1
SURGICAL PROTOCOLS FOR HOUSE OFFICERS
H. K. ADUFUL FRCS(Eng.), FWACS
The care of surgical patients involves a good understanding of the Physiology of the human body both in health and disease.
Surgical care involves the preoperative preparation of the patient, the postoperative care, and the subsequent discharge and Rehabilitation. A good work up of patients for both elective and emergency operation is therefore required. This involves good admission
notes, clinical examination, and ancillary investigations.
On admission:
1. Take the history of the presenting complaint, highlighting the salient points.
2. Past medical history; highlight history of hypertension, Diabetes mellitus, Sickle cell disease and other haemoglobinopathies,
renal disease, liver disease, deep vein thrombosis and pulmonary embolism, chronic obstructive airway disease and asthma.
3. Drug history should include all significant drugs taken in the past year. These should include non-steroidal anti inflammatory
drugs (NSAIDS), steroids, diuretics, cardiac drugs and antihypertensives, anti diabetics, anticoagulants, antiepileptics.
4. Allergies; all known allergies must be documented.
5. Examination; Perform a good clinical examination involving all systems.
a. Generally look for jaundice, pallor, dehydration and lymphadenopathy.
Investigations:
1. Full blood count and sickling test must be done on all patients admitted for operation unless this test has been performed in the
past two weeks and the patient has not bled since then.
2. Blood urea and electrolytes and creatinine (Renal profile) include blood glucose in all diabetics.
3. Liver function tests for all patients with hepato-biliary and pancreatic disease.
4. Thyroid function test must preferably be performed on all patients with goitre esp those with thyrotoxicosis.
5. X-Rays; Chest x-rays should be performed for all patients above the age 50yrs and all patients with hypertension, cardiac disease, chronic obstructive airway disease (asthma), previous history of TB, and patients whose clinical examination suggests a
chest infections.
a. Erect chest x-ray is required for all patients with peritonitis to rule out a perforated bowel as the cause of peritonitis (about
80% sensitive), and pancreatitis.
b. Other specific x-rays that may be required are barium enemas, cervical x-rays, thoracic inlet x-rays in goitres.
6. Ultrasound scan the request for this scan must usually be made in consultation with the Resident or Consultant on the unit. It is
indicated in all patients with suspected hepato-biliary and pancreatic disease, renal disease and gynaecological disease, patients
with abdominal masses and suspected intra abdominal abscesses.
7. Electrocardiograms (ECG): This investigation must be carried out on all patients with hypertension, cardiac, renal disease and
all elderly patients.
8. Pulmonary function tests must be performed on all patients with chronic obstructive airway disease, asthma and cardiac disease.
9. Arterial blood gases are also required for all patients with pulmonary and cardiac disease.
10. Other tests include
a. Indirect laryngoscopy for patients with goitres both for therapeutic and medico-legal reasons.
b. CT Scans
c. Angiograms
d. Other specialised investigations should only be requested with the approval of the Consultant in charge of the patient or his
resident.
11. Obtain and document all the laboratory, radiological, pathological and biochemical reports before any major ward round.
a. All abnormal reports must be discussed with Residents and action taken on them. Otherwise the results must be discussed
with the Consultant.
b. Remember to communicate all abnormal reports to the Anaesthetist and discuss patients with him or her.
12. Grouping and crossmatching of blood is required for a lot of surgical operations whether elective or emergency. The following
provide a rough guide to the blood requirement for some common major operations (see appendix)
13. Transfusion:
a. Transfuse pre-operatively only if indicated. Remember that each transfusion exposes the patient to the risk of HIV, Hepatitis B and C infection and may also reduce the immunity of patients with cancer.
14. Haemoglobin of 10g/dl or more is adequate for all surgical operations provided the rough guidelines above (12) is followed.
Remember that in patients with chronic anaemia e.g. Sickle cell patients a haemoglobin of 8 or 9g/dl is adequate warn the
Anaesthetist before hand.
15. Investigate all cases of anaemia by asking for
a. blood film comment, sickling and electrophoresis,
b. stool examination to rule out worm infestation
c. renal profile to rule out renal failure,
d. upper and lower GI endoscopy or Barium meal and enema to rule out GI tumours.
e. If the haemoglobin is below 9g/dl transfuse with at least 2 units of blood, which will raise the haemoglobin level by 2
units. Transfusion of one unit may not make any difference to the patient’s status.
16. Consent:
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2
a.
17.
18.
19.
20.
21.
Obtain informed consent from the patient or his or her closest relatives if he is not competent or is a minor after explaining
the operative procedure to him.
b. Remember to mention stomas (colostomies, ileostomies etc.) if there is the possibility of bowel resection.
Document the operative procedure clearly and if possible mark the site and side of the operation on the patient prior to the patient being given the preoperative preparatory drug(s).
a. For example site of hernias, breast lumps must be marked while the patient is awake to avoid the wrong being accidentally
operated on when the patient is asleep.
Postoperatively check the fluid requirement, pain relief and antibiotic regime of the patient daily.
a. In the case of fluid requirement check at least half daily and replace all NG and other losses with the appropriate fluid in
order not to build a large deficit at the end of the day.
b. Postoperative patients must have more regular pain relief if pethidine is used. Eight hourly regimes do not give adequate
analgesic cover. Two to 4 hourly regimes at lower doses may be the optimum.
Check the temperature, fluid and drug charts every day and act on any abnormalities. Remember to stop the administration of
drugs like antibiotics if they are not needed.
Check the full blood count of all patients on the 3rd postoperative day. In patients who bleed during operation and require transfusion however, check the full blood count 24 hours after transfusion.
Investigate all cases of fever in the postoperative period (see Surgical infections, DVT, PE)
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Prophylaxis against Deep Vein Thrombosis (DVT):
DVT prophylaxis is indicated in the following;
 Patients with a past history of DVT or pulmonary
embolism.
Obese patients

Elderly patients
Patients with malignant diseases

Patients undergoing pelvic operations.
Immobile patients
 Patients undergoing orthopaedic operations of the
Patients with a history of oral contraceptive pill uslower limb.
age.
 Septic patients
Patients with varicose veins undergoing major surgery.
Methods
Mechanical
 Early mobilization
 Graded compression stockings [Antithrombosis
stockings] e.g. T.E.D. (Thrombo-embolism Deterrent) stockings.
 Intraoperative intermittent pneumatic compression.
 Effective pain relief
 Deep breathing exercises
 Elevation of limb
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Pharmacological
 Subcutaneous Heparin 5000units bid. This method
has been shown to offer a clear advantage in reducing the incidence of DVT and PE.
 Low molecular weight heparin.
Enoxaparin (Clexane) 2000u subcut. Or
Dalteparin (Fragmin) 2500u subcutaneously daily.
Dextran
Heparinoids
Fundaparinux
Melagatran
A combination of the above methods reduces the incidence of DVT to less than 5%.
Aspirin? Aspirin prevents platelet aggregation and
hence clotting. It is, however, not useful in the acute
prevention of DVT i.e. in patients admitted for operation. It is, however, useful when taken over long
periods.
SURGICAL INFECTIONS
Surgical infection is of particular importance to the surgeon for the following reasons;
1. Surgeons treat infections and abscesses
3. The implications of these are increased cost to both the
2. Patients who develop postoperative infections
patient and the health system.
a. are likely to remain in hospital for longer periods
4. Prevention of postoperative infections is therefore of
b. require additional treatments e.g. operations, drugs
paramount importance and will result in considerable
and dressings.
savings to the patient and the health system
c. are delayed in the return to normalcy and work
5. Postoperative infections play a major role in the cause of
d. may develop wound dehiscence
fever after operations. Investigation of infections in the
e. may develop incisional hernias
post operative periods is therefore a major activity for all
doctors in the surgical unit.
Preventable surgical infections
 Wound infection
 Deep infections eg. intraabdominal infections and
abscesses ( subphrenic, subhepatic, pelvic and in-

fections within loops of small bowel), pleural infections etc.
Chest infections
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3

