In the final episode of our surgical series, we will be discussing how to recognise and respond to common surgical emergencies that you will encounter as a surgical FY.
Surgical Series Episode 4: Surgical Emergencies
Summary
This on-demand teaching session, presented by Dr. Savana, offers an in-depth look into surgical emergencies, specifically bowel obstruction. Throughout the session, participants will go through clinical scenarios and will be encouraged to interact and ask questions. Aimed particularly at medical students and professionals planning a career in the NHS, this webinar is designed to build a community, offer support, and equip them for their future medical career. Relevant investigations and management pathways will also be discussed, offering a comprehensive understanding of various surgical emergencies. The webinar is part of a series presented by B isa, an organization dedicated to supporting international medical students in Bulgaria.
Description
Learning objectives
- At the conclusion of the session, learners will be able to correctly identify the symptoms of a surgical emergency, such as a bowel obstruction.
- Learners will understand the importance of a thorough medical history and physical examination in identifying the cause of a patient's symptoms and forming a diagnosis.
- Students will be able to describe the various causes of bowel obstructions and understand why immediate intervention is necessary in the case of a closed loop obstruction.
- By the end of the session, learners will understand the steps in managing a patient with a bowel obstruction, including essential recommendations like nil by mouth, administration of IV fluids, and arranging for emergency surgery.
- Participants will learn how to interpret relevant laboratory results and imaging studies to confirm a diagnosis of bowel obstruction and assess the patient's surgical risk.
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All right. Hello everyone and welcome to our last episode of the surgical series. Um This webinar is part of a series designed for new doctors and medical students who are considering a career in the NHS. And today's topic is surgical emergencies. Um Quick thing about B isa our aim is basically to build a more connected community for international medical students in Bulgaria and make it more accessible for students to reach out for help and support. And we understand the unique challenges faced by Im GS studying and graduating from Bulgaria. So our goal is to simplify the transition to professional practice and equip you for your medical career. And I'd like to introduce our presenter for the surgical series, Doctor Savana. He is a foundation year two doctor, having completed his medical training at the University of East Anglia and is approaching the end of his foundation training in the East of England Deanery. And today will be interactive. So please don't hesitate to leave any answers in the comments section and please uh join me in welcoming doctor Savana. Hi guys, thanks for coming. Um Thank you, Simon. Er So yeah, like like Simon said Um, I'll be your, um, kind of, er, speaker for this evening. Er, we're going to be covering, er, surgical emergencies. Er, so if we could, could go on to the next slide. So what I'll do today is just cover a few different cases. Um, we'll just kind of do some clinical scenarios and, yeah, like Simon said, just feel free to interact, you know, get your mics on or if you don't feel like putting your mics on, um, drop a message in the chat, it might be a bit easier. And um, yeah, we'll just go through each case and at the end, you can ask any questions if you, if you'd like. Perfect. So we'll start with the first case. So this gent. So the first case is a 75 year old gentleman who's presented to the surgical assessment unit with sudden onset of abdominal pain and vomiting. So when you ask a bit more about the pain, he says that it's very severe. It's crampy in nature. He feels like his abdomen is distended. And in terms of his past medical history, he's got diabetes, he's got gallstone disease and in terms of his past surgical history, he's had a previous laparotomy for bowel cancer. So you've done your kind of basic history. What, what are you, what do you do next? What would you guys do in that? Um, once you've taken the history? So you, so after you take your history, you want to do an examination and you want to get some observations as well. So if we go on to the next slide, uh so you do the observations. Um so they get done whilst you're speaking to the patient and you look at them and the heart rate's 100 and 10. So the patient's tachycardic, er, they're maintaining their BP um at 100 and 35/90 they're slightly tachypneic um, with a respirate of 22 and their temperatures are normal. So when you examine them, uh, you focus on the abdomen because they've come in with abdominal pain. Um, and you find that their abdomen is distended, the pain's all over the place. It, it's not localized to one particular area and when you listen for bowel sounds, you can't hear any. So, given the, the history, the past medical history and the examination findings, what differentials are you guys thinking about at the moment? B obstruction? Absolutely. Absolutely brilliant. So, peritonitis. Yep. So, um, so bowel obstruction is a really good one. What, what in the examination findings that you would point towards, um, bowel obstruction, would you say? Yeah, previous surgery and absent bowel sounds perfect. And so, ii know you said peritonitis, um, so maybe the generalized abdominal pain would, you know, maybe indicate peritonitis? Um, brilliant. So if we go on to the next slide, we do some investigations. So with investigations, you start with the thing, the easy things first. So get some blood sent. So you send some bloods and you find that the white cells are 11. So it's slightly elevated C RP is 100 and 50. So it indicates there's some inflammatory process