Traumatology Scenarios

Case 01: Scalp Injuries

Child brought to the emergency ward with a scalp laceration with profuse bleeding. Child is
walking, rational, no features of intracranial lesions.

What are the types of head injuries?

- Scalp injuries
- Skull fractures
- Intracranial injuries

How will you manage?

- Administer analgesics according to WHO pain scale. Can start with Diclofenac Na
provided there are no contraindications such as:
- asthmatic: PG production inhibited by Diclofenac Na and PG maintain airway
patency
- chronic renal disease: PG cause afferent arteriole dilation of glomerulus so
Diclofenac Na cause blood vessel to shrink and it worsens chronic renal
disease
- allergies, GI bleeding, coagulopathy
- The laceration needs to be sutured to stop bleeding
- Get consent from the patient (or if child < 18, get consent from parent)
- Take patient to minor casualty theatre/ ward
- May give prophylactic antibiotics and tetanus toxoid depending on the level of
contamination
- Shave the edges and take 3 artery forceps per side to place on the edges of the
wound, using the forceps to evert the aponeurosis
- Clean the wound with normal saline or povidone iodine
- Inject local anesthetic (lignocaine) into the edges of the scalp wound
- Maximum dose is 3mg/kg or if given with adrenaline, max dose is 7ml/kg
(because adrenaline causes vasoconstriction so lignocaine lasts longer)
- Side effects are cardiac arrythmia and convulsions
- Adrenaline not used in end arteries which can go into spasm, such as penis,
earlobe, nose and fingers

Case 02: Extradural Haemorrhage

Ruggerite brought to the ward after hitting ground on the side of neck during a match,
suffered LOC for 5 minutes. Currently he is consciousness and talking

Most likely cause: Extradural Haemorrhage

When do you suspect neck injuries?

- Any neck pain

- Difficulty moving neck

What are the types of intracranial haemorrhage?

- EDH:
- acute, more common in sporting injuries\
- feature suggestive of EDH is an overlying subcutaneous haematoma (“boggy
mass over temporal area”)
- SDH:
- more common in elderly and alcoholics
- due to brain shrinking thus bridging veins are more likely to rupture
- SAH
- ICH

What is EDH and what are the sequelae?

- EDH is due to temporal bone fracture leading to damage of middle meningeal artery,
leading to accumulation of blood between dura and skull
- Classical features:
- History of trauma to temporal region
- Immediate LOC afterwards: due to synaptic disruption
- Followed by a period of consciousness
- Before developing altered consciousness (“lucid interval”), coma and death.
This can be due to:
- midline herniation: across falx cerebi
- horizontal herniation: subtentorial shift
- subuncal shift
- last is conal shift (brainstem herniation leading to respiratory
depression)
- this is because of Monroe Kellie Principle
- Features of brainshift:
- pupils dilated first on the same side, then both side
- Initially there is transient constriction

What is the management?

- Primary survey
- Check GCS
- Components of GCS: eyes, verbal and motor
- importance of GCS:
- assess patient’s level of consciousness in an OBJECTIVE manner
- useful to detect detioration/ improvement and important in handing
over
- GCS< 13 go for Non contrast CT (contrast not used because both brain and
haematoma will appear same)
 - CT: lenticular mass
- Prepare for craniotomy/ cranioplasty:
- Get consent for surgery
- Continue monitoring
- There is no significant blood loss in head injury, however we will keep blood
ready as there can be perioperative blood loss
- (If there are signs of significant blood loss in a head injury, it mean the
bleeding is elsewhere)
- Inform OT, anaesthetist, superiors, surgeon
- Shave whole head and take patient to OT as soon as possible
- No need mannitol/ antibiotics for EDH
- Craniotomy: make a burr hole to evacuate bleeding
- Cranioplasty: raise a flap, evacuate bleeding, close flap

Case 03: Chest Injuries

Patient brought to A/E after falling from a height and has hit his chest on the ground. He is
dyspnoeic, no signs of other injuries/ fractures

What do you suspect?

- Pneumothorax
- Fracture of rib leading to painful breathing

What is meant by flail chest and what is the management?

- fracture of 2 or more adjacent ribs, which creates an isolated segment that moves
independently from the rest of the chest in a paradoxical manner
- If less than 4 ribs/ elderly/ low Oxygen saturation: segment is fixed with CPAP, to
keep lung expanded
- >4 ribs: fix it by wiring

What is pneumothorax and what are the types?

- Definition: air in the pleural cavity

- Types
- Tension:
- there is a unidirectional valve formed by intercostal muscle and soft
tissue causing air to get sucked in during inspiration, but doesn’t leave
during expiration
- On examination, sound emitted from the wound only in inspiration
- This is deadly as it mediastinal shift causes kinking of venacava
reducing the cardiac output, leading to distributary shock
- Open:
- There is a bidirectional valve allowing air to enter and leave
 - On examination, sound emitted from the wound during inspiration and
expiration
- Closed:
- There is no flow of air through wound
- On examination, no sound emitted from the wound

What are the features of tension pneumothorax?

- asymmetrical lung expansion

- tracheal deviation away from affected area
- Tympanic percussion over affected area
- Absent lung sounds and diminshed air entry

What is the management of tension pneumothorax?