Urinary tract infections
Factors influencing surgical infection
1. Wound infection
Definition :
 discharge from wound of pus or material from
which pathogenic organisms are cultured
 accompanying wound oedema and cellulitis.
 In most cases manifest after patient has been discharged usually within 6 weeks.
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Infection of peripheral (thrombophlebitis) and central lines
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Deep infections especially those involving prosthetic materials may take months to manifest.
Several factors affect the incidence of wound infections and deep infections eg intra-abdominal sepsis.
These include the type of operation, preoperative
factors, and intraoperative factors.
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Factors influencing increased wound infection
Pre-operative factors
 Obesity
 Diabetes mellitus
 Malnutrition
 Alcoholism
 Shock, hypovolaemia
 Increasing
 Steroid
 Cytoxic therapy
 Anergy to recall antigens
 Irradiation
 Advanced malignancy
 Impaired circulation
 Re-operation
 Prolonged pre-operative stay
 Pre-existing infection or skin contamination
Poor tissue perfusion or hypoxia
Avascular tissue
Necrotic tissue
Foreign body
Haematoma
2. Chest infection
Predisposing factors
 Anaesthesia
 Upper abdominal incisions without inadequate analgesia
 Chest operations
 Immobility
 Pre-existing respiratory disease eg Asthma, COAD
etc.
 Others see above.
3. Urinary infection
 Predisposing factors
 Aseptic catheterisation
 Prolonged catheterisation
Intra operative factors
 Contamination from
o opened viscus
o patient skin
o operating theatre personnel
Prevention
Wound infection
Preoperative
 Antiseptic skin preparation
 Unshaved skin
 Adequate perfusion
 Aseptic technique
 Mechanical preparation of colon
 Gastric washouts in GOO
 Appropriate systemic antibiotics in contaminated
surgery either as prophylaxis or for treatment.
 Antiseptic soap wash
Intra-operative
 Adequate tissue perfusion and oxygenation (prevent
hypovolaemia or shock and reduced oxygen tension
during operation.
 Adequate lavage with normal saline
 Closed drainage avoiding egress through wound
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Monofilament sutures
Closed wound dressing
Delayed primary closure
topical antibiotics
2. Chest infection
 Early mobilisation
 Breathing exercises
 Adequate analgesia
3. Urinary tract infection
 Aseptic catheterisation
 Early removal of urethral catheters
4. Thrombophlebitis of the intravenous catheter site
 Remove catheter
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4
1.
2.
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6.
1.
2.
3.
Full blood count
Wound swab for culture and sensitivity
Blood cultures
Urine culture and sensitivity
Infected catheter tips for culture and sensitivity
Sputum culture and sensitivity
Investigations
7.
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9.
10.
11.
Management
Drain pus by removing wound sutures or in deep ab4.
scesses external (interventional radiology)aspiration or
5.
open drainage Laparotomy/thoracotomy, transrectal or
through posterior fornix
6.
Remove infected foreign materials and prosthesis.
Remove infected catheters and IV or central lines and
reset line on unaffected sites
Prophylaxis against infections:
 Antibiotic prophylaxis is required in operations
when,
 The patient has a synthetic prosthesis e.g. heart
valve, pacemaker etc. or if the patient has heart
valve disease.
 A synthetic material is to be inserted e.g. vascular
prosthesis, mesh repair of hernia, orthopaedic operation where metal prosthesis is inserted.
The appropriate antibiotic for prophylaxis must
1. be active against the organisms normally resident in the
hollow viscus to be operated on.
2. be given over a short period i.e. over 24 hours or less.
No added benefit is derived from continued use beyond
24 hours.
3. achieve a high blood and tissue concentration throughout
the operation.
Prophylaxis in Hepato-Biliary Surgery;
1. Organisms that are usually implicated in biliary tract
infections include E. coli, Klebsiella and other gut organisms.
2. Antibiotic prophylaxis therefore involves,
a. Gentamycin 80mg 8 hourly or 12 hourly for 24
hours.
b. Cefuroxime 750 mg 8 hourly.
c. Ceftriazone 2g stat
Radiology
Chest X-Rays
Abdominal ultrasound
CT scans and MRI
Scintigraphy WBC scans and Technetium scan
Mobilise
Encourage coughing and expectoration and institute
chest physiotherapy
Give antibiotics based on the possible organism causing
the infection (usually broad spectrum if gut flora involved) and give the appropriate antibiotic when culture
and sensitivity results are available
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A hollow viscus is to be opened e.g. cholecystectomy, bowel surgery, surgery on the urinary tract, and
surgery on the bronchial tree.
a.
It is hence given intravenously about an hour before
operation or during induction of anaesthesia.
However, some drugs can be given per rectum e.g.
metronidazole or orally e.g. ciprofloxacin.
i. These drugs are well absorbed and blood and tissue concentrations can match the levels achieved
when they are given intravenously.
b.
d.
e.
f.
3.
Ceftazidine 2g stat
Ciprofloxacin 400mg 12 hourly
Others include imipenem, piperacillin, which, are all
quite expensive and should only be used as second
or third line drugs in severe infections.
Prophylaxis should not continue beyond 24 hours unless
there is gross spillage of bile during operation.
Prophylaxis in Large Bowel Surgery
This involves both mechanical preparation of the bowel and antibiotic prophylaxis.
Mechanical preparation:
This involves the cleansing of the bowel of stool to decrease the bacterial load. Note that bowel preparation is not required when
the patient has an obstructed bowel.
Methods;
1. Oral mannitol 250 - 500mls of the 10% solution given
4. Oral balanced electrolyte solution i.e. Klean prep or
orally continuously till the stools passed are clear. This
GoLyTely 4.5 litres drank continuously till patient passgives a good bowel clearance.
es clear fluid.
2. Magnesium Sulphate 2 satchet in warm sweetened bev5. Others include colonic washouts and enemas, for lower
erage. Magnesium Sulphate is bitter when taken on its
GI procedures and suppositories to evacuate the rectum
own and hence will not be tolerated. Check the dosage
for anal procedures.
for paediatric patients before administration.
6. In all cases of oral bowel preparations the possibility of
3. Oral Picolax (Sodium Picosulphate) 2 satchet in water.
dehydration and circulatory collapse must be borne in
One satchet for the elderly.
mind. In such situations intravenous fluids (normal saline or Ringers Lactate) must be set up.
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1.
2.
Antibiotic prophylaxis:
Broad-spectrum antibiotics active against large
bowel organisms including anaerobes including
Bacteroides species must be used.
The combinations available include;
a. Gentamycin 80mg 8 or 12 hourly and metronidazole 500mg 8 hourly.
b. Second or third generation cephalosporins
and metronidazole 500mg 8hourly. E.g.
Prophylaxis in Surgery on the Stomach and the Small Bowel:
1. No mechanical bowel preparation is required, an overnight fast, however, ensures an empty stomach and very
little small bowel content.
Prophylaxis during insertion of prosthetic material:
 These procedures include the insertion of pace makers, arterial prosthesis and insertion of meshes for
hernia repair etc.
 The organisms most likely to cause infections in this
situation are mainly Staph. aureus, Streptococci.
The following combinations are usually used;
1. Cloxacillin or Flucloxacillin 500mg and Ampicillin
500mg to be given 6 hourly over 24 hours.
2. Co-Amoxiclav ( Augmentin ) 1.2 G stat
3. Gentamycin 80mg and Penicillin 2-4g stat.
2.
Prophylaxis during operations on patients with heart valve disease:
1. The organisms most likely to cause subacute endocardi2.
tis under these circumstances are Staph. epidermidis or
Strept. faecalis which are sensitive to Ampicillin or
Amoxycillin and Gentamycin.
d.
e.
Antibiotic prophylaxis follows the same guidelines as
those for large bowel.
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4.
5.
6.
c.
Cefuroxime 750mg 8 hourly or Ceftriazone
2g stat or Ceftazidine 2g stat.
Ciprofloxacin 400mg 12 hourly and metronidazole 500mg 8 hourly.
Clindamycin 600mg 8-12 hourly and Gentamycin 80mg 8 hourly
Erythromycin 1g 6hourly
Antibiotic prophylaxis is therefore aimed at these
organisms using mainly broad-spectrum antibiotics.
Cefuroxime 1.5 g stat
Clindamycin 300-600mg stat.
Erythromycin 1g stat in the event of penicillin allergy.
Give Ampicillin 1g and Gentamycin 80mg at induction
of anaesthesia and continue with Ampicillin 500mg 6
hourly and Gentamycin 80 mg 8 or 12 hourly.
The jaundiced surgical patient
The Surgeon is usually called upon to treat patients with extra-hepatic bile duct obstruction caused by
i. common bile duct stones
ii. carcinoma of the head of the pancreas
iii. lesser causes including lymph node enlargement in the porta hepatic, chronic pancreatitis, cholangiocarcinoma etc.
Pre-operative preparation of the Jaundiced patient:
Investigations:
1. Full blood count, sickling and clotting profile
2. Blood urea and electrolytes and serum creatinine (BUE
and Creatinine)
3.
4.
5.
Liver function tests
Ultrasound scan of the upper abdomen
others to be ordered by seniors; CT scan, PTC
Problems likely to be encountered in the patient with obstructive jaundice include.
1. Deranged clotting leading to bleeding as a consequence
ii. given an infusion of mannitol 200 to 500 ml of
of poor vitamin K absorption.
the 10% immediately preoperatively or during
a. To rectify this give 10 mg of Vitamin K intramuscuoperation to induce diuresis,
larly daily for 3 to 5 days.
iii. given prophylactic broad spectrum antibiotic.
b. In the emergency situation, however, 2-4 units of
3. Anaemia which should be corrected preoperatively.
fresh frozen plasma should be given at most an hour
4. Hypoglycaemia resulting from the inability of the liver
before operation.
to store glycogen.
2. Hepato-renal failure; this is a real problem especially
a. It is therefore necessary to infuse at least 1-2 litre(s)
during the post operative period.
of 10 % dextrose daily to prevent this complication.
a. It is related to dehydration leading to poor renal
5. Sepsis: Pooled bile in the biliary tree is a good culture
function.
medium and hence patients with obstructed jaundice are
b. It may also be related to sepsis.
