Surgical emergencies for the ED doctor

Dr Rebecca ThomasSurgical Registrar

Wanganui Hospital, March 2014

• A happy surgical registrar is a sleeping one

• BUT……– People get sick/injured 24 hours a day–We’re here if you need us

Overview

• Guidelines on when to call• What to do first• What to say

• Some more specific situations + tips

Guidelines

• When do I call the surgical registrar?

• If there is:– A hole in something– Something where it shouldn’t be– Something blocked– Something badly infected or inflamed

– Significant concern from you or your colleagues about a patient

A hole in something

• Ruptured aneurysm– Abdominal, iliac, [popliteal]– >60 years, abdominal pain, hypotension,

pulsatile mass

• Major bleeding– E.g. GI bleed– E.g. after trauma

• Perforated viscus– Free air on CXR

Something where it shouldn’t be

• An incarcerated hernia• Rectal prolapse• A foreign body• Innards on the outside

Something blocked

• Bowel obstruction– Small or large– Volvulus

• Ischaemic gut• Ischaemic limb

Something badly infected or inflamed

• Pancreatitis• Appendicitis• Cholecystitis/cholangitis

Things not on the list• ENT things

• Most patients with:– Minor complaints– Normal obs– Simple diagnoses/differentials– Problems that they could be discharged home with…..if it

wasn’t 2am, dark outside, they have a sick cat, they’ve run out of milk, forgotten their slippers, and they can’t get a ride home.

– E.g. biliary colic, small abscesses (if drainable in ED), gastroenteritis

• Please give us a call in the morning – we can review these people just before ward round if necessary.

What to do first

• History• Exam• Investigations• Differential diagnoses• Initial treatment

What to say

• Who you are• Where you’re calling from• What you want– “I need you to come in now”– “I need some advice”– “I think this person needs to be

admitted”

Hernias

• Epigastric/umbilical/inguinal/femoral

• Pain, incarceration, strangulation, obstruction

Pancreatitis

• Commonly gallstones, alcohol• Amylase 3x/upper limit of normal + a

good story• Don’t miss other pathology– AAA, perforated DU

• CXR, LFTs, CRP, FBC, lactate, pO2

• Severity criteria – Ranson’s, modified Glasgow, APACHE II

Ischaemic gut

• Often a difficult diagnosis to make– Elderly patient– Often in AF– Pain out of proportion to exam– Elevated lactate– Dilated bowel loops on AXR

Ischaemic limb

• Pain, pallor, paraesthesia, pulselessness, perishingly cold

• Pain pain pain pain pain + paralysis

Massive GI bleed

• Call me!

• 2x big IV lines• Bloods – urgent crossmatch, coags,

FBC• 2 litres saline, then blood