- Needle throcastomy: insert a wide bore needle into the second intercostal space
midclavicular line, there will be a gush of air
- This also converts it into an open pneumthorax
- Can connect infusion set into a bottle of water
- The definitive treatment is insertion of an intercostal tube, until which we do needle
thoracostomy

What are the basic steps in insertion of an intercostal tube?

(Dr Dulantha has a note on inserting an Intercostal tube as well)

- Obtain consent for procedure

- Prepare the instruments, local anesthesia, Intercostal tube, blade, drapes
- Position patient: semi recumbent position with head elevated, hand behind head
exposing the safe triangle
- Safe triangle:
- 5th Intercostal space, lateral border of pec major and lattismus dorsi
- Called safe triangle because no major blood vessels/ stuctures that can be
damaged, thinnest part of chest wall
- Too posterior: Long thoracic nerve causing loss of serratus anterior and
winged scapula
- Too anterior: can damage breast tissue/ pec major which is highly vascular
- clean and drape patient
- Since the sternal angle is covered by drapes, locate the highest rib in the axilla,
which is the second rib and go down to just above the 5th rib ie 4th intercostal space.
We go just above the rib to avoid the neurovascular bundle located just below the rib
- Infiltrate with local anaesthetic (1% lignocaine 3ml/kg max) up to the parietal pleura
(as this also sensitive to pain)
- Make an incision 1-1.5cm wide enough to pass tube and finger, disect muscles upto
parietal pleura
- If we are using a prepared intercostal tube with trochar, we will hear a popping sound
then retreat the trochar and pass the tube (if a trochar is used, we should do in a
controlled manner to reduce trauma to underlying tissues)
 - If there is no trochar mount the tube on a long pointed artery forceps to push it
- Pass the tube upwards and backwards to apex of lung, making sure that the last hole
of the tube is inside
- Anchor the intercostal tube as it can dislodge while trying to connect the tube to the
underwater seal. This is done using a Roman shoelace suture
- Underwater seal consists of two tubes, one is immersed in water which is connected
to intercostal tubes, the other is suspended above the water. Principle is that the air/
blood in lungs displace air in the bottle which leaves the bottle
- Initially there is vigorous bubbling, later the fluid level starts fluctuating

Next day morning, you notice the water level is not fluctuating, what is your management?

- First reason is that the lung may have expanded, so check for correction of tracheal
shift, lungs sounds are normal and chest expansion is normal
- Other reasons:
- Clot in tube
- Kinking of tube
- Dislodgement of tube
- Confirm the lung expansion with an chest x-ray, then remove the tube:
- As the tube is removed, the intercostal muscles with close with the first few
breaths
- Remove with maximum inspiration and place a pressure dressing over it

Suppose bubbling is still present the next day, what do you supect?

- Normally bubbling is supposed to stop within 1 to 2 hours and fluid level starts
swinging
- If it is still bubbling, it could be a bronchopleural fistula which need thoracotomy and
and surgical repair

When will throcatomy be done?

- If the initial loss is > 1000cc or >300cc per hour loss, do not depend on intercostal
tube, go for thoracotomy

Case 04: Abdominal Injuries

40 year old man after a bull attacked his stomach, there are multiple bruises but no obvious
penetrating injuries. He is conscious and rational

What is your initial management?

- According to ATLS protocol, I will assess ABC to exclude life threatning injuries
- I suspect bleeding due to organ damage, I will assess this by checking the BP and
PR
- Both BP and PR is low, suspect class III haemorrhage
 - Insert 2 wide bore cannula
- Try dorsum of the hand first
- if not possible as peripheral veins have collapsed, to make veins prominent,
place tourniquet, place hand down and tap on the vein to make it go into
spasm, ask patient to clench and unclench hand (if conscious) and flex the
hand to stretch the skin over the arm
- If it is not working, try the median cubital vein but the joint needs to
immobilised by placing a splint
- If that also fails, can attempt a central line insertion, but this should be
attempted by a senior
- A vein that is always present is the greater saphenous vein (above and in
front of medial malleolus)
- Venous cutdown maybe attempted
- Take blood for cross match with a minimum of 6 units
- Give IV crystalloid:
- too much normal saline can cause acidosis especially if the patient has
hypovolaemic shock, as they are already have acidosis
- 4L of Normal saline to replace 1 L of fluid
- Hartmanns has lactate to prevent lactic acidosis
- Give as fast as possible
- Until blood is ready, infuse with normal saline
- Liver damage can occur with trauma to any part of abdomen, Spleen injuries occur
with trauma to left side (spleen in located between ribs 9 and 11)
- Prepare patient for emergency laparotomy

Case 05: Compound Fracture

Young cyclist fell into muddy paddy field, has a fracture in R/s LL with two open wounds, mild
oozing of blood. He is in pain, no LOC and rational

Diagnosis: Open/ Compound fracture

Management of patient:

- I will start with ATLS protocol to identify and exclude life threatening injuries which
are:
1. life threatening chest injuries: pneumothorax, haemothorax, flail chest
2. cervical spine injury
3. expanding ICH
4. concealed intra abdominal bleeding
- Analgesia: start with an opiod after excluding contraindications (analgesia is the next
most important thing after primary survey)
- Clean the wound superficially to remove mud and debris
- Examine the neurovascular status:
- pulses distal to the fracture with the names (eg DP, PT)
- CRFT
 - Start broad spectrum antibiotics and tetanus toxoid
- The patient needs surgery, the timing depends on the scenario
- Emergency: signs of neurovascular compromise such as absent distal pulse,
tense calf muscles.
- Urgent: Open fracture but no features of neurovascular compromise, then we
can send patient for the next theatre list (however still considered an
orthopaedic emergency)
- Elective: uncomplicated closed fracture
- Patient will need an X-ray, but if there is neurovascular compromise, do not waste
time and send the patient to OT
- When sending to OT: inform OT and ask to prepare external fixators, anesthetist,
seniors, cross match and DT blood

Principles of management of open fracture in the OT:

- Adequate wound exposure (as external wound might be small, but underlying
fracture will be large)
- Wound debridement under GA
- Remove any foreign bodies and thorough cleaning with copious normal saline and
soft brush
- Remove small pieces of floating bone, but leave large pieces of bone that are
attached to fascia (else it will lead to bone shortening)
- Remove dead muscle (non contractile, lusterless ie lost its shine, dusky in color)
- Control arterial bleeding by repairing them then and there and ligate them
- Nerve repair takes time so we mark them and come back later to repair them
- Keep wound open
- Reduce and immbolise (with external fixator, if not available POP cast with window or
last option is back slab)

Surgical Emergency Scenarios

Case 01: Acute Appendicitis

25 y/o girl present with RIF pain, mild fever, n/v present, otherwise well

Differential diagnosis:

1. Acute appendicitis
2. Ruptured ectopic pregnancy
3. Twisted ovarian cyst
4. Obstructed inguinal hernia (less likely in her age)
5. Elderly woman: Diverticular disease (can occur on R/S) and coecal CA

What are features to suggest acute appendicitis?

 - Most important: Mc Burney’s point tenderness
- Other features of alvarado’s score (eg migrating RIF pain, rebound tenderness)

What investigation would you do?

USS Abdomen
- Can reliably detect inflamed appendix (refer USS features)
- Also can detect an ovarian cyst and appendicular abscess

What is your management?

- Analgesia: Diclofenac Na provided no contraindications, if no response, increase

according to the WHO pain ladder
- IV antibiotics: 3rd Gen cephalosporin such as ceftriaxone, metronidazole
- Start a maintenance normal saline drip
- Prepare patient for urgent appendectomy: inform OT, anaesthetist
- No need to group and DT (as its a minor surgery, risk of bleeding is less), even
grouping and saving may not be needed
- (Group and DT: we are reserving blood which we definitely have to give, Group and
Save: if blood is needed, blood bank has one hour to find blood)
- No need to shave RIF :P

What is acute appendicitis and causes?

- Inflammation of the appendix, causes can be broadly divided to obstructive and non
obstructive causes
- Obstructive causes: Fecoliths, round worm in children, caecal diseases such as
Caecal CA, IBD in adults (thus in all appendicitis in adults, exclude caecal CA)

What are the sequlae of acute appendicitis?

- Complete resolution
- Appendix rupture (inflammation surrounding appendix causes thrombosis of
appendicular artery leading to ischaemia and gangrene)
- peritonitis (very rare)
- Appendicular mass/ segment: this is important as presence of appendicular
mass is a contraindication for surgery and we need to treat conservatively

What are the types of appendectomy?

- Open vs Laparoscopy
- Open: easier procedure, less expensive, done when there is rupture of appendix (as
laparoscopy cannot clean it)
- Laparoscopy: misdiagnosis is less as a full peritoneal survey can be done, which can
detect conditions such as ruptured ectopic pregnancy, twisted ovarian cyst, other
general advantages of laparoscopy
What is mucocoele of appendix?

Assume open appendectomy done in the morning

- During night round, what are the things you will look for? General condition: fever,
pain, vitals, abdominal examination
- Assume during the night round, the patient complains of pain. O/E afebrile,
tachycardia.
- Possible causes?
- Common: Subcutaneous or Intramuscular haematoma
- Internal bleeding due to slipped ligature on appendicular artery
causing a appendicular bed haematoma
- (too early for sepsis, wound dehiscence unlikely as in Grid-Iron we are
only separating the muscles, not tearing)
- Management: open wound, palpate for a mass, do USS to confirm
haematoma and if so, send to OT for exploration
- After an appendectomy the next day morning patient complains of pain, generalised
abdominal pain, tachycardia, febrile.
- Possible cause? Peritonitis due to stump blowout causing intestinal contents
to leak
- Examination features you are looking for? Features of acute abdomen such
as guarding, rigidity, abdominal distention, rebound tenderness
- Management: resucitate with iv N/S, take blood for FBC and CRP, Blood
cultures, start broad spectrum iv antibiotics, prepare patient for emergency
midline laparatomy

Case 02: Acute Cholecystitis

40 y/o presents with RHC pain, with n/v and febrile

Dgx: Acute cholecystitis

What are the features in History and Examination?

- History
- Nature of pain: started from epigastrium, radiate to RHC once GB involved
- Past history of similar pain
- Diagnosed patient with gallstones?
- Examination
- local tenderness over RHC
- features of generalised peritonitis
- Murphy’s sign: only positive in subacute cholecytitis

What is the management?

