1. Surgical EmergenciesSurgical Emergencies
Mr. Paul MacKenzie BSc (Hons), BM BS, MRCS
CT 2 Surgical Trainee
Royal Devon and Exeter Hospital

2. Saturday Morning at the RD&ESaturday Morning at the RD&E
You’re feeling a bit worse for wear from the
Mess Night Out.
You’ve just finished Post Take Ward Round
and are dutifully updating the Consultants
list and putting out bloods that your
colleague for got to do the night before.
The Consultant, Registrar and SHO are all
in theatre and are going to be a while……..
You wished you stayed in bed and phoned in
sick…….

3. ““FEEL FREETO COPE”FEEL FREETO COPE”
This is how to survive……..

4. 9.30 am Dorothy9.30 am Dorothy
85-year-old –
Residential Home
Resident
Sudden Onset
Abdominal Pain at
7.30am
Confused
Clammy
In the Ambulance
passed a small amount
of PR Blood

5. Assess The Patient in an ABCAssess The Patient in an ABC
MannerManner
A – Patent and Protected
B – Good Air entry bilaterally
◦ Sats 95% on Air
◦ Respiratory Rate 25
C – Cold, Clammy Peripherally Shut Down
◦ BP 85/70
◦ HR 135
D – Confused
◦ GCS 13/15
◦ Moving All four Limbs

6. E – Abdomen diffusely Tender
◦ Feels Rigid
◦ Guarding
◦ Rebound Tenderness
◦ Patient is Lying Completely Still – Any
attempts to move her and she screams
◦ PR Examination – Empty Rectum, small
amount altered blood on the glove

7. CXR (Portable)CXR (Portable)

8. What is the abnormality on theWhat is the abnormality on the
CXR? (1)CXR? (1)
A – Left Lower Lobe Pneumonia
B – Tension Pneumothorax
C – Tissue Heart Valve
D – Coronary Artery Bypass Grafts
D – Metallic Heart Valve

9. ECGECG

10. What Does the ECG Show (2)What Does the ECG Show (2)
A – Atrial Flutter
B – Ventricular Flutter
C – Atrial Fibrillation
D – Ventricular Fibrillation
E – Supraventricular Tachycardia

11. ABGABG

12. How would you describe the ABG?How would you describe the ABG?
(3)(3)
A – Metabolic Alkylosis
B – Metabolic Acidosis
C – Respiratory Alkylosis
D – Respiratory Acidosis
E – Mixed Metabolic/Respiratory Acidosis

13. Differential Diagnosis?Differential Diagnosis?

14. What is the most likely Diagnosis?What is the most likely Diagnosis?
(4)(4)
A – Bowel Obstruction
B – Diverticulitis
C – Appendicitis
D – Ischaemic Bowel
E – Ruptured AAA

15. ManagementManagement
Call for Senior Help!
Stabilise the patient
◦ IVI
◦ IVABx
◦ Catheterise
◦ Oxygen
Take Bloods (Inc. G+S)
CT Scan + ? Laparotomy

16. 11am Abigail
23-year-old
Sudden Onset Severe
Central Abdominal
Pain
Recent Laparoscopy
for Investigation of
Pelvic Pain – Likely
due to retrograde
menstruation

17. Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over
24 hours, she has a low grade24 hours, she has a low grade
temperature and vomits once. Shetemperature and vomits once. She
has a high WCC and CRP. What ishas a high WCC and CRP. What is
the most likely diagnosis? (3)the most likely diagnosis? (3)
A – Renal Colic
B – Ruptured Ectopic Pregnancy
C – Ovarian Cyst Accident
D – Retrograde Mentruation
E – Appendicitis

18. Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over
24 hours, she has a low grade24 hours, she has a low grade
temperature and vomits once. Shetemperature and vomits once. She
has Normal Bloods. What is thehas Normal Bloods. What is the
most Likely Diagnosis? (4)most Likely Diagnosis? (4)
A – Renal Colic
B – Ruptured Ectopic Pregnancy
C – Ovarian Cyst Accident
D – Retrograde Mentruation
E – Appendicitis

19. Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over
24 hours, she has a low grade24 hours, she has a low grade
temperature and vomits once.temperature and vomits once.
What is the most ImportantWhat is the most Important
Diagnosis to Exclude? (5)Diagnosis to Exclude? (5)
A – Renal Colic
B – Ruptured Ectopic Pregnancy
C – Ovarian Cyst Accident
D – Retrograde Mentruation
E – Appendicitis

20. 11am Abigail
23-year-old
Sudden Onset Severe
Central Abdominal
Pain
Recent Laparoscopy
for Investigation of
Pelvic Pain – Likely
due to retrograde
menstruation

21. ABC Assessment
A- Patent and Protected
B – RR 20, Sats 98% Air
C – BP 100/80, HR 120
D – NAD
E – Abdomen Distended, tender in
Epigastrium with rebound tenderness and
guarding

22. Elicit a good history!
Background & PMHx
◦ When was the laparoscopy?
◦ Who By?
◦ Read the Op note… Complications
◦ Any Medications?
◦ Gynae History
Presentation
◦ Onset of Pain, Nature of Pain, Radiation