going on and you find that the lactate is 4.5. So you guys have mentioned this already, but what might the these bloods indicate uh brilliant infection and ischemia? So there's, you know, the white cells are elevated CRP is elevated. So there is some kind of inflammatory process going on and because the lactate is up as well, that means when the lactates up whenever you do uh blood gas, it might mean one of a couple of things. So either the patient's dehydrated, um they're septic um or, you know, there's ischemia going on. So that will this will all tie in a bit later. So given all of the, you know, the history, the examination and the initial bloods, what do you want to do next? What w what imaging do you want to do? So, yeah, you, so you could do act um 00 sorry, you could do an X ray, sorry. Um But I think given, you know, the um the kind of the, the lactate is quite high, essentially um a lactate at 4.5 is fairly high. So you want to maybe get an act straight away to um kind of look for the kind of the, the things you mentioned in the in the chat. So, um but an X ray would also potentially be a good place to start. Um For example, if you had a perforation, you'd notice um you know, free air under the diaphragm perhaps. But I think in this case because the, you know, the patient might be quite unwell because of that because of what the lactate is. Go for act. So if you go on to the next slide, so you do act and it shows it shows this. So in summary, the report is dilated loops of small bowel with gas fluid levels, two transition points along the course of the small bowel. Er, and they are signs of a closed loop obstruction so well done to everyone that said bowel obstruction. Um, this person has a, um, bowel obstruction present. Um, if you could go onto the next slide, please. So you confirm the diagnosis of bowel obstruction, like I said, does anyone know what a closed loop obstruction is? Yeah, brilliant. So I think very simply like, like you said, so, I mean, it's an obstruction at two different points. Um, so if, so you, I guess the, the definition is, um, an obstruction in which, you know, there's two points of obstruction along the course of the bow, um, at a single location and then that forms, er, a closed loop. So that's the definition of bowel obstruction. Um, they closed loop obstruction. Um, so that's what's causing this man's symptoms, um because of the lactate, um, the fact that there's an obstruction, it might indicate ischemia, like I said, so it's part of the bowel might, might be dying due to the blood supply being um affected by the obstruction. So I think someone said this already, but what may have pre predisposed this man to being obstructed? There was something in the adhesions, brilliant. So, adhesion or bowel obstruction secondary to his previous laparotomy for his bowel cancer. So, it's, it's one of those things to, you know, when, when you have a kind of surgical issue, you might want to go and operate, but that might predispose you to, you know, getting obstruction in the future. So now we know what it is. How do you think we're going to manage the obstruction? Yeah, we could, we could resect the bow. Absolutely. Yeah. Surgery. Yeah, perfect. So, nil by mouth. Absolutely. Especially if you want to take the per person in for surgery. IV fluids in the meantime. And because of, um, so th in this person, the, er, bowel obstruction was in the small bowel. So, um, you know, if the person is vomiting, you might want to put an NG tube in as well, which is decompress the bowel. Brilliant. Um, so there's this kind of technique called drip and suck for small bowel obstruction. You, the drip is, uh, you give IV fluids and the suck is the NG tube. So you decompress the bowel, um, brilliant. So, if we go on to the next slide, so, like I mentioned, you put an angio tube in, you catheterize a patient, you get, um, you have IV fluids and analgesia, don't forget analgesia. Um, and because of the fact that it's a closed loop obstruction, uh, you book the patient for emergency surgery. So closed loop obstructions, um, because they're obstructed at two points might be, you know, you, you want to relieve that obstruction because there's, there's, there's probably quite a high risk for perforation. So, um, you know, absolutely. Take them to the theater if it's closed loop obstruction. Um, obviously the decision to take them at the theater depends on a lot of other factors as well. So you want to look at their functional status. Um, you wouldn't if someone that was 90 years old with, you know, that had, um, a previous M I and, you know, had a coronary stent, um, you know, hypertension. Um, oh, obstructive sleep apnea came in. You probably wouldn't want to operate on them because they'd die probably during the anesthetic procedure. But, um, someone that was a bit younger fit and well, then they'd be a more likely candidate for surgery. Brilliant, well done guys. So I think everyone here, um, checked in with some good answers. Uh, so I'll just quickly go over bowel obstructions, which is on the next slide. So, like, like the name suggests, it refers to a mechanical blockage of the bowel. Um, it can affect the small and large bowel and like I said, the, um, the adhesions are one of the causes. Um, otherwise you can get, uh, bowel obstruction, secondary to strictures. Um, because of IVD, for example, um, hernias, so hernias can get obstructed, uh, malignancy, obviously causing mechanical compression of the bowel, diverticular disease and bulbous as well. So it's when the bowel twists on itself. So the features of bowel obstruction, er, there's obviously going to be pain. It can be quite a, um, almost a colicky pain because, er, the bowels almost like contracting to try and push this. Um, you know, um, the stuff along past the obstruction, which I obviously can't do, er, vomiting is, um, you know, quite, is quite an early sign in small bowel obstruction, maybe a later sign in large bowel