Core Lecture

Department of Emergency Medicine

National Taiwan University Hospital

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 3. Urological emergencies 4. ENT emergencies 5. Ophthalmic emergencies 6. Gynecologic emergencies

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

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

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

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)

AIRWAY ASSESSMENT
Stridor
Debris

in oropharynx Airway obstruction

AIRWAY INTERVENTIONS
Jaw

thrust AVOID HYPEREXTENSION OR FLEXION OF THE NECK Log roll to side for emesis

CERVICAL SPINE STABILIZATION

Place

hands on either side of the

head Maintain neck midline

BREATHING ASSESSMENT
Look,

listen, and feel Observe chest symmetry Note work of breathing Jugular vein distention Tracheal deviation

BREATHING INTERVENTIONS
If

breathing is absent, begin mouth to mask ventilations If breathing is shallow or labored, maintain airway control

CIRCULATORY ASSESSMENT
Level

of consciousness Carotid pulse (absent or present) Capillary refill Skin color Skin temperature Sites of bleeding

CIRCULATORY INTERVENTIONS
If

pulse is absent, begin CPR Apply direct pressure to open wounds

SECURE AIRWAY

Assist airway Oral airway, nasal airway, LMA Endotracheal intubation Oral, nasal Surgical airway Cricothyroidotomy Tracheostomy

LMA and Intubating LMA

Intubating LMA

Contraindication: < 11y/o

Needle Cricothyroidotomy

NEUROLOGICAL ASSESSMENT
Level

of consciousness AVPU scale Awake Verbal response Pain response Unresponsive

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

Traumatic SAH
Most common: 30-40%

Blood within the CSF and subarachnoid (SA) space Tearing of small SA vessels Blood often seen in the basilar cisterns, interhemispheric fissures and sulci

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 #

Acute Subdural Hematoma (SDH)

30% of head injuries Forceful accelerationdeceleration injuries Blood between the dura and brain Hyperdense, crescent shaped, extend beyond suture lines Quick clinical course Prognosis: 60-80% mortality

IICP
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,

Increased BP

bradycardia, and Cheyne-Stokes respiration (irregular breathing) Altered Breathing

Slow Pulse

BATTLES SIGN

RACCOON EYES

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

OBSERVATION OF HEAD INJURY

Progressive headache Vomiting Consciousness Dyspnea Extremity weakness Seizure

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

Pericardial Effusion

Pneumothorax

BECKS TRIAD
1. Decrease blood pressure 2. Distended neck vein 3. Distant or muffled heart sounds

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.

LIFE-THREATENING ABDOMINAL INJURY

1. Liver laceration 2. Spleen laceration 3. Large vessel injury 4. Pelvic fracture

PELVIS

Apply pressure on pelvis to determine its stability Perform genitalia exam at ones discretion

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

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

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

Neurogenic shock

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

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

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

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

ACUTE ABDOMEN

Differential diagnosis Surgical abdomen / medical abdomen Pain history Onset, location, intensity, duration, radiation, quality, associated symptoms Symptoms sequence

SEVERE ABDOMINAL PAIN

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

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

PEDIATRIC SURGERY EMERGENCY

1. Respiratory distress * Esophageal atresia * Diaphragmatic hernia 2. Skin defect * Gastroschisis * Omplalocele * Menigocele

PEDIATRIC SURGERY EMERGENCY

3. Bowel obstruction Pyloric stenosis, intussusception Adhesion, incarcerated hernia, Malroatation 4. Abdominal pain *Acute gastroenteritis *Acute appendicitis *Mesenteric lymphadenitis

GYNECOLOGIC EMERGENCY

Vaginal bleeding 1. Dysfunctional uterine bleeding 2. Uterine myoma 3. Hypermenorrhea 4. Abortion 5. Atony uterus

GYNECOLOGIC EMERGENCY

Ectopic pregnancy * Missed period * Vaginal spotting * Abdominal pain

GYNECOLOGIC EMERGENCY

Abdominal pain * Pelvic inflammatory disease * Acute appendicitis * Ovarian cyst (torsion) * Ileus * Menstruction

Urological Emergency

Painful conditions Bleeding conditions Trauma conditions Others

ENT Emergency

Foreign body Epistaxis Deep neck infection Others

Ophthologic Emergency
Red

eye Foreign body Blurred vision Others

REEVALUATION

Time interval Same personnel Vital signs Laboratory examination Early suspicion Early consultation

MEDICAL ETHICS

Treat a person not a disease Treat a patient as your family Be patient to a patients complaint Be kind and more smile Careful explanation

Suggestive Readings

Advanced Trauma Life Support (ATLS) for Doctors (American College of Surgeons Committee on Trauma, 1997) ( , , 1999)

Questions?
Department of Emergency Medicine
National Taiwan University Hospital