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Core Lecture

Core Lecture. Surgical Emergency Tsung-Chien Lu, MD. GOAL. 1. Recognize different surgical emergencies 2. Learn a correct notion 3. Decrease delayed diagnosis 4. Prevent secondary injury. GUIDELINES. 1. Surgical emergencies 2. Pediatric surgery emergencies

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Core Lecture

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  1. Core Lecture Surgical Emergency Tsung-Chien Lu, MD

  2. GOAL • 1. Recognize different surgical emergencies • 2. Learn a correct notion • 3. Decrease delayed diagnosis • 4. Prevent secondary injury

  3. GUIDELINES • 1. Surgical emergencies • 2. Pediatric surgery emergencies • 3. Urological emergencies • 4. ENT emergencies • 5. Ophthalmic emergencies • 6. Gynecologic emergencies

  4. PRINCIPLES OF MANAGEMENT 1. Life-saving a. Identify life-threatening injury b. Appropriate resuscitation 2. Maintain vital status a. Detailed physical examination b. Continuous resuscitation 3. Further evaluation and management a. Laboratory examination b. Consultation

  5. TRAUMA 1.The 5th leading causes of death of Taiwanese 2. The 1st leading cause of death of young adults 3. Approximately 8,000 patients died from trauma annually

  6. WOUND CARE 1. Copious irrigation 2. Remove foreign body 3. Antiseptic solution 4. Adequate debridement 5. Primary / Delayed suture

  7. PRIMARY SURVEY A. Airway and C-spine control B. Breathing and ventilation C. Circulation and hemorrhage control D. Disability E. Exposure M. Monitor (Foley: indication and contraindication)

  8. AIRWAY ASSESSMENT • Stridor • Debris in oropharynx • Airway obstruction

  9. AIRWAY INTERVENTIONS • Jaw thrust • AVOID HYPEREXTENSION OR FLEXION OF THE NECK • Log roll to side for emesis

  10. CERVICAL SPINE STABILIZATION • Place hands on either side of the head • Maintain neck midline

  11. BREATHING ASSESSMENT • Look, listen, and feel • Observe chest symmetry • Note work of breathing • Jugular vein distention • Tracheal deviation

  12. BREATHING INTERVENTIONS • If breathing is absent, begin mouth to mask ventilations • If breathing is shallow or labored, maintain airway control

  13. CIRCULATORY ASSESSMENT • Level of consciousness • Carotid pulse (absent or present) • Capillary refill • Skin color • Skin temperature • Sites of bleeding

  14. CIRCULATORY INTERVENTIONS • If pulse is absent, begin CPR • Apply direct pressure to open wounds

  15. SECURE AIRWAY • Assist airway Oral airway, nasal airway, LMA • Endotracheal intubation Oral, nasal • Surgical airway Cricothyroidotomy Tracheostomy

  16. LMA and Intubating LMA

  17. Intubating LMA

  18. Contraindication: < 11y/o

  19. Needle Cricothyroidotomy

  20. NEUROLOGICAL ASSESSMENT • Level of consciousness • AVPU scale • Awake • Verbal response • Pain response • Unresponsive

  21. LIFE-THREATENING HEAD INJURY • Intracranial hemorrhage Epidural hematoma, subdural hematoma, intracerebral hematoma, subarachnoid hematoma • Diffuse axonal injury • Management a. Evacuation of hematoma b. Decrease IICP and mass effect c. Maintain cerebral perfusion

  22. Traumatic SAH • Most common: 30-40% • Blood within the CSF andsubarachnoid (SA) space • Tearing of small SA vessels Blood often seen in the basilar cisterns, interhemisphericfissures and sulci

  23. Epidural Hematoma (EDH) • 0.5-1% of head injuries • Blood between the skull and dura • Middle meningeal artery (MMA) > dural sinuses, veins, fracture line • “Classic” LOC then ‘lucid’ (30%) • 80% associated with skull #

  24. Acute Subdural Hematoma (SDH) • 30% of head injuries • Forceful acceleration-deceleration injuries • Blood between the dura and brain • Hyperdense, crescent shaped, extend beyond suture lines • Quick clinical course • Prognosis: 60-80% mortality