23. Investigations
Bedside – Urine Dip & BHCG
Bloods – ABG, FBC, UE’s, LFT’s,
Amylase, CRP
Imaging – Erect CXR

26. Management
Call For Help!
If Stable Enough – Likely Pat Will Need
CT – You can request these on Medway
If Unstable, Patient will Need
Laparotomy – You can help get things
ready – Check G&S, Check Antibiotics
Rx’d, Inform theatres and liaise ,
Catheterise

27. 12pm Barry
77-year-old
Gradual Onset,
Lower Abdominal
Pain, came on over
few days, getting
worse
Distended, not
opening bowels and
not passing wind for
48 hours

28. The Significance of Past Medical History!
Barry had an Open Resection of a sigmoid
Tumour 4 years ago
Barry has Motor Neurone Disease
Barry has had a recent Urinary Tract Infection
Barry has had a recent nasty Chest Infection
Barry is awaiting a hip replacement and has
severe pain from Osteoarthrtitis

29. The Importance of Cllinical Examination
PR and Listen for Bowel Sounds!

30. Investigations
Bedside – Urine Dip
Bloods – FBC, UE’s, LFT’s CRP, TRACE
ELEMENTS, Mg, Phosphate, Calcium
CXR/AXR
?CT

33. Management
CT Scan – To identify point and Cause of
Obstruction
Conservative vs Surgical Management
Concept of ‘Drip and Suck’ – NG tube
and Catheterise

34. 2pm Laura
55-year-old
Grumbling RUQ pain
last 48 hours
Now much worse
Central, radiating
through to the back
Associated with
nausea and vomiting
Sweaty and Clammy

35. What Endocrine Hormones doe theWhat Endocrine Hormones doe the
Pancreas Produce? (1)Pancreas Produce? (1)
A – Cholecystokinin
B – Amylase
C – Lipase
D – Insulin and Glucagon
E – Serotonin

36. What is the most common causeWhat is the most common cause
for pancreatitis? (3)for pancreatitis? (3)
A – Trauma
B – Alcohol
C – Gallstones
D – Scorpian Stings
E - Tumours

37. GET SMASHED
G – Gallstones (45%)
E – Ethanol (35%)
T – Tumours
S – Scorpian Stings
M – Mumps (or Microbiology)
A – Autoimmune
S – Surgery/Trauma/ERCP
H – Hyperlipidaemia/Metabolic
E – Emboli/Ischaemia
D – Drugs/Toxins

38. Modified Glasgow Score (Score 1 for)
P – pO2 < 8
A – Age 55>
N – White Cell Count 15>
C – Calcium <2
R – Urea 16>
E – LDH 600>, AST/ALT >200
A – Albumin <32
S – Blood Glucose >10

40. Management
?ITU
CXR
USS
Catheterise
Aggressive Fluid Management
?IVABx
CT after 5 days – Surgery only indicated
in Severe Cases where necrosis is
present

41. 3pm Mark
67-year-old fit tennis
player
Sudden Onset Severe
Loin to Groin Pain
after a tennis match
Caused him to
Collapse
Past Medical History
– Previous Renal
Colic and
Hypertension

42. What is the most likely Diagnosis?What is the most likely Diagnosis?
(4)(4)
A – UTI
B - Renal Calculi
C – Inguinal Hernia
D – Femoral Hernia
E – Ruptured AAA

43. What is the most ImportantWhat is the most Important
Diagnosis to Exclude? (3)Diagnosis to Exclude? (3)
A – UTI
B - Renal Calculi
C – Inguinal Hernia
D – Femoral Hernia
E – Ruptured AAA

44. What is the most Important FirstWhat is the most Important First
Line Investigation? (2)Line Investigation? (2)
A – CXR
B – AXR
C – FAST Scan
C – Urine Analysis
D – Full Blood COunt

45. ABC Assessment
A – Patent and Protected
B – RR 16, Sats 96% Air
C – BP 110/65, HR 98
D – NAD
E – Tender in lower abdomen and right
flank & renal angle

46. BUT…… 30 minutes later
A- Patent and Protected
B – RR 24, Sats 95% air
C – BP 80/40, HR 128
D – GCS 13/15
E – Abdomen tender ?More distended

47. What is the definitive Investigation?What is the definitive Investigation?
(5)(5)
A – CT Angiogram Aorta
B – MR Angiogram
C – USS
D – FAST Scan
E – Plain CT

49. Management
Urgent Vascular Surgery Review – Needs
to be in theatre NOW!
Cross Match (at least) 4 units – Activate
Massive Transfusion Protocol
Permissive Hypotension – Don’t Ram
him full of Fluids
Catheterise
Going to need Arterial Line/ Central Line
etc. So Let Anaesythetics team know!

50. Causes of Abdominal PainCauses of Abdominal Pain

51. Key Surgical EmergenciesKey Surgical Emergencies
Ischaemic Bowel
AAA
Perforation
Bowel Obstruction
Peritonitis
Pancreatitis
Acute GI Bleed
Ischaemic Limb

52. Key Points for Doing Well in AMKKey Points for Doing Well in AMK
Work hard and revise all year – this
exam is not designed to be ‘revised for’
READ THE QUESTION CAREFULLY
If you can narrow the answer down to
two – its worth a shot
Take a night off the night before the
exam