- Analgesics: Diclofenac Na once C/I have been excluded

 - (opioid use controversial as theoretically opioids cause spasm of sphincter of oddi,
however it’s not clinically proven. In the past, it used to be given with a smooth
muscle relaxants such as hyoscine bromide)
- Definitive management options are:
- Conservative management: antibiotics, analgesics, observe patient for 48-72
hour to see if resolving. If symptoms are worsenin/ ongoing sepsis/ rupture of
GB go for surgery
- Surgical management: depend on the surgeons opinion
- Scheduled cholecystectomy 3 months later (rationale is that patient is
very likely to get recurrence)
- Immediate/ “Hot” cholecystectomy where surgery is done in the same
admission. Disadvantage is that because tissue is inflamed, can’t get
tissue planes properly, GB is soft so higher chance of rupture

What is the cause of acute cholecystitis?

- Stone get obstructed in cystic duct

- Thrombosis of GB arteries due to inflammation causes relocation of GB bacteria (not
ascending infection as bile is sterile)

What are the sequelae of acute cholecystitis?

- Infection
- rupture leading to peritonitis
- resolution
- recurrence
- empyeme of GB
- mucoele: no new bile enters, bile pigment already present will get reabsorbed,
leaving white bile

What are the causes of acute cholecystitis?

- Calculous cholecystitis
- Acalculous cholecystitis: Dengue

How to prepare patient for cholecystectomy?

- informed consent: explain that the surgery might need conversion to laparatomy
- continue IV fluids, keep NBM
- IV antibiotics: ceftriaxone and metrndiazolee
- Analgesics: pethidine 50mg IM
- Pre op medication
- Group and save: high risk of bleeding as can damagecystic artery and hepatc artery

Case 03: Ruptured gastro-oesophageal varices

Chronic alcoholic presents with severe haematemesis “buckets of blood”, second episode of
haematemesis, PR 100, BP 90/60, tachypnoea

What are the important examination findings to look for?

- features of chronic alcoholism: muddy sclera, parotid enlargement

- features of liver failure: shrunken liver, ascites
- (alcoholic with enlarged liver: hepatoma/ ameobic abscess)

What is the management?

- insert 2 wide bore cannula, 14G-16G, start N/S 500ml as fast as possible, if BP still
low, repeat bolus, if still low, exclude other causes of shock eg cardiogenic cause
- give oxygen via face mask
- Urgent GI endoscopy thus inform endoscopy room, surgeon/ endoscopist, my inform
anaesthetist even though it does not need anaesthesia
- Band ligation/ sclerotherapy via endoscopy
- Apart from surgical management:
- Terlipressin/ vasopressin
- Sengstaken–Blakemore tube, Minnesota tube

What are the causes of haematemesis in this patient?

- ruptured variceal bleeding

- gastric erosion
- peptic ulcer disease, less common now (duodenal ulcers do not cause
haematemesis as pylorus closed so it cause malena)

Case 04: Large Intestinal Obstruction

80 y/o man presents with absolute constipation, distention of abdomen, tachycardia, BP

normal

Dgx: large intestine obstruction (elderly large bowel more common, young small bowel more
common)

What are the examination findings to look for?

- Signs of peritonitis due to rupture of intestines (presence is a contraindication for

conservative management)

What are the possible causes?

- CA colon especially rectosigmoid CA, cause a closed loop obstruction between CA

and illeocecal valve
 - Volvulus: sigmoid colon has a V-shaped narrow mesentery and can easily twist
around it (other part of colon with mesentery is transverse colon but it is broad so
less likely to twist) so initially venous obstruction leads to swelling, then arterial
swelling leads to ischaemia
- Colonic strictures
- Crohn’s disease: due to pan mural inflammation
- Diverticilitis and Diverticular abscess
- TB

What investigation can be done to confirm?

- Plain x ray
- Intestinal obstruction
- Small bowel: step ladder pattern, pliae circularis, central location
- Large bowel: periphery, haustrations
- Any large bowel obstruction, look for caecum. If > 12cm, very likely chance
that is going to rupture
- Volvulus: coffee bean sign
- Peritonitis: ground glass appearence

Case 05: Acute Retention of Urine

70 y/o male present to the casually ward presents with inability to pass urine for 8 hours,
known HTN andDM

What are the possibilities?

- Acute Retention of Urine/ Acute on Chronic Retention: Lower abdominal pain and
palpable/percussable bladder
- Chronic Retention: painless palpable bladder
- Anuria: no pain and no palpable bladder
- How to differentiate Chronic Retention vs Anuria? (maybe difficult to palpate bladder):
Perform USS to examine bladder

What is the definition of acute retention?

Inability to pass urine with painful and palpable bladder, with at least 500ml of urine

What are the causes of acute retention?

- Structural causes:
- BPH
- Urethral stricture
- FB obstruction
- Prostate CA
- Functional causes:
 - Neurogenic bladder: DM, Spinal cord injuries, previous pelvic surgeries,
radiation causing fibrosis, obstructed labour damaging pudendal nerve

Assume acute retention of urine, management is catheterisation. Describe the procedure of

catheterisation?