obstruction. The abdomen can get distended and obviously, and the patient will be constipated. They'll have, they'll have absolute constipation as well. So they won't be passing stools and they won't be passing flatus either. So, whenever you see someone and they've got abdo pain, just asking whether they've, whether, whether they're, you know, passing stools, passing flatus is a good, um, kind of indicator of, um, you know, whether, whether they're obstructed or not. Um, so in terms of investigations, um, the easy things first. So bloods, um, including a B bga venous blood gas, so you can get a lactate lactate is very important. Um And don't forget to send things like a group and save and cross match as well. So that if they do need to go to the theater, you've got all those um all those bits of information on file. Um And the ideal imaging is act uh with contrast because it gives you a lot of detail and you can see where the bowel is obstructed really well, an X ray is, um, you know, it, it's probably a fair initial investigation. But, um, if you're, but if you want detail and you want to see exactly where the obstruction is act would be, would be better because when you go into the operating room, you want to see where the obstruction is. So you can, um, do your, you know, get to get to your, um, the place where it's an issue, um, management, like I said, er, ng tube to decompress the bowel IV fluids, um, to keep the patient hydrated whilst, um, they can't eat anything, um, a catheter for, you know, in input output monitoring. So keep a note of, um, keep a strict, in strict input output chart. So you can have a lot of third spacing so the fluid can leak into the third space, um, with bowel obstruction and then, you know, obviously keep them nil by mouth. If there's an obstruction, putting stuff in orally is not going to help the obstruction. So you want to relieve all the, the, the pressure um with an NG tube. Um So, you know, keep the nn by mouth. Um, and then, you know, s surgery if there's a closely of obstruction, evidence of bowel ischemia, uh all the cause requires surgical intervention. So, you know, like malignancy or hernia, for example, um brilliant. And then, like I said, the complications you the bowel can get ischemic because the blood supply is affected what the um obstruction is present. And yeah, obviously, if the pressure builds up the bowel can perforate as well, so you can get intraabdominal sepsis and the, you know, the patient can get very ill from that. And also, you know, it puts them at the risk of death. Brilliant. So that's case one goes well done. Um So now we're gonna, before we move on to case two, does anyone have any questions about bowel obstruction, bril? Ok. So we'll move on to case t so in case two, so a 64 year old gentleman presents to A&E and that's this is with severe abdominal pain which radiates to his back. Um, he also had a syncopal episode on the way to the hospital. So this came on rapidly and it's never happened before in terms of his um past medical history, he's got hypertension, he's got high cholesterol and he's a smoker. So you've done your history. Um What do you want to do? Now, I will caveat this by saying that you obviously in real life, take a more detailed history. Um Yeah, I'll check the, check the BP. Absolutely. So if we go on to the next slide at, yeah, absolutely. So, yeah, brilliant. Well, yeah, really good answers guys. So, um I think a general point I, I've kind of condensed all the, um, you know, assessments just for the purpose of this talk. But with any, any time you get asked to review a patient just do an A to E um so it's methodical, it's thorough and you don't miss anything out. But obviously I've just condensed everything for the purposes of this talk. So you do your robs and I've just put the um kind of pertinent ones on this slide. So the blood pressure's 90/60 his heart rate's 100 and 15. So the man is hemodynamically unstable because his, his BP is low. He's hypertensive and he's tachycardic. It's always quite a bad sign when someone's heart rate is higher than their systolic BP. You know, the cardiovascular systems really um kind of is working really hard to maintain their um maintain circulation. So, um because this man had abdo pain, you examine the abdomen, so it's extremely tender and you feel a pulse to a mass, er, quite near the middle of the abdomen. So at this point, what, what, what's kind of your red flag? What, what's so aortic dissection and a AAA? Absolutely. Absolutely. Well, done to say, um, obviously your aorta runs through, um, you know, thr kind of down your abdomen. Um, when you feel a pulse, oral mass in the abdomen, you worry about a ruptured AAA. Um Perfect. So given, given this, um, you know, what, what exam, what investigations do you want to do? Yeah, so a CTA. Absolutely. Um, so we'll get onto that in a second. So if we get you to go on to the next slide for the time being, um So, you know, by the time you get, by the time you get to A&E the bloods are done, so the hp is 80 which means, you know, the per the person's likely lost some blood and the lactate is 3.5. So, um you know, there's, there's volume loss there. Um So getting back onto the imaging um Simon, you mentioned the CTA. So that's absolutely the right answer. So, um we've mentioned this already, but what are you looking for on the? Um I pull it out. Yeah. Point of care. Ultrasound. That's a great answer. So, um in A&E a lot of clinicians are trained in point of care. Ultrasound. It's a really good, quick way to look at all the major organs really quickly and efficiently. It won't give you lots and lots of information, but it will help you rule out um certain pathologies er quickly and efficiently. So you basically do a focused look of the major organs of the lungs. Um you know, you're looking for any um kind of pneumothorax, effusion. Uh you look at the heart for any kind of uh kind of tamponade um or any bar issues, um any