prone to develop septicaemia especially when the biliary
c. To prevent this, the patient must be
tree is opened during bypass operations, ERCP and
i. adequately rehydrated prior to surgery.
stenting and also during percutaneous transhepatic cholangiography (PTC).
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a.
Antibiotic prophylaxis with broad-spectrum antibiotics, which are active against gram negative and
gram positive gut organisms for example, a. Gen-
THE DIABETIC SURGICAL PATIENT
Pre operative preparation of the Diabetic patient:
Always try to involve the diabetes Physician and the Anaesthetist in the management of all diabetic patients who need
operations.
Well controlled non-insulin dependent diabetic
Action
1. Schedule patient first or second on the list
2. overnight fast
3. check the blood glucose level on the morning of the operation
4. omit oral antidiabetic on the morning of operation and
convert to soluble insulin.
Insulin dependent diabetic for major Surgery;
Action
1. Schedule patient first or second on the list.
2. Overnight fast and omit morning dose of long acting or
intermediate acting insulin.
3. Check the blood glucose and urea and electrolytes an
hour before operation.
tamycin b. Cefuroxime or c. Ciprofloxacin etc. are
given.
The following scenarios may be encountered;
5.
6.
4.
5.
Start intravenous 5 or 10% dextrose alone or with insulin and potassium using the Alberti regime or any of its
modifications. (see below)
Plan to continue the Glucose, insulin, and Potassium
regime postoperatively.
Start 500 ml of 10-20% glucose with 10mmol potassium
and insulin depending on the blood glucose level. (see
Alberti regime below)
This regime is usually scheduled to run over 4 - 6 hours,
blood glucose should, however, be checked 2 - 4 hourly
and the necessary adjustment made to the regime.
Uncontrolled diabetic (hyperglycaemic or with ketoacidosis ) or diabetic patients presenting as emergencies;
Action
1. Involve the Diabetic Physician as early as possible.
6. Insert a wide bore cannula, 2 cannulae if possible.
2. Inform the Anaesthetist and involve him in the initial
7. Rehydrate the patient with normal saline or Ringers lacmanagement
tate.
3. Reschedule all elective operations until diabetes is con8. Start patient on the glucose, insulin, potassium regime (
trolled.
Alberti see below)
4. In the emergency situation aim to bring blood glucose to
9. Continue to monitor blood glucose every 2 -4 hours.
below 14mmol/l or ideally around 10mmol/l and correct
10. Catheterise the patient.
any attendant fluid, electrolyte, and acid/base imbalance.
11. start the patient on broad spectrum antibiotics
5. Check blood glucose, urea and electrolytes and depending on the patients condition the arterial blood gases and
pH.
Alberti Regime;
This regime is based on 500ml of 10-20% glucose, with
10mmol potassium and insulin dose based on the serum glucose level. Dextrose saline or 5% Dextrose can be used in the
place of higher glucose concentration in certain circumstancDiabetic for minor operation under local anaesthetic;
Action;
1. Patient need not starve
2. Early breakfast with oral antidiabetic agent or insulin as
usual.
es. This regime is administered over a 4 - 6 hour period and
must be reviewed over 2 - 4 hours.
Check protocol for the management of diabetic patients
from the Dept. of Medicine Korle-Bu
3.
If there is a long wait before operation set up 5% Dextrose infusion with or without insulin depending on the
blood glucose level.
THE SURGICAL PATIENT WITH RENAL FAILURE
These patients pose serious problems when they present for elective operations or in the emergency surgical situation. The main
problems include inability to handle fluid loads and also a rising serum potassium level that will lead to cardiac arrest if not treated
promptly.
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7
Urine output is no longer a parameter for determining the adequacy of hydration. The central venous pressure monitoring and
regular auscultation of the lungs helps to prevent overhydration.
Action;
1. Check the blood urea and electrolyte and creatinine.
2. Monitor the urine output by inserting a urethral catheter.
This helps to determine the amount of fluids to be administered since daily requirement is made up of insen-
3.
sible loss, the urine output and other losses e.g. NG aspirations.
Insert central venous catheter if available.
Sometimes urgent action is required when the patient’s serum potassium exceeds 6.5 mmol or if the serum potassium is rising so
fast that it may exceed the level quoted earlier before the next test result is obtained.
Action
1. Start intravenous 10% glucose with 10 mmol of insulin.
2. Give calcium resonium per rectum or orally. Ca++ is
This facilitates the transport of glucose and potassium
exchanged for K+ . If Na+ is low Sodium resonium is
into the cell, and hence helps to reduce the serum potasused.
sium level.
3. Contact the Renal Physician as early as possible to arrange dialysis.
SURGICAL EMERGENCIES
Surgical emergencies present situations where prompt action to stem the physiological changes that the Pathological condition
induces is needed and hence help to determine the outcome of surgery.
The patient who presents with a surgical emergency may have been starving for hours or days, or may have lost body fluids through
bleeding, vomiting, diarrhoea, and third space fluid loss. In addition the Patient may have an infection e.g. peritonitis.
Such a patient may therefore present with shock, fluid and electrolyte depletion, and acid base imbalance. Preopoerative preparation is therefore of paramount importance to try and correct as near to normal as possible, the fluid, electrolyte and acid-base imbalance. This gives the patient the best chance of survival.
All emergency patients must be fully clerked, noting the onset of symptoms, any treatment given, current medication, allergies,
anaesthetic problems in the past and the time of the last meal the patient took.
Perform a thorough examination and make note of all your findings. Arrange all necessary investigations, and institute initial treatment.
Relieve pain; an element of caution has to be exercised here. If review by a senior person is expected within 15 to 20 minutes
then it is better to withold analgesics until the patient is reviewed. As may usually be the case, however, the resident may be held up
in a clinic or theatre and might therefore not be able to review the patient within an hour or more. Under such circumstances a single dose of analgesics can be given. Avoid putting patients on regular analgesics before a senior reviews.
Call your Resident to review the patient.
Emergency conditions likely to present to the House Officer and their management include;
Intestinal Obstruction:
Causes;
1. Hernias both external and internal
2. Adhesions and Bands; Laparotomy scars and children
with intestinal obstruction.
3. Obstructing tumours; older patients with change in bowel habits, weight loss rectal bleeding, anaemia etc.
4. Volvulus of small and large bowel; sudden onset with
rapidly increasing abdominal girth.
Investigations:
1. Full blood count (FBC) Sickling.
2. Blood urea and electrolytes and creatinine.
3. Group and save or crossmatch blood at least 2 units in
the adult.
4. Erect chest x-ray may show gas under the diaphragm
signifying a perforation, or evidence of chest infection.
5.
6.
7.
5.
6.
Intussuception; Colicky abdominal pain, abdominal
mass, red currant jelly stool, rarely mass at the rectum.
Worms; only seen in children with heavy worm infestation.
Gallstone ileus; Very rare in our environment. Characteristic x-ray finding of small bowel obstruction and gas
in the biliary tree.
Plain abdominal x-ray; supine films are quite adequate
to diagnose intestinal obstruction and shows up as dilated loops of bowel. An erect abdominal film, however,
shows air fluid levels.
Special x-rays e.g. Instant barium enema is only used to
determine the level of large bowel obstruction and
should only be requested by a more senior person.
Action:
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1.
2.
3.
4.
5.
Nil by mouth
Start intravenous fluids Normal saline or Ringers lactate.
Give the initial one litre over at least 45 minutes to 60
minutes.
Pass a nasogastric tube
Pass urethral catheter and monitor the urine output aiming at 30 - 50 ml/hr in the adult or 1 - 2 ml/kg/hr in the
Paediatric patient.
Start patient on broad-spectrum antibiotics. (Gentamycin
or Ciprofloxacin or Cephalosporins, and metronidazole).
6.
7.
8.
Bacteria always translocate through the bowel wall when
it is obstructed.
Prepare the patient for operation by explaining the operation and obtaining informed consent from the patient or
his relatives.
Remember that some patients with intestinal obstruction
secondary to adhesions may be managed non operatively. These patients have soft non-tender abdomen and
show signs of improvement whilst on admission.
the possibility of construction of stomas must be explained to patients and their relatives
Peritonitis:
Inflammation of the peritoneum may be localised or generalised. Localised peritonitis has the potential of spreading to involve the
whole of the peritoneum.
The source of infection is usually from a hollow viscus but occasionally generalised peritonitis may develop in patients with nephrotic syndrome. Peritonitis secondary to tuberculosis is not included here since the usual presentation is chronic abdominal pain.
Localised peritonitis;
Causes
1. Acute cholecystitis
2. Acute appendicitis
3. Acute diverticulitis
4. Salpingitis
5. Inflammatory bowel disease e.g. Crohn’s disease rare.
Investigation;
1. Full blood count and sickling.
2. Blood urea and electrolytes, creatinine and blood glucose.
3. Ultrasound scan (cholecystitis and salpingitis)
4. Liver function tests and serum amylase.
Apart from acute appendicitis most cases of localised peritonitis are managed non-operatively with antibiotics unless spreading
peritonitis sets in.
Action;
1. Nil by mouth. If a non-operative treatment is envisaged,
4. Start intravenous antibiotics using broad-spectrum antihowever, sips of water can be allowed.
biotics including metronidazole. In Acute cholecystitis,
2. Start intravenous fluids dextrose saline or normal saline
however, metronidazole is not required routinely except
or Ringers lactate.
in diabetics.
3. Nasogastric tube is required in those who are vomiting.
The following combinations are useful;
 Gentamycin and Metronidazole or Clindamycin.
 Cefuroxime or Cefotaxime and Metronidazole or
Clindamycin.

