAXIMin. Um And so rifAXIMin is used um it, you know, in patients with um um so cirrhosis as well as lactulose which helps prevent encephalopathy and spiron lactone, which is used for ascites and she's got no known drug allergies. She's referred to orthopedics who conduct a joint aspiration and have advised you to start antibiotics for septic arthritis. Uh She's put on the list for surgical joint irrigation and debridement. So the joint irrigation which would be washing out and debridement, which would be removing any damaged tissue. Uh which antibiotics would you prescribe, prescribe for her septic arthritis? Um And I'm just gonna release the poll. Uh So this is our, our last case for today. Mhm. Ok. I'm just gonna give it a few more seconds for um more responses. Ok. So 83% of people going for D uh and 16% of people going for C uh So the correct answer is the uh flucloxacillin. So I'll just talk through. Why isn't the other options? Um So a which is Comox 1.2 g I VTD. S uh is used for intraabdominal infections in my local trust and it's not b because Erythromycin 500 mgs per oral BD is used for mastitis in patients that are penicin allergic. Um and it's not C which is Ciprofloxacin 500 mg BD uh because it's used for prostitis. Uh and it's not e cefTRIAXone 1 g IV once daily. Um because this would only be correct if you suspect septic arthritis secondary to gonorrhea. So gonorrhea would be more common in otherwise healthy young, uh sexually active people. Ok. So again, just to show you on the left the nice guidelines which show uh flucloxacillin and also uh to the right, my local trust guidelines which shows flucloxacillin 2 g VQ DS. Yes. No. OK. Um So these are just uh the references that I used. Um and this is a feedback form um which I'll put into the chart now. Um And just if you guys could kindly take the time to complete the feedback form, it will help guide our future sessions. Let us know what we've done well, what we could improve in and it also help you claim the attendance certificate as well. Um Thank you very much. Um Was there any questions from today's talk? Mhm. And I hope you found today's session useful. Um Next week's session will be on surgical emergencies. Part two, which will be delivered by Doctor Hermione J. Thank you. Thank you very much.