um kind of um intraabdominal organ injury and um uh you, you can look at the aorta as well. So pocus is a great answer. In fact, if you go on to the next slide, the the clinician in uh A&E has done a pocus. So this is what you see when you look at the aorta. So what, what can you say? Yeah, so I mean, I guess the basic principles of an ultrasound, the you, you, well, I said it before this is the aorta. Um So you can see the lumen is uh or, you know, it's, it's outlined by the, the black bit here, obviously, for a normal aorta, you'd um you'd want to see just a, a black circle just indicating that the er wall of the aorta is OK. But you can see this like hyper um lucent stuff just around these sides. So that might be a, like a clot um from where the um you know, the bloods kind of burst out of the aorta and clot. So, you know, it could be a dissection as well. Um So it basically tells you that there's some kind of pathology going on in the aorta. Um So, whilst the purpose is, you know, it's obviously told you and the aorta is the issue. You want to do some further imaging. And this is where the CT angiogram comes in. It tells it, it scans the, you basically push some dye into the um into the vasculature. And then when that circulates, you'll be able to see the exact point at which the, you know the um in the aorta where there's a dissection or where there's a rupture. So if we go on to the next slide, so, yeah, you can, you could say, so you do the CT angiogram and it says this. So in the left posterolateral wall of the lower lobe of the bilobe er ab abdominal aorta, there is contrast extending into the wall in keeping with an acute intramural hematoma. So, so this this uh this this aorta is aneurysmal. So you can tell it's quite big. Um and the, the the contrast is basically leaked into the wall. Um and it's, it's in keeping with blood that's basically kind of being lost from the AORTA. So this person's got a ruptured AAA um which is obviously a surgical emergency. How do you want to manage this vascular surgery? Absolutely. Yeah, brilliant open surgery. Great, great answers. So if you were in A&E you would, you know, if you got the report, the radiologist will recall you before the before submitting the report, just to say this person's got a ruptured AAA at that point, you know, you want to get vascular surgery involved very quickly. Um In the meantime, you want to keep the person stable. So make sure they've got access, make sure they've had their, you know, all their group and save cross match. Um, you might want some blood as well depending on their hemoglobin. Um, you want to get this person reviewed by vascular surgery as quickly as possible and if they're fit enough, they need to go for go to the theater for open repair of their AAA. Brilliant. So if we go on to the next slide, like I said, urgent massive surgery review and theater for an open triple AAA repair. Um So with, with, with a ruptured AAA and an er, wouldn't be suitable, you need to open the person up. Brilliant. So I'll just talk a little bit about triple uh triple A's rupture AAA. So if you go on to the next slide, so a AAA stands for abdominal aortic aneurysm. And what this means is that the abdominal aorta is basically dilated greater than three centimeters. So, the er, the risk factors for this include smoking, hypertension, hyperlipidemia, er, family history and being male. So if we think back to this person that came in, er, that they were a smoker, uh I think they were hypertensive um and they were um hyperlipidemic as well and they were male. So they had all the quite a lot of risk factors for um er, for a AAA ruptured trip for a AAA, sorry. Um, so usually, I mean, depending on the size, people are largely asymptomatic for AAA S. Um, and they're usually found incidentally on screening, um, because they're, er, asymptomatic. Um, and, you know, they, they can grow quite quickly you want to screen. Um, there's a national screening program for all men aged 65. Um, I won't go into the exact numbers because there's a pathway for, um, you know, the frequency of screening depending on the size of the aneurysm. Er but I would recommend looking it up because um you know, it can be quite useful to know that. Um but it's just worth knowing that the reserve screening program for men aged 65 and over. Um, so then uh AAA S can rupture um when they get to a certain size. So um when, when that happens, you get abdominal pain, um it radiates to the back. Um you can get limb ischemia as well. So if there's um a clot that um w when the AAA ruptures, if you get a clot that flies off, uh because of the bleeding, um and that includes a distal artery, you can get um limb ischemia secondary to this. So it's got a colloquial name, trash foot. Um and then the things like syncope come in when the person's, you know, hemodynamically unstable and um they can get vomiting due to the pain and when you examine them, you'll feel like a large pulsar mass. So, um obviously, IMA if you imagine this aorta's got to be really big and aneurysmal for it to burst, you'll feel it when you touch their tummy. So, like I said, signs of shock, if they ruptured, say, you know, syncope, um and uh syncope being one of the main ones. Um So, if the, the AAA ruptures anteriorly into the peritoneal cavity, it's got a very uh poor prognosis. Um But however, this only happens in 20% of patients, er, the rest rupture posteriorly. So, um in terms of the management, you want to um get IV access. So you probably need two large more cannulas in the um er in as soon as possible. Uh You want to be at least resuscitating with fluids, but you probably need some blood as well depending on how much blood they've lost. Um You might want to put out. Um Actually, no. Um So, yeah, like I said, urgent vascular review and you want to uh intervene surgically if they're fit um complication wise, we talked about trash foot. Um You can get rhabdo. So if there's um you know, if, if there's