- Explain to the patient what you intend to do and obtain verbal consent
- Gather equipment, place patient in suppine position
- Wash hands and wear two pairs of sterile gloves
- Apply drapes exposing the penis.
- Retract the prepuce if necessary, and clean the glans with two cotton swabs soaked
in povidone iodine starting from glans penis (if allergic to povidone iodine, use N/S)
- Squeeze a full tube of Lignocaine (contains 2%,20cc, minimum 10cc) gel into the
urethra, using the nozzle supplied after removing the cap
- Give 2-3 mins and is mainly for lubricating use (anaesthetic effect takes 30 mins,
used for cystoscopy)
- Take the catheter with the inner sheath from its outer covering.
- Remove the outer pair of gloves and remove the end segment of the inner sheath to
expose the catheter tip.
- Use the “No Touch Technique”
- Hold the penis stretched and held upwards, holding the corona between Index middle
fingers, using the thumb to hold the glans enis ("Cigar holding grip")
- Hold the catheter with the dominant hand with intact inner sheath and pass it
carefully and slowly touching only the inner sleeve cover of the catheter (never the
catheter itself).
- Lower the penis to a horizontal position once you have reached the perineum for it to
slip through the prostatic urethra. (prostatic urethra and bulbar urethra are at right
angles when the penis is held upwards)
- Insert the catheter up to Its hilt (or bifurcation) and take the hand off to see whether it
is recoiling. If it recoils you are not in the bladder (expressing urine means only that
the tip is in the bladder).
- Inflate the Foley balloon to the required volume (10 cc) using sterile water (Never use
saline as if it gets crystalized, balloon might not get deflated).
- The balloon size is marked on catheter (30cc) but inflation up to the full volume will
result in bladder instability leading to peri catheter leak.
- Ensure that the prepuce, if present, is reduced at the end to avoid paraphimosis.
- Attach catheter to thigh
- Always record the volume of urine obtained and note if it is blood stained
- If it is a large volume > 1000ml, it is post obstructive diuresis.
- The patient has the potential to lose about 10-14L/day, thus the fluid needs to
be replaced intravenously)
- Bleeding due to stretched bladder suddenly compressing
- This can NOT be prevented by intermittant clamping and unclamping as
bleeding start as soon as 10ml of urine removed

What are the early complications of catheterisation?

 - Failure to catheterise due to stricture: try a smaller size catheter, even size 10 could
be attempted. Failing which a temporary measure is a NG tube. Failing which
suprapubic cystostomy
- Trauma and causing bleeding (not haematoma, as it occurs where there is a space),
later can cause stricture
- False tract formation
- Pericatheter leak:
- first exclude catheter block (if so flush catheter)
- this occurs due to large balloon causing trigonal irritation
- deflate the balloon and the inflate balloon with a smaller volume
- do NOT try to insert a larger size catheter to try to prevent leakage
- (urethra size is 28 Fr)

What are the long term complications of catheterisation?

- Infection:
- There is a risk of ascending infection
- Silicone prevent infection by preventing formation of a biofilm (occurs due to
hyaluronidase production by bacteria, very difficult to treat)
- However after 28 days the silicone coating dissolves, so if it needs to be kept
in longer a pure silicon catheter can be used, but can be kept for a maximum
of 3 months
- Stricture formation:
- Due to use of an oversized catheter which compresses the urethral glands
that secrete mucus. These glands get obstructed, thus the mucous
accumulates and leads to infection, abscess and stricture formation
(spongiofibrosis)
- Stricture is NOT due to trauma because trauma is usually superficial and it
heals unless there is trauma to the deeper structures, which is rare
- Calculi formation: catheter acts as a nidus
- Catheter hypospadias: prolonged pressure on meatus

Case 06: Acute Limb Ischaemia

60 y/o male with a history of IHD presents with sudden onset pain and numbness in R/S LL

What are the specific features in history and examination?

- History: SOCRATES of pain, paresthesia, paralysis

- Examination: Absent pulses, pallor, perishingly cold

What is the possible cause?

- Acute Limb Ischaemia (DVT unlikely as its very acute, no risk factors for DVT)
- Can be due to insitu thrombus or embolus (embolus is usually blood clot, but can be
air/ fat)
What are the possible places an embolus can develop from?

- Heart:
- AF in L/S atrium (not R/S as that will lead to PE) especially when defibriliation
occur
- Ventricular aneurysm
- Hypokinetic segment
- Rheumatic heart disease leading to vegetations
- Bacterial Endocarditis
- Aorta (aortic aneurysm, aortic plaques), Iliac and Femoral Arteries

What is the management, assuming it is an embolus?

- Start heparin (either UFH/ LMWH is fine)

- May consider starting aspirin as well
- Prepare the patient for urgent embolectomy:
- informed written consent
- pre op investigations (ECG, Cross match and DT, RFT, LFT)
- inform OT, anesthetist, vascular surgeon
- start pre op medications, insert urinary catheter
- if late presentation, may also perform fasciotomy as we anticipate
compartment syndrome
- (fogarty catheter inserted through femoral artery and embolus removed)

Instruments
Suprapubic Catheter

What are the indications for a suprapubic catheter?

Basically due to failed Foley Catheter induction, which includes:

- tight phimosis
- Urethral meatus strictures due to Balanitis Xlerotica Obliterans
- Urethral stricture due to infection
- BPH
- Bladder neck stenosis

What are the steps in inserting a suprapubicc catheter?

