Applied Surgical Science & Critical Care

Abdominal Pain

Perforated Viscus, Septicaemia & AF

  • Stem: Unwell patient/Middle aged man/ Pt with OA on NSAIDs- with septicaemia, CXR- free air under diaphragm, A, peritonism, pneumoperitoneum (CXR) etc…
    1. What does the X-ray show?
      —It shows the Air Under Diaphragm.
    2. Tell me about the ECG. (Irregularly irregular)
      How will you read ECG?
      What is the rate?
      What do I look out for in the ECG?
      How to calculate Heart Rate from ECG? (No. of QRS in 30 blocks multiplied by 10).
      What will you find in ECG?
      —absent P wave
    3. What is the most likely diagnosis (differential diagnosis)?
      —A perforated Viscus (perforated gastric or duodenal ulcer)
    4. What are the risk factors of perforation?
      —Prolonged use of NSAIDs
      —Helicobacter pylori infection
      —Use of Steroids
      —Previous Peptic Ulcer disease
      —Malignancy
    5. Mechanism/Pathophysiolosy of NSAIDs causing peptic ulceration?
      —Topical irritant effect of NSAIDs on the epithelium
      —Impairment of barrier properties of mucosa
      —Gastric PGs synthesis suppression (by inhibition of Cyclo-oxygenase)
      —Reduction of Gastric mucosal blood flow
      —Interference with repair mechanism of superficial mucosal injury

ACUTE PANCREATITIS

Stem–
~You are the on-call CT1 & have been called to see a patient in the resuscitation room of the ED. He is a 30-year-old man who was with his friends in a party throughout the weekend. He came to ED with complain of severe epigastric pain radiating to back & associated vomiting. Considering this as critical care station, you will be asked about the pathophysiology & management of this patient.
Or,
~A 62-year-old female has been referred to you with severe constant epigastric pain radiating to the back & is associated with bilious vomiting.
Her observations are as follows:
T 380 C, BP 130/90 mm Hg, P 120/min, RR 24/min, O2 saturation 82% on room air. She has passed 50 ml of urine since she came.
Blood results: Hb-12.4 g/dl, WCC- 17 x 109/L, Plt- 254 x 109/L,
Amylase- 2500 U/L, CRP- 50, Glucose- 6.5 mmol/L, Na- 135 mmol/L, K- 4.5 mmol/L, Urea- 18.4 mmol/L, Creat- 63 mmol/L, Corrected Ca- 1.8 mmol/L, LDH- 200 IU/L, Albumin- 30 g/L
ABG on room air: Ph 7.38, PaO2– 10 kPa, PaCO2– 5.9 kPa, HCO3– 26 mmol/L, BE- +1.7 mmol/L

  1. What is your differential diagnosis?
    Ans-
    • Acute pancreatitis
    • Perforated viscus, e.g. perforated duodenal ulcer
    • Gastritis/Peptic Ulcer Disease
    • Biliary colic
    • Acute cholecystitis
    • Ascending cholangitis.
  2. What would be your initial management & investigation of this patient?
    Ans-
    I will follow A,C,B,D approach–
    ⮕ I will start oxygen, Cardiovscular monitoring, observation, IV access with two large bore cannula & start fluid resuscitation.
    ⮕ I will take a history while performing an examination.
    ⮕ Catheterize the pt & attain strict fluid balance (strict fluid balance monitoring), keep pt nil-by-mouth; N-G tube may be used.
    ⮕ Analgesics, Anti-emetics & DVT prophylaxis.
    ⮕ Investigations: FBC, U&E, LFT, s. Amylase, Lipase, LDH, AST (Aspartate transaminase), Ca, Glucose, C-reactive protein, & ABG,
    ⮕ ECG- flattened T-waves
    ⮕ Erect Chest radiograph- to exclude perforation/look for effusion
    ⮕ Abdominal radiograph- pancreatic calcification, sentinel loop
    ⮕Ultrasound scan- to exclude/confirm gallstone aetiology &/or dilated CBD
    ⮕Abdominal CT- in case of suspecting other potential differential diagnosis e.g. perforation
  3. What is pancreatitis?
    Ans-
    Pancreatitis is an inflammation of the pancreas, which may be either acute or chronic- causing considerable morbidity & mortality. It can be mild, moderate, or severe depending on the presentation.
  4. What are common causes of pancreatitis?
    Ans-
    The commonest causes of pancreatitis in the UK are:
    Gall stones & Alcohol.
    Use the mnemonic I GET SMASHED:
    –Idiopathic,
    –Gallstones,
    –Ethanol (alcohol),
    –Trauma,
    –Steroid,
    –Mumps (& other viruses- Epstein-Barr, CMV),
    –Autoimmune diseases (PAN- polyarteritis nodosa, SLE),
    –Scorpion sting (e.g. Tityus trinitatis), Snake bites,
    –Hypercalcemia/ Hyperlipidemia/ Hypertriglyceridemia/ Hypothermia,
    –ERCP,
    –Drugs (Azathioprine, Diuretics- furosemide & thiazides, NSAIDs, Sulphonamides, Didanosine etc.)
  5. (The site manager rings to ask you) Where would you manage this pt? What factors would help you make this decision?
    Ans-
    The need of bed for the patient of pancreatitis in the HDU (high dependency unit) or in the ICU (intensive care unit) depends on the predicted severity of the attack.
    As per the Guidelines from the British Society of Gastroenterology, the following factors may suggest the severity at initial assessment (& hence a need for a higher-level bed):
    1. Clinical impression of severity (i.e. end-of-the-bed assessment)
    2. Obesity (BMI >30 kg/m2)
    3. APACHE II (Acute Physiology And Chronic Health Evaluation II) score >8
    4. Pleural effusion on chest radiograph
    5. At 24 hours a CRP (C-reactive protein) >150
      or, Glasgow score >3 also suggest a severe attack.
  6. Describe the different scoring systems for the assessment of severity of pancreatitis.
    Ans-
    • Glasgow criteria: mnemonics- PANCREAS
      -PaO2 on room air < 8kPa,
      -Age > 55 years
      -Neutrophils (WCC > 15 x 109/L)
      -Calcium < 2 mmol/L
      -Renal (Urea > 16 mmol/L)
      -Enzymes (LDH > 600 U/L)
      -Albumin < 32 g/L
      -Sugar (blood glucose > 10 mmol/L)