lots of blood being lost and um the, the, the muscle, the muscles aren't being um kind of fed with blood properly, then you can get rhabdo um major hemorrhage from the source of rupture. And if you, depending on where the um aorta ruptures, um you can affect the arteries that branch off the aorta. So, er, if it's above the renal arteries, for example, you can get um kind of renal artery ischemia. Uh and that can cause, you know, things like an AK I um cos you might get deranged U using when this person comes in as well. So that's trip, that's a ruptured AAA in a nutshell. Any, any questions on that? Brilliant, well done guys. So I think everyone was uh again gave some really good answers for that one. So that, so now we'll move on to Case three, which is on the next slide. So case three is about a 40 year old lady. She's presented to A&E with severe retrosternal chest pain. She appears to be in respiratory distress as well. So when you ask her more about this, she's been profusely vomiting for the last few days. Um you also think she may be intoxicated, you can, you know, maybe smell alcohol on her breath. Um, she looks clammy and very unwell. She doesn't have any significant past medical history. So what are your initial thoughts? A CS? Yeah, that's a common things are common. So that's a, that's a great answer. I know this er, talk is surgical focus but don't even if you are in, in the surgical team, don't forget to um think about all the other non surgical causes of your pain as well. Pe or pneumothorax. Yep. So yeah, again, really good answers. So pe would cause, you know, respiratory distress, it would cause chest pain. Um, and then pneumo pneumothorax would do this as well. Brilliant. Mallory Avior. Brilliant. That's a really good answer. What would, what in the history would point towards Mallory Vor vomiting? Absolutely. So this person's been profusely vomiting for days now and they drink alcohol as well. So it may not be the first time that's happened. So, um, you know, if they're, if they're vomiting falsely, then, um you know, they might have some kind of um esophageal um er kind of pathology going on. Brilliant. So if we go, go on to the next slide, so you do the obs and um the obs show that the person's tachycardic, this lady's tachycardic uh with a heart rate of 100 and 20 the blood pressure's 100/60. Um So again, they hemodynamically unstable. Um the respirate is 26. So there's some kind of lung pathology going on potentially and their temperature is 38.2. When you examine them, they've got delayed cap refill. Um So this can indicate multiple things. It might be sepsis, it could be um cardiovascular compromise, er, or both. And then when you uh listen to auscultate, their lungs, they've got reduced air entry on the left side and they're delta percuss. Um their, their abdomen is soft, non tender. Um and you do notice some subcutaneous emphysema. So what is um, what, what, what do you, what, what do you think is going on, I think it, ok. Pneumothorax. Yep. Yep. That's really good. So, that's Great Boars syndrome. Perfect. So, there's a, there's a couple of things on here which kind of point towards boar harvest syndrome. So, um, you said Simon that you think they might have a pneumothorax? Yeah, that's really good. So, they've got reduced air entry on the left side and they're delta percuss as well. Um, and the, the, the worry is um that they've got subcutaneous emphysema. So, does anyone know what that is? Yeah, great, great, great job Helen. So yeah, it's air under the skin. So, um you know, this obviously, if you look at most people's skin, no air under the skin. So if this happens, you know, something really serious has gone on. So there's just air getting in through the subcutaneous tissues, um which is usually indicative of um you know, um ball hars. So if we go on to the next slide, uh so, you know, we do bloods because it's quite a quick investigation shows raised white cells and raised CRP. So it's indicative of an infection, sepsis, inflammation. Uh HP is 100 so slightly anemic. Um So they've lost some blood potentially and the ECG shows sinus tachy and what imaging could you do at this point? I mean, there's multiple imaging um modalities you can do chest X ray. Great. So uh that's a really quick um thing you can do, especially if you're in A&E um, you can do a portable chest X ray whilst um, you know, you're arranging maybe, maybe other um er, imaging modalities. So it will obviously show you some, you know, er, it was a quick way of kind of ruling out some major lung pathologies such as pneumothorax, effusions, uh pneumonia. So, yeah, that's a really good one to start off with and you can do act as well because, um, you know, this person's got, you know, abdo pain you're worried about um war harbors. You want to image the um the esophagus as well. Brilliant. So if we go on to the next slide, so, like I said, you, uh like you guys said, um you do a, you can do a chest X ray first. So this shows a left sided pleural effusion, uh pneumomediastinum and gastric distension. So, um and then if we go on to the next slide after this, uh we do act after that. So we see a left pneumothorax and pneumomediastinum with gas noted around the esophagus and bilateral pleural effusions. So, uh oh II II don't know if my cursor is coming up on, on your guys screens, but um you can see all these different pathologies on, on the CT quite, quite well. So the pneumothorax you can see is um kind of at the top of the um can't see the cursor. Ok. I'll just have to try and er point it out by describing it but if you look at the top of the left lung, um you can see that kind of area of black. Um, so you can, you can tell that there's a bit of a gap between the lung lung, parenchyma and the, er, the pleura. So, um air is basically accumulated in the pleural space. So that's the pneumothorax there, top of the, um, the, er, left lung and the pleural effusions, um, it's more significant on the left. So