- Informed verbal consent

- Place patient in supine position, clean and drape, put sterile gloves
- Mark position 2 fingerbreadths above the pubic symphysis
 - Give 1% lignocaine around skin and deep tissue
- On marked site, make a 1cm incision using scalpel
- Insert the trochar(covered with the peelable sheath) in the midline, via incision using
rotatory movements, while pointing it towards the anus
- Then remove the trochar, leaving behind sheath. At this point urine will come out, so
insert the suprapubic catheter, inflate the bulb with 20cc with DW
- Finally pull the tag of the peelable sheath and it will come off. If this does not work,
use a dressing scissor to cut the sheath off

What are the complications?

- Can perforate viscus especially if bladder is not palpable

- If not inserted in the midline, can damage the rectus muscles (which is vascular) and
the inferior epigastric artery
- If there are blood clots in bladder, they can obstruct catheter

Tracheostomy

What are the indications of tracheostomy tubes?

- prolonged ventilation such as an ICU patient(ETT can be kept for a max of 2 weeks,
because pressure on the cuff can lead to ischaemia and tracheomalacia, also the
entire aerodigestive tract is obstructed so cannot feed patient)
- In a patient with maxillofacial trauma (eg crush injury/ RTA) as we cannot insert a
ETT
- Respiratory failure which needs prolonged ventilation
- B/L Partial RLN palsy after thyroidectomy, this leads to complete obstruction
of epiglottis which needs prolonged ETT
- Trachemalacia after removal of a large goitre
- Elective: after a larygectomy eg carcinoma of larynx/ severe trauma

Where is tracheostomy inserted?

It is inserted between the 3rd and 4th tracheal ring, any lower and you enter the
mediastinum, any higher and can cause subglottic stenosis)

What are the complications?

- During insertion, can damage local structures

- Isthmus of thyroid can be injured
- Internal jugular vein and carotid artery
- Pushs too far and can damage the oesophageus
- (In children, it can damage the brachiocephallic veins which as it can be
located above the jugular notch, which if it is perforated can lead to bleeding
and death. In adults this is less likely as the vein is in the superior
medaistinum)
 - On either side is the suprapleural membrane (Simpson fascia) which if
damaged, can lead to tension pneumothorax
- Obstruction: by secretions and blood clots
- Dislodgement: the tube can come out if not properly secured, to prevent this we:
- inflate the pilot ballon to inflae the cuff (this also prevent aspiration and air
leaking)
- We tie a plastic tape to the phalange and wrap it around the patients neck
- If it dislodges, it can lead to pneumomediastinum and subcutaneous
emphysema

What are the parts of tracheostomy?

- Phalange
- Connector bulb (attached to the ventilator)
- Stillette (part going into neck), with pilot ballon, cuff and tape
- (Tracheostomy comes in a standard size)

How will you manage a patient with tracheostomy?

- Patient cannot speak so we should give them a bell/ pen and paper
- Keep the patient close to nursing station, in case they get sudden obstruction (patient
becomes blue and dyspnoeic), this is prevented by regular suction using suction
catheter (block sucker while inserting to trachea, open sucker while retracting)
- To look for dislodgement, feel the skin everyday for subcutaenous emphysema and
inspect tube to see if it is an odd angle/ position
- Since the tracheostomy bypass the air sinuses, which keep the air warm and
humidified, we need to humidify the air by either fixing to a humidifier/ place wet
gauze over the opening
- The cuff can lead to osteomalacia, so have to deflate the cuff every once in a while
- Need to confirm the position of the tracheostomy by doing a xray, it should be just
above the carina, else only one lung is ventilated

Epidural Needle

What are the indications for epidural?

- Caesarian section
- Pelvic or perineal surgery (haemoridectomy, perianal abscess)
- Epidural analgesia
- Post op analgesia (we can continue to give morphine if we insert a catheter)

Why do they have the characteristic zebra pattern? The markings are to identify the length

How is epidural inserted?

- Get consent
 - Place position in lateral/ seated position
- Infiltrate LA around the L4/L5 space
- Enter the L4/L5 space (refer layers from skin to dura)
- Tip of needle is curved to reduce the chance of dura perforating
- We use heavy bupvicaine (its long lasting compared to lignocaine which is long
lasting, heavy because of the dextrose solution)

What are the complications of epidural?

- Perforation of dura (this is a problem as we use a much higher dose compared to

spinal because in spinal we directly enter the CSF. Thus accidental perforation can
lead to high spinal and cardiac arrest)
- Infections
- Dislodgment

Airways

LMA
- Used in surgery/ trauma to maintain airway
- Compare ETT and LMA
- ETT: can keep for longer period, more skill required, lower risk of aspiration
and air leak
- LMA: can keep for shorter period, less skill required, higher risk of aspiration
and air leak
- The cuff sits on laryngeal opening, which prevents toungue falling back
- In modified LMA, we can insert an ETT through it

Methods of accessing airways

- Supraglottic: Oropharyngeal, Nasopharyngeal airways
- Infraglottic: LMA, ETT
Cricothyroidostomy
- A needle is inserted on the cricothyroid membrane
- However it is not a true airway as patient cannot breathe through it
- It is used to provide high pressure oxygen to oxygenate airways, however with time
the CO2 accumulate which can lead to hypercapnoea and cardiac arrest
- Thus it can be used to buy time until a permanent airway can be established

Double J stent

- What are the ways it can be inserted?