Ciprofloxacin and Metronidazole or Clindamycin.
In cases of Salpingitis it is expedient to add Tetracycline or Doxycycline to cover Chlamydia, which is a common cause of this
condition.
In acute appendicitis prepare the patient for appendicectomy.
Acute appendicitis can present as a right iliac fossa mass indicating a simple phlegmon or an abscess. Conditions to consider in
this situation are carcinoma of the caecum in the over 40’s, amoeboma, or Crohn’s disease.
Action;
1. Conservative treatment is usually advocated for appendix mass.
2. Nil by mouth
3. Intravenous fluids
4. Analgesics
5.
Antibiotics? Controversial. Advocates of antibiotic therapy, however, abound. Follow what your Consultant
recommends. I advocate antibiotics and I recommend
metronidazole or Clindamycin with Gentamycin or
Ciprofloxacin or Cefuroxime for all patients with appendix masses.
Appendix abscess which is characterized by swinging pyrexia, continued ill-feeling and enlarging right iliac fossa mass should be
treated by a combination of antibiotics and drainage of the abscess.
8
9
In all patients over 40 years whose appendix masses resolve with conservative treatment, arrange a Barium enema to rule out caecal
carcinoma before interval appendicectomy.
Occasionally Acute cholecystitis may present with a mass in the right hypochondrium. This may be due to an inflammatory mass
involving the gall bladder, bowel and omentum, or an empyema of the gall bladder.
Action;
In addition to the usual FBC and Sickling and BUE arrange an urgent ultrasound scan.
If the diagnosis is empyema of the gall bladder prepare the patient for operation (cholecystectomy or cholecystostomy ). Remember
to keep the patient on broad spectrum antibiotics.
Acute diverticulitis is not a common condition in our environment. It presents with signs similar to acute appendicitis but localised
in the left iliac fossa. It is an affliction of older individuals usually above the age of 40.
Investigation
1. FBC Sickling
2. BUE
3.
4.
Action;
1. Nil by mouth
2. Intravenous fluids
3. Intravenous antibiotics metronidazole or clindamycin
and gentamycin or cefuroxime or ciprofloxacin.
4.
Erect chest X-Ray (May show gas under the diaphragm
if there is perforation)
Plain abdominal X-Ray
When the condition settles, arrange a Barium enema to
confirm the diagnosis and rule out left sided or sigmoid
carcinoma.
Salpingitis usually presents a diagnostic problem in young women. It must be suspected if the patient has just had her periods and
also has vaginal discharge.
Tenderness is suprapubic and usually bilateral and cervical excitation is positive.
Treatment;
1. Broad-spectrum antibiotics including tetracycline or
doxycycline and pain relief.
2. If pain, tenderness and hyperpyrexia persist despite antibiotic treatment then consider the possibility of pelvic
3.
abscess, spreading peritonitis or pelvic appendicitis and
prepare for operation.
An initial laparoscopy prior to operation may help to
resolve the diagnostic problem.
Generalised Peritonitis:
Generalized infection of the peritoneum is a cause of severe morbidity and mortality. It can be associated with severe complications
if not recognized and treated properly. Peritonitis associated with perforation of the large intestine carries a bad prognosis from the
effect of faecal peritonitis.
Causes;
1. Perforated appendix
5. Perforated diverticulum
2. Perforated duodenal or gastric ulcer
6. Strangulated and perforated bowel
3. Typhoid perforation
7. Pelvic inflammatory disease and septic abortion
4. Perforated gall bladder
8. Ischaemic bowel.
Investigation;
1. Full blood count and sickling.
2. Group and crossmatch 2 units of blood.
3. Blood urea and electrolytes and creatinine and serum
amylase.
4. Blood glucose
Action;
1. Nil by mouth
2. Set up intravenous fluids normal saline or Ringers lactate with wide bore cannula. Give the first litre of fluid
over 45 to 60 minutes.
3. Remember that the preoperative resuscitation of patients
before operation is of paramount importance if such
gravely ill patients are to survive.
a. The initial fluid for resuscitation must therefore be
as near physiological as possible.
5.
6.
7.
8.
Blood culture
Erect chest x-ray (gas under the diaphragm)
Supine abdominal x-ray (dilated paralysed bowel).
Electrocardiogram (ECG) in old individuals.
b.
4.
Use Ringers lactate or normal saline or colloid
preparations like haemacel.
c. Do not use 5% Dextrose or maintenance fluids eg.
Badoes solution in the initial resuscitation protocol.
All losses from the nasogastric tube or diarrhoea must
however, be replaced volume-for-volume with normal
saline containing potassium or gastrointestinal replacement fluid.
9
10
5.
6.
7.
8.
9.
Potassium deficit can usually be corrected by adding 20
millimoles of potassium to each litre of intravenous fluids once urine output exceeds 30ml/hr.
Pass a nasogastric tube
Pass a urethral catheter and monitor urine output hourly
aiming at 30 - 50 ml/hr or 1-2-ml/kg/hr.
Relieve pain.
Change all oral medications to intravenous, rectal or
sublingual forms.
10. Start intravenous broad-spectrum antibiotics.
a. Metronidazole in combination with Gentamycin or
Ciprofloxacin or Cefuroxime or Ceftriazone.
b. Clindamycin and Gentamycin
c. In typhoid fever use a combination of Metronidazole and Ciprofloxacin or Ceftriazone and metronidazole.
11. Prepare the patient for operation.
Gastrointestinal Bleeding:
Bleeding from the gastrointestinal tract can be life threatening and can also be very stressful not only to the patient, but also to relatives and attending doctors alike.
Level headedness is therefore paramount in the management of this frightful condition and following laid down protocols help a lot
to alleviate the stress involved.
Upper Gastrointestinal bleeding;
Causes
1. Chronic or acute duodenal ulcer
2. Erosive Gastritis secondary to NSAID, steroids, aspirin
usage, and alcohol abuse.
3. Gastric ulcers.
4. Oesophageal and gastric varices
5. Neoplasia Gastric carcinoma, leiomyomas and gastric
lymphoma
Action;
1. Insert a wide bore cannula (2 more acceptable) and take
blood for
2. Full blood count and sickling, Clotting screen,
3. Crossmatch at least 4 units of blood and 2 units of fresh
frozen plasma
4. Blood urea and electrolytes and Liver function tests.
5. Start Normal Saline or Ringers lactate or preferably colloid solution (Remember the best solution is blood). Run
a litre of fluid over 30 - 45 minutes if patient is in shock.
6. If possible insert a central venous line to monitor the
central venous pressure.
7. Nil by mouth in case operative treatment becomes necessary.
8. Pass a urethral catheter and monitor urine output hourly.
Aim at 30-50mls of urine hourly.
6.
7.
8.
9.
9.
10.
11.
12.
13.
Stress ulcers following severe burns or trauma or severe
sepsis.
Mallory Weiss tears.
Blood dyscrasias.