it's kind of that, um, gray, um, kind of dullness at the, at the bottom of the, er, this slice of the, um, left lung and there's maybe a tiny polar fusion on the, uh, the right side as well. And the, er, esophagus um, is basically in the, the, the middle of the chest wall, I guess. And all the black bits that you can see the, um, the kind of gas around the esophagus. Um, and that's obviously, um, there because the esophagus is perforated and there's, it's causing air around the, um, around it. Um, brilliant. So I know he, you mentioned this already but um, this all indicates boar Hars. So now, you know, Boar Hars, how are you, how are you treating it? Uh, so IB PPIs maybe, maybe less, less say IB PPIs. So if we think back to the bloods, um, or even the observations, let, let's start off easy. So, yeah, IV fluids, no mouth IV antibiotics. Perfect. So, um, you know, the w the worry is, this person is septic because of their boars. So, the, the stuff that's in your esophagus, you know, doesn't belong in your, um, mediastinum or around your lung, parenchyma. So, um, with that you can get a lot of, um, you know, a high chance of infection when that happens. So this person might already be septic based on the bloods and the observations. So, um, at the very least they need IV fluids. So, you know, do your sepsis six. you want, you want to um take three and take three things and give three things. So uh you want to take uh blood cultures. Um you want to take um oh, so like cultures um lactate and um yeah, so uh catheterize and then in terms of give you um give fluids, antibiotics and um uh by oxygen as well. So, er yeah, sepsis six as um as for any patient and then antibiotics. Um there might be different protocols depending on what trust you work for, but follow your guidelines. Um It, it's, it will usually be some kind of broad spectrum antibiotic with some good cover. Yeah, Comox would be a good one. It's um you know, you might want to um combine this with um something like metroNIDAZOLE and Gent. Um Yeah, brilliant. So, so Comox Club would give you the gram positive cover. It's got maybe um it's got maybe some gram negative cover as well, but you can get that with something like, um, er, vancomycin and anaerobic cover is, um, covered by the metroNIDAZOLE. So IV antibiotics. Um, how likely is media ST Stennis in this case? It's probably quite likely because, um, you know, imagine all, all this stuff that's not meant to be there is now there and with that comes, um, you know, a very high risk of infection. So it's probably very likely there's some element of media stenosis. Brilliant. Well, and guys, yeah, brilliant. Um So Comox, you know, it's got a little bit of anaerobic cover as well. Um Which is why you can give it for things like UTI S um brilliant. So if we go on to the next slide. Um So, yeah, in terms of managing boar harbors uh IV fluids, IV antibiotics, um, you can give anti antifungals. Um It's something I found online. I'm, I'm not too sure how commonly it's given, but I just like to check it in anyway. And you want to get the thoracic surgeons on board, er, very quickly, see if there's any um kind of um interventions they want to do or maybe the um upper gi surgeons. Perfect. Um So now we'll just talk a bit about boar harvest. So, if you go on to the next slot. Perfect. Thank you. Yeah, absolutely. Brilliant. Um So ho is, um when the esophageal wall ruptures and it, it's a full thickness, um, er, it's a full thickness rupture of the esophageal wall and um when someone is chronically vomiting, um they're really for um ejecting their gastric contents against the um unrelaxing, um e er esophagus, um and the um relaxed sphincter. So these tears occur vertically and when, when this happens, you get retrosternal chest pain, um respiratory distress, subcutaneous emphysema, which is quite a rare complication of it. So it doesn't always happen. Um and this always follows, you know, very severe vomiting, retching. So, um like I said, the patients can be septic due to the gastric contents entering the mediastinum. Er hence why um mediastinitis is um a very real possibility um in terms of investigations, er, bloods, chest x ray, er CT act abdomen pelvis, um with IV and oral contrast um like was like, like it was done in this er case. So I guess when you do oral contrast, you can look for um the contrast um leaving the esophagus um because of the um the rupture. So that will give you a good idea of where the ruptures happened. Um And if you're in, if you're in theater, you can also do an on table endoscopy as well to look for the size of the perforation. Um So, stabilize a patient with um IV fluids, IV, antibiotics, uh antifungals. So, thank you, Helen. Um So common source of um er so ca Candida is a very common source in the esophagus. So that's why you give the antifungals. So that makes sense and then you want to basically um wash out the, the contamination and um maybe put in chest strains as well. Um If there, if there's a pneumothorax. Um So yeah, that's, that's bo harbors um any questions on that, it's I will say it's not something I commonly encounter but um it, you know, it is something to bear in mind and it's also kind of cool as well. Cool, great job guys. So some, yeah, some really good answers in there. Very impressed. So I'm just gonna move on to the last case now. So if we could go on to the next slide. So, um last case is about a 45 year old gentleman. He presents with an abdominal lump and this is extremely tender. He says he's vomited a few times. Um, and he's had this lump for over a year now, but it's suddenly become very painful. He works in a warehouse by, um, um, you know, he works in a warehouse and his day to day job is lifting heavy objects. Uh, in terms of his past medical history, he's got type two diabetes and he's overweight as well. Um He's not, he's never really bothered to um, get this lump checked out. But uh, but he's now come in because it's suddenly very