- Retrograde: inserted through cystoscope, through the guidewire (red)
- Anterograde: if the ureteric orifice too small, it can be inserted into kidney
through skin via radiological guidance
- One end in kidney, other in bladder neck
- The length is fixed for adults (13cm), shorter for paediatrics and transplant
- Can be kept for 6/12 but in practice we keep for 3/12 as it can get encrusted. Usually
the clinical indication is over by 2/52 (stone, stricture)
 - Since the tube bypasses the obstruction, it causes paralysis of the ureter, thus do not
expect the tube to pass through
- 40% drain through the lumen, 60% drain around stent, thus it’s not possible to get a
blocked stent

Oncology Scenarios
Case 01: Oesophageal Carcinoma

70 y/o smoker presents with progressively worsening dysphagia

What is dysphagia?

- Difficulty swallowing
- Misnomer because “dys” means painful eg dysuria but dyshagia is not painful
- Odynophagia is painful swallowing

What are the causes of dyphagia?

- Oropharyngeal causes: bulbar palsy in CVA,

- Oesophageal causes:
- Structural causes
- Oesophageal CA (initially solids -> liquids)
- Strictures: ingestion of corrosives (acetic acid in rubber industry,
detergens causing alkaline burns) GORD
- Functional causes (motility disorders) such as Achalasia cardia (can present
in adulthood), Corkscrew oesophageus, Diffuse oesophageal spasm, Chaga’s
disease
- External compression:
- Mediastinal tumour/ LN enlargment (eg HL/ NHL, secondaries)
- R/s atrial dilation
- L/s subclavian artery looping around oesophageus

Can also divide according to acute and chronic. Acute causes include children swallowing
FB eg coins, batteries

What are the inevestigations you would do?

- Investigations to diagnose disease

- Upper GI endoscopy: can take biopsies
- Ba Meal
- not done anymore
- not Ba swallow (as Ba meal is a thin paste so it coats the oesophegus
well, but Ba swallow is a thick paste)
 - Better that the Ba meal is CT-Barium-Oesophagram, as with CT we
can see the soft tissues, LN spread, distal and local spread

How to prepare a patient for upper GI endoscopy?

- take consent, inform it’s an outpatient procedure

- fasting for 6 hours (but in motility disorders, may have fast for longer)
- procedure done in endoscopy room
- put patient in Left lateral position reason??
- spray 10% lignocaine spray in the oropharynx
- place mouth guard
- insert up to pharynx and then ask patient to swallow, advance under direct vision
- (no need antibiotics, as no bacteria in oesophageus)
- we can tell which part of the oesophageus we are in based on the length of scope
passed
- if any lesions seen, take biopsies
- if there is an annular lesion which scope cannot pass through, do not try to pass the
scope beyond that point as it can perforate and cause mediastinitis

What are the histological types of oesophageal cancer?

- Squamous cell
- Adenocarcinoma:
- typically in lower 1/3rd of oesophageus
- Can be due to:
- Barret’s oesophageus changing to adenoncarcinoma
- Encroaching gastric CA

Once oesophageal CA diagnosed, what investigations need to be done?

- Basic investigations to assess fitness for surgery (as patient will most likely go for
surgery): FBC, RFT, LFT, ECG
- Staging of disease: (Local/ Locally spread/ Metastases)
- Transoesopageal USS to assess depth
- CECT of chest and abdomen

What are the treatment options?

- Surgery: radical oesophagectomy

- after oesophageus is removed, there needs to be anastomoses between
stomach to pharynx (if entire oesophageus removed) or oesophageal stump
(if part of oesophageus removed)
- the stomach is tubularised and pulled upwards
- the anastamoses location can vary:
- chest (Ivor-Lewis): higher risk of mediastinitis and pleural effusion
- left clavicle (McKeowns): if it leaks, it leaks into the neck so no risk of
mediastinitis
- Now becoming popular is laparascopic oesophagectomy with throcascopy
 - Radiotherapy
- Chemotherapy also possible
- Palliative care: The most important thing is to allow patient to swallow as inability to
swallow is extremely distressing
- stenting
- bypass surgery: bring stomach into oesophageus by passing tumour, in front
of sternum

Case 02: Obstructive Jaundice due to Head of Pancreas Carcinoma

What is the difference between medical and surgical jaundice?

- Medical jaundice is due to prehepatic causes (such as haemolysis) and hepatic

causes (liver disease, enzyme deficiencies, cholestatic jaundice: hepatitis causes
obstruction of intrahepatic cannaliculi)
- Surgical jaundice is due to post hepatic obstruction of billiary tree

What are the causes of surgical jaundice?

- intraluminal: gallstones, parasites

- Intramural: strictures in biliary tree (most commonly due to past cholecystectomy, due
to malignancy such as cholangiocarcinoma)
- Extramural: Head of pancreas carcinoma, periampullary carcinoma. How to
differentiate the two causes
- Periampullary CA:jaudice is intermittant as tumour sloughs off and regrows
- Pancreatic CA: jaundice is persistant

What investigations would you order?

- Serum Bilirubin, direct and indirect

- USS abd:
- distension of Common Bile duct (usual is 6-8mm, >1cm means obstruction)
- If there is intrahepatic duct dilation without CBD dilation, it means obstruction
by liver or at hilum (such as perihilar lymph node enlargement by secondary
from gastric cancer)
-

Case 03: RIF mass due to Caecal Tumour

What are the causes of RIF mass and discomfort in 60 year old male?