Others including Dieulafoy syndrome
Take a good history asking about peptic ulcer disease,
NSAID use, alcohol abuse (oesophageal varices, acute
gastric erosions), abnormal bleeding.
Start intravenous Ranitidine 50mg 8 or 12 hourly or
intravenous omeprazole 40mg 12 hourly if peptic ulcer
is suspected to be the cause of bleeding.
Insert a large bore Nasogastric tube warns of continued
bleeding. (note that the use of nasogastric tubes may be
controversial so follow your team’s procedure.
Prepare patient for possible endoscopic injection sclerotherapy or injection of bleeding ulcer or operative intervention.
Inform your Resident or Consultant.
Lower gastrointestinal bleeding:
This condition is characterised by the passage of bright red or slightly altered blood per rectum. Bleeding may sometimes be torrential and hence patient may present in shock.
Usual causes include;
1. Haemorrhoids
2. Carcinoma
3. Polyps
4. Diverticular disease
5. Colitis infective or ischaemic.
6. Fissure in ano
7. Angiodysplasia in the elderly.
Action
1. Follow the same procedure as for upper GI bleeding in
your resuscitative effort.
2. Remember that massive upper GI bleed eg bleeding DU,
bleeding varices and bleeding from the small bowel sec-
8.
9.
Solitary rectal ulcer etc.
bleeding may also come from the small bowel where the
commonest in our environment is bleeding from the
Peyers patches secondary to typhoid fever.
10. Occasionaly bright red bleeding from the rectum is secondary to massive upper gastrointestinal bleeding.
ondary to typhoid ulcer may present as lower GI bleed
with the passage of bright red bleeding.
10
11
Bleeding haemorrhoids can sometimes be torrential and can quickly lead to exsanguination. When confronted with such a situation follow the protocol above and in addition to this
1. Elevate foot end of the bed
2. Pass a large Foley’s catheter with at least a 20 ml balloon per rectum. Inflate the balloon with water till it is retained in the rectum. Now put some traction on the catheter to make the inflated balloon sit in the anorectum to put pressure on the bleeding
haemorrhoid.
3. Keep the balloon on for about 4 to 6 hours and then deflate to check if bleeding has stopped, which is usually the case, then
remove the catheter. If bleeding is still a problem re-inflate the balloon and call for help.
Most cases of lower GI bleeding stop spontaneously and need to be investigated afterwards.
Further investigations;
1. Proctoscopy
2. Sigmoidoscopy Rigid or flexible
3. Colonoscopy
4. Barium enema
5.
Other special investigation usually requested by more
senior personnel.;
a. Red cell scan
b. Selective mesenteric angiogram.
Acute Pancreatitis:
Presents with acute abdominal pain and can mimic a variety of acute abdominal conditions eg Acute peptic ulcer or perforated peptic ulcer or acute cholecystitis or peritonitis etc.
Diagnosis is therefore made with a high index of suspicion.
Investigation;
1. Full Blood count and sickling
2. Blood urea and electrolytes and creatinine and Calcium.
3. Serum amylase
4. Blood glucose.
5. Liver function tests.
6.
7.
8.
Action;
1. Insert a large bore cannula
2. Nil by mouth
3. Intravenous fluids start with Normal saline or Ringers
lactate. Do not use 5% Dextrose.
4. Pass a urethral catheter to monitor the urine output and
aim at an hourly output of 30 - 50 mls with your infusions.
5.
6.
7.
Erect Chest X-Rays look for effusions and atelectasis.
Plain abdominal x-ray. Look for sentinel jejunal loop,
colonic cutoff, and pancreatic calcification.
Others include arterial blood gases which usually abnormal in severe cases.
Relieve pain with Pethidine, or morphine with an antispasmodic.
Pass a nasogastric tube.
Note that the treatment of acute pancreatitis is mainly
symptomatic and is aimed at the correction of shock,
pain relief and prevention and treatment of respiratory
problems etc.
Prevention of pancreatic abscess;
1. The use of antibiotics in acute Pancreatitis is controversial. Recent evidence, however, points to some beneficial effects in preventing pancreatic abscess. Drugs of proven efficacy are Ciprofloxacin or second or third generation cephalosporins.
2. You should follow your Consultants protocol and do not start any antibiotics until the patient is reviewed.
Gastric outlet obstruction:
Causes;
1.
2.
3.
Chronic doudenal or prepyloric ulcer - due stricture or
oedema.
Hypertrophic pyloric stenosis (Congenital and adult)
Carcinoma of the antrum
1.
2.
Dehydration and electrolyte and acid base imbalance.
Shock leading to renal failure
1.
2.
Full blood count and sickling
Group and crossmatch at least 2 units of blood for operation.
Blood urea and electrolytes and creatinine and blood
glucose.
3.
4.
5.
6.
Problems;
3.
4.
Leiomyoma of the antrum and duodenum
Carcinoma of the head of the pancreas
Pancreatic pseudocyst.
Metabolic alkalosis
Hyponatraemia, hypokalemia, hypochloraemia.
Investigation;
4. Erect chest x-ray to rule out aspiration pneumonia.
5. Plain abdominal x-ray and barium meal.
6. Upper GI endoscopy.
11
12
Action;
1. Insert a wide bore cannula
2. Start intravenous fluid, Use only normal saline or dextrose saline with added potassium in the resuscitation
since these fluids are acidic compared to blood and contain sodium, potassium and chloride ions and hence help
to correct the acid base and electrolyte imbalance. Do
not use 5% dextrose, Ringer’s lactate or any maintenance fluid in your resuscitation.
3. Pass a urethral catheter to monitor urine output aiming at
30 - 50 ml / hour.
4. Pass a nasogastric tube. This helps make the diagnosis,
help keep track of continued losses, and also help to
prevent vomiting and its attendant aspiration pneumonia.
5.
6.
7.
8.
Check urea and electrolytes regularly and correct any
abnormality.
Remember that until the serum electrolytes are within
the normal range the patient electrolyte derangement is
not corrected and hence fluid prescription should not include 5% dextrose or maintenance fluid.
All continued losses from the Nasogastric tube must be
replaced volume for volume with normal saline or dextrose saline containing at least 10mmol of potassium/litre.
Obtain consent for operation
Abscesses:
Breast abscess;
1. Mainly occurs in young women most of whom are lactating.
2. Best treatment involves;
a. Evacuation of pus by incision and drainage or aspiration through a wide bore needle or cannula and
b. Antibiotics, which are active against Staph. Aureus.
3. In the middle aged and elderly an underlying Carcinoma
of the breast must be suspected and biopsies taken during incision and drainage.
Investigation;
1. Full blood count and sickling
2. Blood urea and electrolytes.
3. Blood sugar
4. Prepare the patient for operation.
Perianal abscess
Investigation;
1. Full blood count and sickling.
2. Blood urea and electroytes.
3. Blood glucose or urine glucose.
Action;