painful. Um What, what are you guys thinking at this point? Great answer, Simon. Absolutely. So perfect. Well, and to me, so, um, yeah, so this man's got a couple of risk factors for an abdominal hernia. So I think the fact that he's um overweight and he works in a warehouse, lifting heavy objects are probably his biggest risk factors. So this, you know, maybe a lot of people do get hernias, but they're not always a problem. So um hernias can sometimes be reducible, they can sometimes be incarcerated and they can sometimes be strangulated. Um So I'll go into the specifics of each one later. But in this case, what are the more co what, what, what do you think's going on? Is it um reducible? Is it incarcerated or is it strangulated? Actually, you guys have mentioned it. Um So yeah, strangulated and incarcerated. So it's, it's definitely one of those two. It's not um it's probably not irre er reducible because if it was reducible, it probably wouldn't be causing him this much pain. But anyway, we'll work through this case. So let's go on to the next slide. So you, you do his observations, um his heart rate's 100 his blood pressure's 100 and 28/85 and his temperature is 36.8. So nothing, nothing too major. Um He's maybe slightly tachycardic but otherwise he, his observations are fine. Um as diligent doctors, you do your um exam, clinical examination. So you examine the lump. So the lump is around his umbilicus, it's very tender to touch, you can't press it down um at all and whenever you try he's, you know, like he, he's in a lot of pain. Uh, there's also an area about erythema around the lump as well. So you guys have always said what you think it is. So, this is a hernia and at the very least it's incarcerated. So, what investigations are you doing at this point? Bloods. Yeah, absolutely. And CT as well. Great. So, bloods, um, will tell you if there's any kind of in, you know, um, uh, infection going on. Um, and you can also do a lactate as well to look for any bowel ischemia, which it will be quite important in this scenario. So, if we go on to, yeah, oscal take the hernia for bowel sounds as well. So, um, your bowel can get obstructed when there's a strangulation, um, or incarceration. So, um, absolutely. Um, listen for bowel sounds perfect. Um, so if we go on to the next slide, so the you do bloods first because they're quick to do. And, um, so, yeah, good, good, good, good point. So you don't always need to do act to, um, kind of diagnose a hernia that's incarcerated or strangulated. In fact, a lot of the times you can just diagnose it clinically, but if you are worried about bowel ischemia, you want to just get some imaging, you want to see if there's, um, kind of any, um, any bowel in the, um, that kind of w where the strangulation is, um, if there's any signs of bowel ischemia on the CT, so that will help you with your surgery as well. And, um, your management generally, um, but generally when it comes to hernias, um, especially the reduce ones, you can just diagnose it, um, clinically with symptoms. Um, cool. So, in terms of bloods, the thing that's standing out is the lactate at 3.5. So, what do you think that signifies to you guys if you saw that, what would you think ischemia? Absolutely. So this bowels obviously stuck, um and the blood supply is compromised, hence why the lactate has gone up. So, you know, this, this, this bowel that's stuck is at risk of um ischemia necrosis. And um yeah, that's, that's quite, that's quite an urgent thing. So, like I said, you want to do some CT imaging, which is on the next slide. So I think this one's quite obvious. So if you look at the, the top of the CT, you can see, you know, there's, you know what looks like bowel there, that should not be there because the stuff on the sides of it is all, you know, subcutaneous tissue, the anterior abdominal wall is actually that kind of thin gray line, which is um kind of below this, you know, this thing that's sticking out. So, uh part of the bowels obviously gone through the anterior abdominal wall and um become stuck. So the C three report says anti abdominal wall defects through which small bowel loops and omentum are protruding out of the abdominal cavity. Mesenteric gas bubbles, mesenteric fat, stranding, mild, a mild amount of free fluid in the hernia sac. The findings suggest strangulated hernia with bowel ischemia. So that's confirmed your diagnosis and given the diagnosis, what, how are you going to manage this? You could resect it. I mean, yeah, if, if the bowels, if the bowel's dead and there's, um, er, you might have to resect the bowel. Absolutely. Um, but in more general terms, you want to take this person to theater urgently, you want to relieve that obstruction just to prevent any bowel, any bow from dy, from dying. Um, er, if not already dead. Yeah, you want to give IV antibiotics, fluids, um, uh, you know, all that stuff as well. Uh, but surgery is very important for this patient. Brilliant. So, if we skip on to the, er, two slides ahead, if that's ok. Yeah. Brilliant. So, uh, I'm just gonna talk very quickly about strangulated hernias. Um, so hernia, general terms is when part of an organ or a tissue protrudes through the wall of the cavity that contains it. So you can get, um, hernias everywhere, um, all over the abdomen. So, um, there could be inguinal, umbilical femoral if you've had surgery before they can, you know, you, you'll have an abdominal wall defect there that's prone to getting hernias. So that's an incisional hernia. Um, you can obviously get, um, hiatus hernias when your stomach goes through your diaphragm. So, you know, multiple different types of hernias and I touched on this before so they can either be reducible. So the hernia pops out, you push on it and it pops back down, er, very easily. Um, usually there's not that much pain. Er, the hernia can be, er, irreducible or incarcerated. So that's the same thing. So the hernia is stuck. Um You can't push it down but