      ~Interpretation: Score ≥ 3 severe Pancreatitis
    • Ranson’s Criteria:

      ~Interpretation:
      Score  ≥ 3 severe Pancreatitis
      Score 0-2 2% mortality
      Score 3-4 15% mortality
      Score 5-6 40% mortality
      Score 7-8 100% mortality.
  7. What are the complications of pancreatitis?
    Ans-
    Complications of pancreatitis can be divided into:
    1. Systemic-
      • ARDS (acute respiratory distress syndrome),
      • Renal failure
      • MODS (multi-organ dysfunction syndrome),
      • Diabetes &
      • Death.
    2. Regional-
      • Abscess formation,
      • Infected necrosis,
      • Pseudocyst,
      • Gastrointestinal bleeding,
      • Splenic artery pseudoaneurysm &
      • Mesenteric venous thrombosis.
  8. When should a patient with gallstone pancreatitis undergo cholecystectomy?
    Ans-
    British Society of Gastroenterology guidelines advise definitive treatment (i.e. cholecystectomy if fit, ERCP- endoscopic retrograde cholangiopancreatography & sphincterotomy if not) should be performed during the same admission or within 2 weeks of discharge.

Head Injury/EDH

HEAD INJURY/EDH:
Stem~ A 24-year-old young male brought to ED after RTA. On arrival, he had GCS 15, & then he vomited twice & after 20 minutes he become unconscious; now GCS decreased to 8. You have been called to see this patient. Considering this as critical care station, answer the following questions.

  • How will you manage this patient?
    — I will follow the A, B, C, D protocol
  • What will you expect in the CT scan?
    — biconvex, midline shift, & compression on the ventricle.
  • What is the normal ICP?
    — Its 7-15 mm Hg( supine) &
  • How will measure ICP? (Different methods?)
    —Invasive method:
    -Intraventricular catheter (EVD- external ventricular drain)
    -Extradural probe
    -Subarachnoid probe
    -Intraparenchymal probe
    -Lumbar CSF pressure
    —Non-invasive method:
    -Transcranial Doppler
    -Tympanic membrane displacement
  • What body parts are injured?
  • What is GCS & what are its constituents?
  • Single test to confirm diagnosis? – CT head
  • When will you consider CT brain for trauma?
    —High Risk Criteria:
    – GCS < 15 at 2 hours post-injury.
    – Suspected open or depressed skull fracture.
    – Any sign of basilar skull fracture:
    ->Hemotympanum.
    ->Racoon Eyes.
    ->Battle’s Sign.
    ->CSF oto-/rhinorrhea.
    – ≥ 2 episodes of vomiting.
    – Age ≥ 65.
    – Any head injury in anticoagulated patient.

    —Medium Risk Criteria:
    – Retrograde Amnesia to the event ≥ 30 minutes.
    – “Dangerous” Mechanism:
    -Pedestrian struck by motor vehicle.
    -Occupant ejected from motor vehicle.
    -Fall from > 3 feet or > 5 stairs.
  • NICE guidelines: Criteria for performing a CT head scan. :
    —For adults who have sustained a head injury & have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
    –GCS < 13 on initial assessment in the emergency department.
    –GCS < 15 at 2 hours after the injury on assessment in the emergency department.
    –Suspected open/depressed skull fracture.
    –Any sign of basal skull fracture (hemotympanum, ‘panda’ eyes, CSF leakage from the ear or nose, Battle’s sign).
    –Post-traumatic seizure.
    –Focal neurological deficit.
    –More than 1 episode of vomiting.
    A provisional written radiology report should be made available within 1 hour of the scan being performed. 
  • Describe CT head. – lenticular/ biconvex lesion, midline shift, compression of ventricles—extradural haematoma.
  • Management of raised ICP?
  • GCS drops – management?
  • Cause of secondary GCS drop?