1. Best treatment is incision and drainage.
2. Antibiotic treatment is only indicated in diabetics, patients with immune suppression or those who are septicaemic. Use gentamycin or ciprofloxacin or cefuroxime
and metronidazole or clindamycin.
The usual organisms involved are Strept. pyogenes and
Staph. Aureus.
Investigation;
1. Full blood count and sickling.
2. Blood urea and electrolytes
3. Blood glucose
4. Blood culture in the severely ill.
Pyomyositis:
These patients are usually very ill with deep abscesses affecting the big muscle masses.
Investigations;
1. Full blood counts and sickling
2. Blood urea and electrolytes
3. Blood glucose
4. Blood cultures.
Action;
1. Start intravenous fluids normal saline or dextrose saline.
2. Start intravenous antibiotics use Benzylpenicillin and
gentamycin or Flucloxacillin or Cloxacillin or Augmentin or Cefuroxime.
3. Prepare the patient for incision and drainage.
4. Relieve pain
Gluteal abscess (Injection abscess);
Investigations;
1. Full blood count and sickling
2. Blood urea and electrolytes
3. Blood/urine glucose
Action;
1. Best treatment is incision and drainage.
2. Antibiotics needed in Diabetics, the immunosuppressed
or patients who are septicaemic.
Cellulitis;
Examine all peripheral pulses to rule out arterial insufficiency as a predisposing factor.
Rule out diabetes mellitus.
Action;
12
13
1.
Intravenous antibiotics Benzylpenicillin and gentamycin
or Benzylpenicillin and flucloxacillin or cloxacillin or
coamoxyclav.
2.
3.
4.
Elevate the affected limb.
Incision and drainage if subcutaneous abscess forms.
Give prophylaxis against DVT
UROLOGICAL EMERGENCIES
Acute Retention of Urine:
Causes;
1. Benign Prostatic Hyperplasia (BPH)
2. Carcinoma of the Prostate
3. Urethral Stricture
4. Hypertrophic bladder neck
5. Posterior Urethral Valves in children.
6. Clot retention
Investigations;
1. Full Blood count and Sickling
2. Blood urea and electrolytes and serum creatinine
3. Urine for culture and sensitivity once catheter is inserted.
4. Serum PSA
Action;
1. Relieve pain by giving IM Pethidine 75-100 mg.
2. Catheterise patient with Foley’s catheter Ch 14 or 16.
3. Anaesthetise the urethra with 5-10 ml of 2% lignocaine
gel and hold or clamp the penis for 2-5 minutes to facilitate easy catheterisation.
4. Give patient antibiotics eg. IV Gentamycin 80 or 160 mg
stat, IV Ciprofloxacin 200mg stat, or Oral Ciprofloxacin
500mg stat or iv Cefuroxime 1.5g stat..
5. If catheterisation fails or is unduly traumatic then a urethral stricture may exist hence a suprapubic catheter is
required. Call the Urology Resident.
Chronic urinary retention;
Presentation of this condition can be varied and include;
2. Catheterise the patient and put him on slow decompres1. Overflow incontinence
sion of the bladder after the BUE and Creatinine results
2. Inability to pass urine with no pain.
are known.
3. Lower abdominal mass
a. Problems expected after catheterisation;
4. Uraemia and confusion i.e. signs of renal failure.
i. Excessive diuresis leading to dehydration and
hyponatremia.
Investigations;
1. Full Blood Count and sickling
ii. Bleeding from the urinary tract. Slow decom2. Blood urea and electrolytes and serum creatinine.
pression of the bladder therefore advocated.
3. Blood sugar
3. Give broad-spectrum antibiotics as for acute urinary
4. Blood for PSA (consider the cost of this procedure.
retention.
Hence discuss with the Resident)
4. Set up intravenous fluids eg. Normal saline since the
patient may pass large amounts of isotonic urine post
Action;
catheterisation and will become dehydrated.
1. Admit the patient.
5. Assess the prostate gland.
6. If catheterisation fails call the Resident to perform a
suprapubic catheterisation.
Ureteric Colic
Diagnosis is made by;
3. Full blood count and sickling
1. Colicky loin pain radiating to the groin or scrotum or
4. BUE, serum creatinine and serum calcium.
labium majus.
5. Urine calcium and phosphate (Consult the urological
2. Tenderness in the renal angle, or in the right iliac fossa
team before ordering this test.)
(RIF) if the stone is held up at the point where the ureter
crosses the common iliac artery.
Action;
3. Microscopic haematuria.
1. Admit the patient.
2. Relieve pain give IM Pethidine 50 - 100mg and IM
Investigation;
Buscopan 20-40mg stat. or Suppository Diclofenac
1. Urinalysis i.e. Urine R/E or Dipstick examination of
100mg 18 hourly
urine.
3. Strain all urine passed to recover stone since most stones
2. Plain abdominal X-Ray (KUB) this can be followed by a
less 6mm in diameter will pass spontaneously.
formal IVU or ultrasonography after review by the resi4. Refer the patient to the Urologist for further investigadent or Consultant.
tion and management.
Haematuria;
Haematuria must be taken seriously and fully investigated
since it may herald the presence of serious conditions like
carcinoma, schistosomiasis etc.
Causes
1. Renal
a.
b.
c.
Renal cell carcinoma
Transitional cell carcinoma (TCC) of the renal pelvis
Renal calculus
13
14
d.
2.
3.
4.
5.
Analgesic nephropathy (analgesic induced papillary
necrosis.)
Ureter
a. Calculus
b. Transitional cell carcinoma of the ureter
Bladder
a. Schistosomiasis
b. Carcinoma of the bladder TCC or Squamous cell
carcinoma
c. Calculus
d. Cystitis
Prostate
a. Benign prostatic hyperplasia (BPH)
b. Carcinoma of the prostate
c. Prostatitis
Urethra
a. TCC
b. Urethritis
Severe bleeding from the bladder and the prostate can lead to
clot retention and acute urine retention.
Investigations;
1. Full blood count (FBC) sickling and clotting screen.
2. Blood for grouping and x-matching
3. Urinalysis i.e. Urine for routine examination.
4. Urine for culture and sensitivity.
5. Urine for cytology.
6. Plain abdominal x-ray (KUB) if calculi are suspected.
7. Intravenous urogram (IVU)
8. Cystoscopy
9. CT Scan to be ordered only by a senior person.
Action;
1. Admit the patient
2. Relieve pain by giving 50-100mg of pethidine intramuscularly.
3. Pass a wide bore urethral catheter 20ch or above preferably a whistle tipped catheter to facilitate the washing
out of clots. A three way catheter for the irrigation of the
bladder must be passed if bleeding is very heavy.
4. Give antibiotics initially intravenous (use cefuroxime or
Ciprofloxacin etc)
5. Continue further investigations
VASCULAR EMERGENCIES
Acute arterial occlusion
Causes
 Embolism
 Thrombosis
 Trauma
Embolism (Mainly thromboembolism)
An embolus is an abnormal mass of undisclosed material
which is transported from one part of the circulation to another.
Types.
Source of emboli
Heart
 Atherosclerotic heart disease
 Coronary artery disease
 Acute MI
 Arrythmia (atrial Fibrillation)
 Valvular disease
o Rheumatic
o Degenerative
Arterial thrombosis
 Atherosclerosis
 Low flow states
o CCF
o Hypovolaemia
o Hypotension
Arterial trauma
Penetrating trauma
 Direct vessel injury
 Indirect injury