  25. Increased BP Altered Breathing Slow Pulse I I C P • Symptoms Headache, vomiting, cons change • Signs Increase BP, decrease HR & PR papilledema • Neurological findings Focal sign, pupil size and light reflex • Cushing's triad: hypertension, bradycardia, and Cheyne-Stokes respiration (irregular breathing)

  26. BATTLE’S SIGN

  27. RACCOON EYES

  28. Brain Concussion • Temporary disturbance in brain function • Probably due to brain being “rattled” inside the skull by a blow to the head • Usually confused or unconscious • Retrograde amnesia--“What happened?” • Effects clear without residual effects

  29. OBSERVATION OF HEAD INJURY • Progressive headache • Vomiting • Consciousness • Dyspnea • Extremity weakness • Seizure

  30. LIFE-THREATENING CHEST INJURY 1. Airway obstruction 2. Tension pneumothorax 3. Open pneumothorax 4. Massive hemothorax 5. Pericardiac tamponade 6. Flail chest combined pulmonary contusion

  31. Pericardial Effusion

  32. Pneumothorax

  33. BECK’S TRIAD 1. Decrease blood pressure 2. Distended neck vein 3. Distant or muffled heart sounds

  34. Pulsus Paradoxicus • The inspiratory diminution in systolic arterial pressure exceeds 10 mmHg. • To measure pulsus paradoxus, a sphygmomanometer sphygmomanometer is employed for blood pressure measurement in the standard fashion except that the cuff is deflated more slowly than usual. During deflation, the first Korotkoff sounds are audible only during expiration, but with further deflation, Korotkoff sounds are heard throughout the respiratory cycle. The difference between the systolic pressure at which the first Korotkoff sounds are heard during expiration and the pressure at which they are heard throughout the respiratory cycle quantifies pulsus paradoxus.

  35. LIFE-THREATENING ABDOMINAL INJURY 1. Liver laceration 2. Spleen laceration 3. Large vessel injury 4. Pelvic fracture

  36. PELVIS • Apply pressure on pelvis to determine its stability • Perform genitalia exam at one’s discretion

  37. EXTREMITIES • Observe for deformities, impaled objects, open wounds • Palpate for pulses, crepitus, or swelling • Determine capillary refill, skin color, temperature • Assess for pain/tenderness

  38. INSPECT THE BACK • Log roll student with assistance • School nurse must maintain cervical spine control • Inspect and palpate the back for bruising, impaled objects, pain and tenderness

  39. TRAUMATIC SHOCK 1. Hypovolemic shock 2. Neurogenic shock 3. Cardiogenic shock 4. Septic shock

  40. Neurogenic shock • Spinal cord injury may produce hypotension due to loss of sympathetic tone. • Hypotension without tachycardia or cutaneous vasoconstriction.

  41. FLUID RESUSCITATION 1. Access Two large bore IV catheter 2. Fluid Crystalloid, colloid, blood component 3. Amount a. Bolus: 2 liter for adults 20 ml/ kg for child b. maintain amount based on urine output

  42. DIFFICULT CATHETERIZATION 1. Venous cut down 2. Intraosseous infusion (<6 y/o) 3. Central venous puncture

  43. THERMAL INJURY 1. Major burn 2. High-voltage electric injury 3. Inhalation injury 4. Chemical burn

  44. ACUTE ABDOMEN • Differential diagnosis Surgical abdomen / medical abdomen • Pain history Onset, location, intensity, duration, radiation, quality, associated symptoms • Symptoms sequence

  45. SEVERE ABDOMINAL PAIN 1.Hollow organ perforation 2. Acute pancreatitis 3. Colic pain a. Biliary system b. Renal system 4. Ischemia pain 5. Others

  46. COMMON DISEASES 1. Acute cholecystitis 2. (Perforated) Peptic ulcer 3. Acute appendicitis 4. Acute pancreatitis 5. Small bowel obstruction 6. Colon obstruction 7. Vascular occlusion 8. Others

  47. PEDIATRIC SURGERY EMERGENCY 1. Respiratory distress * Esophageal atresia * Diaphragmatic hernia 2. Skin defect * Gastroschisis * Omplalocele * Menigocele

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