it's not yet um strangulated, which is the kind of worst case scenario when it's strangulated, that's when you know the blood supply is being cut off and there's, you know, ischemia and uh necrosis. So, in this case, the hernia was strangulated and like I mentioned before, y you, you diagnose hernias clinically, you don't always need imaging. But if you suspect strangulation, just um you want to book that scan, uh you want to see where it is, see if there's any signs of ischemia on the scan and that will help um er determine your management. Brilliant. So that's, that's the final point. Um And now I would just like to invite any questions. Brilliant. So, first question, can you tell by physical exam if it's strangulated? So, um so strangulated hernia won't, won't be reducible for one, it would be very painful. You might see signs of necrosis um already. So, um you know, you can tell that by the color of the um by the hernia and um it'd be, at the very least it'd be erythematous and extremely tender. Um So, yeah, it, it might be possible to tell if it's strangulated but you want some kind of er, biochemical evidence, you know, by doing things like lactate um full blood count C RP and also um uh uh imaging as well. Well, any, any other questions guys, how often do epigastric hernias strangulate? Um So by epigastric hernias, do you mean hernias that are just in the um epigastric region? Um because um in terms of how often they strangulate, upper midline adominal, say, to be honest, I I'm not too sure how often they strangulate. I've not seen a strangulated hernia myself. Um So I'm, I'm not entirely sure that um I II don't I, I'm not, I'm not too sure if the area makes um that much of a difference, but uh yeah, I'm not too sure. Unfortunately, sorry about that. Great. Thanks guys. If there's no more questions, I'll just hand back to Simon. All right. So before we transition to the Q and A session with uh Doctor Savana, um I'd like to kindly ask for a brief pause to take a moment to fill out our feedback form and you can either scan the QR code on the screen or follow the link in the chat. Um The feedback form is valuable for our presenters who have contributed their free time and resources obviously and um completing this form will help enhance the doctor's portfolio and also enables us to continue offering these talks free charge to students. And after a few minutes, we move on to the Q and A sections, I would say about five minutes and yeah, feel free to leave a feedback. All right. Thank you everyone. Um If anyone has any questions, please feel free to ask them now, very responsive, then you know, um and you brought that BP up and maybe some maintenance fluids and, but especially if there's blood loss, you want to um do a group and save cross match urgently. Um and then get some, get some blood for them as well. All right, if no one else has any questions, um I just wanted to say thank you so much doctor and thank you everyone for attending. It's been really informative. Oh, we have another question. I'm sorry. Yeah, generic question. Uh What's the jump like going from a final year student to being a junior doctor? What are the, what are the biggest hurdles? Uh, the jumps? Um It's not too bad. It obviously depends on what you start on. Um I started on general surgery and yeah, it's uh it's very depending on the job. It can be different levels of um hands on. So, uh on a surgical job, for example, as a, as an fy one, you're a lot of the time you're doing, you're, you're keeping everything ticking over by doing the administrative side of things. So you're doing scribing on the ward rounds, you're booking the bloods, you're chasing up investigations, you're booking people in for, er, endoscopies, that kind of thing. Um, and yeah, you're doing a lot of the chasing admin work when you're in fy two that can, um, change slightly depending on where you're working. So at that point you're, um, in sho, and you're taking referrals, you're going to see people in A&E you're clerking them. Um You may be working on the surgical assessment unit perhaps. Um obviously on medicine, it might be slightly different. So you might be doing ward rounds by yourself on medicine as a, as a um fy one F YT and kind of managing every anything you can and escalating appropriately. So the obvious hurdles are that it's um an unfamiliar environment potentially. Um working is maybe slightly different being a student. There's a bit more responsibility. Um But I think the biggest bit of advice I'd say is um you know, always work within your capabilities. Um So don't be afraid to ask, ask people for help. Um It's always better to ask and to get some advice from a senior if that's on hand, um then to try and you know, do it yourself if you're unsure. Um That way, it's a good learning opportunity and it's better for the patient as well. So it's safe. Um and re resources that II advise for surgery. So, my favorite one that I used, um, at UNI was teach me surgery. That's really, really good. Um, it's, it kind of breaks everything down quite simply and it's, um, concise as well. And I think for, if you're looking at, you know, if you, if you're interested in the scans side of things, um, I use radio pia to get all the scans that I put on this powerpoint. So it's really, really good. It's got the um the scan report on there as well. Um And you know, it, it doesn't teach you how to read scans, but it's quite interesting because you can, you know, see how things might present on things like CT S which can be a bit unfamiliar for people. Um And it's got a, an extensive collection of images on there, so um radio Pia as well. Um But yeah. All right, once again, thank you so much, Doctor Sarana for having us today and thank you everyone for attending. It's been really informative and make sure to join our future events and really excited about seeing all of you again uh for the next events. Have a good evening. Thank you for coming guys. Cheers.