Raynauds disease and phenomenon
Vasoconstrictor drugs e.g ergot





Thrombi and clots
Gas
Fat
Tumour
Miscellaneous (septic etc
o Congenital
o Bacterial
o Prosthetic
Artery-to-artery
 Aneurysm
 Atherosclerotic plaque
 Idiopathic
Paradoxical



Hyper coagulation (polycythaemia, activated protein C resistance [factor V Leiden], protein S&C,&
antithrombin III deficiencies)
Vascular grafts
Intimal hyperplasia


Missile emboli
Proximity of injury to arteries
14
15



Blunt trauma
 Intimal flap
 Spasm
Iatrogenic
Intimal flap
Dissection
Presence of medical device
 Microembolization
Outflow venous occlusion
 Compartment syndrome
 Phlegmasia caerulea dolens
Drug effect
 Ergot
Other causes of acute arterial occlusion
External compression
Drug abuse
 Intraarterial administration
 Drug toxicity
 Contaminant
Clinical manifestation






Acute embolisation
Sudden onset
Pain
Paraesthesia
Pallor
Pulselessness
Perishing cold (Poikilothermia)
Investigation
 There is usually no time
 FBC, Sickling
 Clotting profile
 Fibrinogen and fibrin degradation products
 BUE and Creatinine
 Blood glucose
 ECG
 Chest X-Ray
 Creatinine phosphokinase
Action
 Anticoagulate the patient
 Give a bolus of IV Heparin 10,000U
 Then follow up with IV Heparin 500-1500u/hr by
continuous infusion
 Nonoperative
o High dose anticoagulation
 Prepare the patient for Emergency Embolectomy
Complication
 Myonephropathic syndrome
 Extreme pain, rigidity and oedema.
 hyperkalaemia, metabolic acidosis, elevated CPK,
LDH, AST
 myoglobunuria leading to ATN
 Ischaemic reperfusion injury (release of free radicals, deleterious cytokines etc. into circulation)
 ARDS
 Paralysis
In thrombosis there is less pronounced injury to tissue due to
previous collaterals formation. Prolonged ischaemia leads to
cellular swelling. Muscle is stiff and wooden.





Urine myoglobin
Arteriography
o Usually there is no time for this patient
may be unduly held in the X-ray unit. Useful in trauma when ‘soft signs’ are present.
o May be of use in theatre as completion angiograms.
Duplex scanning
Delayed embolectomy
o Delayed diagnosis with the limb still viable
Thrombolysis
o TPA
o Urokinase
o ? Streptokinase
 Multiple organ failure syndrome MOFS (Sepsis)
 MI
NOTE: The complications listed above are very serious
and may result in serious morbidity with loss of limb and
mortality. Hence acute arterial occlusion must be recognized promptly and help called for.
Chronic arterial occlusive disease of the lower limb
Aetiology
 Atherosclerosis
o Senility Prevalence increases with age such
that 20% of people over 70 years of age
have the disease.
o
o
Diabetes melitus 2-4 fold increase in risk)
Hyperlipidaemias
 Hypercholesterolaemia
 Elevated triglycerides
15
16
o
o
o
o
Cigarette smoking
Hypertension 2-3 fold increase in risk
Abnormalities of homocysteine metabolism
Low levels of oestrogen
Clinical features peripheral arterial disease of the lower limb
 Pain: Intermittent claudication of calf, foot and buttock, progressing to rest pain, worse at night due to
reduced cardiac activity. Rest pain relieved by lowering the affected limb. Patient therefore sleeps with
affected limb hanging out of bed.
 Pulses: Decreased or absent
 Colour: Pale with elevation, rubor with dependencyin pale skin people only.
 Temperature: Colder than unaffected side
 Oedema : Absent or mild; may develop as patient
tries to relieve rest pain by lowering leg,
 Skin changes: Skin is thin and atrophic with loss of
hair. The nails are thickened and ridged




Popliteal entrapment
Aneurysms
Vasculitides (Raynauds phenomena etc.)
Buergers disease

Ulceration: Toes, dorsal foot, areas of trauma esp.
lateral malleolus. May also be seen in the web space
esp. in diabetics. Painful and relieved by dependency. Irregular edge with poor granulation. Bleeds only a little with manipulation. There may be associated gangrene
Muscle: Atrophy particularly below the knee
Gangrene: May be present and is preceeded by rest
pain and ulceration. May start as digital gangrene
and is usually dry.


Features of peripheral arterial disease in other organs
Brain: Carotid artery disease which may present as stenosis or aneurysm. Stenosis is symptomatic and require surgical intervention
when the occlusion is > 70%.
 Clinical presentation is due to microembolisation (platelet emboli) and usually present as
o Transient ischaemic attack (TIA) - transient hemiparesis with full recovery within 24 hours.
o Reversible ischaemic neurological deficit (RIND) – same as above but full recovery up to 35 days.
o Full blown stroke
o Amaurosis fugax – transient blindness ( a curtain being drawn over the eyes and back)
The Heart: Due to coronary artery disease, angina pectoris, myocardial infarction
The bowel
 Due to mesenteric artery disease
 Small bowel ischaemia leading to abdominal angina (abdominal pain after meals)
 Gangrene of the small bowel secondary to complete occlusion or thrombosis.
 Bleeding per rectum due to inferior mesenteric artery disease
The upper limb
The upper limb may occasionally suffer from peripheral arterial disease but this is quite uncommon in our environment. Raynaud
disease and Raynaud’s phenomenon are the usual chronic arterial disease encountered in the upper limb
Evaluation of peripheral arterial disease
Physical examination
o The carotids, the abdominal aorta, the renal
 Pulses by palpation:
arteries (epigastrium and renal angles), the
 Palpate and comment on the nature of the arterial
femorals for bruits. This may indicate stricwall which may be calcified in senile atherosclerosis
tures or aneurysms of the involved vessels.
or in diabetics. Compare pulses of the right to the
 Pulses by Doppler studies
left and also the lower limb pulses to the upper limb
pulses and note any delays.
 Ankle Brachial Pressure Index (ABPI)
 Palpate for aneurysms
 Systolic pressure in the posterior tibial or doro Aorta in the epigastrium slightly to the left
salis pedis arteries is divided by the systolic
of the midline, iliac arteries in the iliac fospressure in the brachial artery.
sae, femorals and popliteal
 Normal 0.9-1.2
 Auscultate
Investigations


FBC Sickling
BUE and Serum creatinine


General
Fasting blood sugar
Serum lipids


Cholesterol
Triglycerides
16
17


Chest X-Ray
ECG
Vascular laboratory
Treadmill Exercises with Doppler Studies, ABPI)
Bicycle Ergometer exercises Doppler Studies, ABPI)
Noninvasive
 Waveform analysis
 Duplex scan
 Triplex (Duplex + colour Doppler)
Radiology
Invasive
 Angiography
 Standard
 Arterial Digital Subtraction angiogram (DSA
Treatment
Conservative
 Encourage exercises. Graded exercises. Improves
the formation of collaterals
 Stop smoking will arrest progression of disease esp.
Buergers.
 Control hypertension
Interventional radiology
 Percutaneous Angioplasties
 Stenting
Surgical operations
These are undertaken usually after angiograms when the site
and extent of the arterial occlusion is demonstrated and also
when the vessel or vessels distal to the occlusion are found to
be patent.
Amputation
Are necessary when the limb is not viable either because of
overt gangrene or when the limb has been deprived of its
arterial blood supply for more than 6 hours and is cold and
paralysed. Amputation is life saving in such circumstances.
Sympathectomy
 Improves blood supply to the skin by causing vasodilatation of the arterioles and hence may help in relieving pain and promoting wound healing. It is
usually reserved for the elderly who will not benefit
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Control hyperlipidaemias (diet and Statins HMGCoA reductase inhibitors)
Control diabetes
Antiplatelet therapy (Aspirin, Clopidrogel, Cilostazol)

