1. Surgical emergencies for the
ED doctor
Dr Rebecca Thomas
Surgical Registrar
Wanganui Hospital, March 2014

2. • A happy surgical registrar is a sleeping one
• BUT……
– People get sick/injured 24 hours a day
– We’re here if you need us

3. Overview
• Guidelines on when to call
• What to do first
• What to say
• Some more specific situations + tips

4. 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

5. 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

6. Something where it shouldn’t be
• An incarcerated hernia
• Rectal prolapse
• A foreign body
• Innards on the outside

7. Something blocked
• Bowel obstruction
– Small or large
– Volvulus
• Ischaemic gut
• Ischaemic limb

8. Something badly infected or inflamed
• Pancreatitis
• Appendicitis
• Cholecystitis/cholangitis

9. 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.

10. What to do first
• History
• Exam
• Investigations
• Differential diagnoses
• Initial treatment

11. 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”

13. Hernias
• Epigastric/umbilical/inguinal/femoral
• Pain, incarceration, strangulation,
obstruction

14. 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

15. 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

16. Ischaemic limb
• Pain, pallor, paraesthesia, pulselessness,
perishingly cold
• Pain pain pain pain pain + paralysis

17. Massive GI bleed
• Call me!
• 2x big IV lines
• Bloods – urgent crossmatch, coags, FBC
• 2 litres saline, then blood