General Surgical causes:

- Caecal Carcinoma
- Appendicular Mass
- Crohn’s disease (and less likely Ulcerative colitis)
- R/S diverticulosis (usually on the left side but right side is common)
 - Amoebiasis causing ameboma

Gyn: ovarian cyst, lateralized fibroid

GU: transplanted kidney, transplanted/ ectopic kidney

Bone: chondroma, osteosarcoma from pelvic bone

(Hernia is not common in RIF)

What investigations can be done to pinpoint the diagnosis?

- USS abdomen and pelvis: look to see if mass is cystic or solid and do CECT if solid
mass
- Colonoscopy, but it may be hard to see a caecal carcinoma so can do a CT
colonogram

Once Caecal Carcinoma is diagnosed, what is your management?

- Need to stage disease: is it confined to caecum or spread to other soft tissue,

peritoneum leading to ascites (to diagnose peritoneal mets, CT only shows fluid so
we need to do a diagnostic laparoscopy, however this is not routine), mets in liver
(best is gadolinium enhanced MRI)
- If tumour is confined to caecum:
- Right sided hemicolectomy (need to remove entire right colon asth entire right
colon shares the same lymphatic drainage)
- Along with a ileocolic anastomosis
- If there is a liver metastases:
- Remove if it is a resectable segment (each segment has it’s own blood
supply)
- If multiple lesions: palliate treatment such as intra-arterial chemotherapy
(inject chemo directly to hepatic artery)

Case 04: Per Rectal Bleeding due to Haemorrhoids

70 year old man presents with per rectal bleeding

What are the differential diagnoses for per-rectal bleeding?

- Colorectal CA
- Haemorrhoids
- Fissure (acute: painful, chronic: painless)
- Diverticulosis
- Inflammatory Bowel Disease (UC more likely that Crohn’s)

What investigations would you do?

 - FBC, CRP, ESR
- Sigmoidoscopy (not colonoscopy initially)
- Colonoscopy (if it clinically appears to be haemorrhoid, we still do a colonoscopy as
the two can co-exist)

Assume it’s haemorrhoids, what is the management?

- Conservative management for grade 1

- Treat constipation with foecal softner, encouraging squatting position when
passing stools (this relaxes the puborectalis muscle so less straining,
therefore use a squatting pan or if using a commode, use a bench to place
legs)
- Sclerosant injection: Inject phenol in almond oil via special syringe using proctoscope
- Barron’s Band Ligation
- Milligan Morgan Haemorroidectomy:
- Under spinal or epidural
- Principle: resect the overlying anal mucosa, cut and ligate the rectal artery,
remove the hypertrophied anal cushions at 3 7 and 11 o’clock positions.
Leave space between them else it can cause anal stenosis. Make sure
ligature is tight else it will get lose and bleed massively into rectum
- New mode of surgery: Haemorrhoid Artery Ligation (HAL) which is less invasive

Case 05: Painless Haematuria

What are the causes of painless haematuria?

- Bladder Carcinoma (and upper tract malignancy)

- Renal Cell Carcinoma
- Infection
- Staghorn calculi
- Rare causes: anticoagulants, bleeding disorders

What are the investigations you would do?

- Basic investigations: FBC and CRP, UFR and culture

- USS abdomen:
- can detect large bladder masses and especially renal masses
- Liver metastases, ascites
- CT urogram
- Pick up renal and bladder tumours
- But still can miss small/ flat bladder lesions thus follwed up with flexible
cystoscopy and ureterscopy
- MRI urogram if allergic to CT urogram, but they have the same effectiveness

Case 06: Breast Carcinoma

52 year old presented with a lump in RUQ of breast for the past 4 months. O/E it is a firm to
hard lump

What are the differentials?

- Breast Carcinoma
- Fibroadenosis
- Fibrocystic disease
- Trauma causing fat necrosis
- Tuberculous mastitis
- Rare: galactocoele, chronic abscess
- (Fibroadenoma is unlikely as it’s first appears in young women
- PHY SIO
- PHY: pericanalicular, hard, young
- SIO: soft, intracanalicular, old)

What are the other features to look for?

- Nipple discharge
- Skin changes
- Areolar eczema
- Other masses in same breast and opposite breast
- Axillary LN, palpable liver

What is triple assessment?

- Clinical assesment
- Radiological (USS/ Mammogram)
- Histopathology (FNAC/ Core biopsy)

What are the clinical features of malignancy?

- recent rapid growth, skin involvement, nipple discharge

- Risk factors: OCP, nulliparity, early menarche and late menopause, breast feeding
(protective), first child at < 30
- Hard lump, irregular margins

What are the investigations to do?

- Mammogram in this patient: due to increased fat, reduced breast tissue (due to
menopause)
- Features of malignancy: Microcalcifications, spiculated edges with irregular
margins, axillary LN enlargement
- Grading system: BIRADS (1-5, 1,2: benign, 3: suspicious, 4,5: malignant)
- USS: look for enlarged axillary LN
- FNAC: C1 to C5
- Histology:
- More invasive, more complications
 - Details on histology report:
- Ductal/ Lobular, Invasive/ Insitu
- ER, PR, HER 2 (worst prognosis is triple negative)

Also discussed Urological malignancies, refer Prof’s book for more information