Short single strictures
Methods
 Endartectomy
 Bypass operations
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Below knee
Above knee
Disarticulation at the hip
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from angioplasty or bypass operations because of
poor run-offs.
Chemical
Operative
Venous thromboembolism
amounts of interspersed fibrin with relatively few
platelets
A thrombus is basically a clot formed in the cardiovascular system in the living person.
 Two types of venous thromboembolism are recognised
Thrombi are composed of fibrin and blood cells
o Deep vein thrombosis (DVT)
formed in any part of the cardiovascular system.
o Pulmonary embolism (PE)
In thromboembolism clots which are formed in one
 The triad of venous stasis, hypercoagulability of
part of the cardiovascular system are transported to
blood and venous endothelial damage (Virchow’s
other areas of the same system and may result in setriad) is recognized as the basis for venous thromvere morbidity or mortality to the patient.
bosis. The various clinical risk factors are related to
Venous thrombi are formed in areas of stasis and
this triad.
are composed mainly of red cells with large
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Deep vein thrombosis
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Acquired factors
Surgery (orthopaedic operations of the lower limb,
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pelvic and general abdominal operations)
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Trauma and sepsis through hypercoagulabilty
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Immobilisation mainly due to stasis
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Obesity through stasis
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Cancer especially abdominal cancers but all cancers
increase the risk of DVT

Pregnancy
Nephrotic syndrome
Oral contraception & (HRT)
Antiphospholipid antibody syndrome
Hyperhomocysteinaemia
Dehydration as in patients with intestinal obstruction and peritonitis
Age greater than 45 years
Genetic factors (Thrombophilia)
Factor V Leiden (activated protein C resistance
 Protein C deficiency
[APC resistance])
 Protein S deficiency
Prothrombin G20210A mutation which leads to in Hyperhomocystenaemia
crease of prothrombin level in blood
Antithrombin III deficiency
Clinical risk factors (THRIFT consensus)
High risk
 Major illness eg. Heart/lung disease, cancer
 Fracture or major orthopaedic surgery (pelvis, hip
 Major trauma or burns
and lower limb)
 Minor trauma, surgery or illness plus history of
 Major pelvic or abdominal operation for cancer
DVT,PE or thrombophilia
 Major surgery, trauma or illness in patients with
 Age above 45
previous DVT, PE, or thrombophilia
Low risk
 Lower limb paralysis (hemiplegic stroke or paraple Minor surgery (<30 minutes)
gia.
 Minor trauma or medical illness
 Major limb amputation
 Young patients
 Will need all the prophylactic regimes discussed be May require only graded compression stockings and
low.
other mechanical prophylaxis
Moderate risk
 Other major surgery and another risk factor such as
varicose veins, immobility
Clinical features
 Common
 Pain full limb
 Tenderness
 Swelling and oedema of the limb. Usually starts
from the ankle and spreads upwards.

 Differential warmth. The affected limb is warmer
than its fellow. The limb is not cold and must therefore not be confused with acute arterial occlussion
 There may be low grade fever
 Occasionally there may be prominent superficial
veins of the limb.
 Less common
o Phlegmasia alba dolens white limb secondary to arterial spasm in the face of acute
DVT
Investigations
 Doppler ultrasonography
 Duplex and colour duplex
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
Phlegmasia cerulea dolens the ‘blue’ lim
which results from extensive venous
thrombosis in which all the tributary veins
of the femoral vein are blocked. This is the
beginning of venous gangrene.
Clinical signs are non specific and not reliable because the are not very different from other cause of
swollen painful lower limb like cellilitis, lymphangitis and ruptured Baker’s cyst etc or non painful conditions like lympoedema and oedema secondary to
cardiac failure. Hence a high index of suspicion is
required to make the diagnosis.
o
Plethysmography
Venography
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
D-dimer test
Treatment
1.
Prophylaxis
2.
Treatment of established cases
Prophylaxis
Mechanical
 Mobilisation
 Elevation of limb
 Graded compression stockings
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Intermittent pneumatic compressions
Effective pain relief
Deep breathing exercises
Pharmacological
 Unfractionated heparin (5000u subcut bd)
 Low molecular weight heparin
 Dalteparin (2500-5000u Subcut. Daily)
 Enoxaparin (2000-4000u Subcut. Daily)
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Fundaparinux
Heparinoids
Dextran
Melagatran
Established DVT
Treatment should start once there is suspicion of DVT.
1. Physical
 Elevation of limbs
 Graded compression stockings

2. Anticoagulant therapy
 Heparinisation
Unfractionated Heparin
o Bolus heparin 5000-10,000u intravenously
o Continuous intravenous infusion 2840,000units/24hrs with an infusion pump
o Or IV 1000-1500units/hr
o Alternatively Subcut. Heparin 15,00017,500u 12hrly if continuous infusion
pump is not available
o Check APTT daily and maintain between
1.5 and 2.5 of the control
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Low molecular weight heparin
o Inactivate Factor Xa
o Produce predictable response
o Laboratory monitoring is therefore not
necessary not necessary
o Less likely to produce thrombocytopaenia
o Dose: dalteparin 100u/kg 12hourly,
enoxaparin1mg/kg 12hrly subcut.
Warfarinisation
Oral Warfarin is started on the same day as heparin treatment is started if the diagnosis is certain
Dose: 10mg day 1,10mg day 2, 5mg day 3, and 5mg daily on subsequent days
Oral dose may vary from patient to patient sometimes based on treatments the patient may be taking concurrently
Check the INR on the 3rd or 4th day of treatment
If the INR is within the therapeutic range of 2-3 then stop intravenous or subcutaneous administration of Heparin. (note
that the therapeutic range may vary from laboratory to laboratory)
Monitor INR and keep between 2-3
Use the INR result to adjust the daily dose of Warfarin (note that the maintenance dose may sometimes be below or greater
than 5mg daily)
Thrombolysis
 Probably only indicated in phlegmasia cerulea
dolens.
 Complications of bleeding very high.
 Agents rTPA, Urokinase, ?Streptokinase
Thrombectomy
 Only indicated in phlegmasia cerulea dolens with
eminent venous gangrene.
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Pulmonary embolism
Clinical diagnosis highly non specific

cardiorespiratory, musculoskeletal conditions may

mimic the condition

Transient shortness of breath

Sharp localised chest pain aggravated by inspiration

(pleuritic-type pain)
Haemoptysis
Severe shortness of breath
Associated right-heart failure
Hypotension
Syncope
Peripheral circulatory collapse
Pulmonary angiogram best
 Ventilation/perfusion scans
 D-dimer test if available
 Chest X-ray not diagnostic but rules out differential
 Arterial blood gases
diagnosis
 Look for DVT
 ECG rules out some cardiac cause of symptoms.
Acute right ventricular strain however diagnostic.
Treatment
 Same as for established cases of DVT
 Involves initial heparinisation before any transport of patient for investigation.
 Treatment must start if there is any index of suspicion
Appendix
Salivary gland operation group and save only
Thyroidectomy
x-match 2 units blood
Mastectomy
x-match 2 units blood
Bowel resection
x-match 2 units blood
Gastrectomy
x-match 2 units blood
Vagotomy and drainage x-match 2 units blood
Hemicolectomy
x-match 2 units blood
APER
x-match 2-4 units blood
Splenectomy
x-match 2 units blood
Pancreatectomy
x-match 4-6 units blood
Cholecystectomy
Gastro-jejunostomy
Strangulated hernia
Amputation
Nephrectomy
Partial nephrectomy
Open prostatectomy
Operations for priapism
Total cystectomy
group and save
group and save
x-match 2 units blood
x-match 2 units blood
x-match 2 units blood
x-match 4 units blood
x-match 4 units blood
x-match 2 units blood
x-match 4 units blood
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