SURGERY
12/8/10
Venkatesh, B et al (2003) “Data Interpretation in Critical Care Medicine” Elsevier
Alex Psirides Notes
PY Mindmaps
FANZCA Part II Notes
Aortic Dissection
Hypertensive Emergency
Priorities
1.
2.
3.
4.
5.
Rapid diagnosis and assessment for surgical intervention
Aggressive blood pressure control
Prepare for massive blood loss
Quantify degree of end-organ ischaemia
Quantify co-morbidity
ABC
Large bore IV access
Analgesia
Anti-hypertensives: esmolol, labetalol, GTN, hydralazine, SNP
Imaging: CT or TOE
Urgent cardiothoracic opinion
AS
SR
Low normal HR
Good preload
High afterload
Normal contractility
Blood conservation
Preoperative
Intraoperative (anaesthetic and surgical)
Postoperative
Burns protocol (EMSB)
Primary Survey – airway burn
Secondary Survey
Burn assessment & management – cool burn, site, depth, TBSA, type of burn (staff
protection), special areas, need for escharotomy, fluid, analgesia, first aid, covering, early
debridement and grafting, CO poisoning
Chest trauma - death within minutes (ATOM FC)
Jeremy Fernando (2011)
Airway compromise
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
Chest trauma - death within hours-days (POTMAD)
Pulmonary contusion
Oesophageal injury
Tracheo-bronchial injury
Myocardial contusion
Aortic injury
Diaphragmatic injury
Cervical Spine Assessment + Management
Protect
History – pain
Examination – swelling, deformity, tenderness
Investigations – 3 xray views + CT (high resolution, 1-2mm slices with sagittal
reconstructions -> misses <1% of injuries)
Classes of Hypovolaemic Shock
I (<20%) to IV (>40%)
P
Systolic BP
CR
LOC
Compartment Syndrome
Surgical emergency -> urgent decompression
Keep limb @ level of heart
Release all bandages
Pressure within 30mmHg of diastolic pressure = diagnosis
Facicotomy
IVF
Stablise #
Monitor for multi-organ failure
Cerebral Perfusion Pressure
CPP = change in pressure (MAP – ICP or CVP)
CBF = CPP/resistance
Cerebral Protection
Aim = prevention of secondary injury
Jeremy Fernando (2011)
A, B, C, D, E approach
Damage Control Surgery
Open
Pack
Resect and stop bleeding in quadrants
Cover
Resuscitate
Definitive care
Determinates of Myocardial O2 Supply and Demand
SUPPLY
-
arterial O2 content (Hb and SpO2)
diastolic BP
HR
blood viscosity
coronary vascular resistance
LVEDP
DEMAND
- myocardial wall tension
- HR
Double Lumen Tube Indications
“Lung isolation”
1.
2.
3.
4.
Blood
Pus
Bronchopleural fistula
Pulmonary carcinoma for large extraction
Electrocution
Turn off power
ACLS protocol
Trauma protocol
Burn protocol
Epidural Abscess
Rapid assessment & diagnosis
Definitive management within 8 hours
Fractured NOF Anaesthesia
Jeremy Fernando (2011)
Priorities
1.
2.
3.
4.
5.
Early operations
Fluid resuscitation
Diagnose reason for fall
Assess and manage co-morbid conditions (polypharmarcy, falls, IHD, COPD)
Liaise with loved ones
Head injury
Prevent secondary injury
Optimise CPP
Manage raised ICP
Protect and assess c-spine
Haemostatic Resuscitation
Permissive hypotension
Early RBC’s
Early plasma & platelets
Pro-coagulant therapy
ICP management
- optimise blood flow in and out of the brain
- decrease the brains metabolic rate
- osmotherapies
L->R Shunt
Aim: decrease shunt
High PVR
Low SVR
Life Threatening Bleeding Sites (CRAFT)
Chest
Retroperitoneum (pelvis)
Abdomen
Floor
Thighs bones
Liver Failure
CAUSES (DAVE): drugs, alcohol, viruses, extras (acute fatty liver of pregnancy, HELLP,
eclampsia, toxins, vascular, metabolic, autoimmune)
MSD
CVS: hyperdynamic and vasodilated, cardiomyopathy
Jeremy Fernando (2011)
RESP: orthodeoxia, platypnoea
GI: ascites, hepatosplenomegaly
GU: hepatorenal syndrome
HAEM: coagulopathy -> major blood loss
CNS: encephalopathy, increased ICP
ELECTROLYTES: hyponatraemia, hypokalaemia, elevated ammonia, hypophosphataema,
hypoglycaemia
Long Anaesthetic
-
invasive monitoring
hypothermia cares
pressure care
IDC
analgesia
VTE prophylaxis
post-operative ventilation
Massive Transfusion in Trauma
= replacement of patients entire blood volume within 24 hours OR >250mL/hr OR >
150mL/min
IV Access and equipment
Notify haematology, blood bank, ICU, surgery, radiology
RBC 10U
FFP 10U
Plt 2U
Cryo 2U
Reverse anti-anticoagulants
Anti-fibrinolytic agents
Consider Damage Control Surgery or rFVIIa (100mcg/kg)
Neck Trauma
Priorites:
1. Secure airway
2. Protect C-spine
Assess – history (AMPLE), examination (ob’s, neck), investigate (xrays, CT, endoscopy),
management (GORD prophylaxis, prokinetics, O2)
Options:
Awake cricothyroidotomy/tracheostomy
Awake direct laryngoscopy
AFOI
Inhalational induction
Femoral-femoral bypass
OLV and Hypoxia
Jeremy Fernando (2011)
Check O2 supply -> ETT
Cardiac output
V/Q mismatch
FiO2 1.0
Suction
CPAP to operative lung
PEEP to dependent
Intermittent reinflation
Clamp bronchial artery if doing pneumonectomy
Return to two lung ventilation
Pancreatitis (I GET SMASHED)
Idiopathic
Gall stones
Ethanol
Triglycerides
Steroids
Mumps and other viruses (EBV, CMV)
Autoimmune disease (SLE, polyarteritis nodosa)
Snake or scorpion bites
Hyper – calcaemia, lipidaemia, Hypothermia
ERCP
Drugs (SAND – sulphasalazine, azathioprine, NSAIDS, diuretics)
OR
Idiopathic
Obstructive
Parenchymal
Polyuria in Traumatic Brain Injury
Osmotic diuretic induced (mannitol)
Diabetes insipidus
Alcohol associated diuresis
Cerebral salt wasting syndrome
Hypertonic salt administration
Appropriate response to fluid therapy
Hypertensive diuresis
Hyperglycaemia
Prognostication in TBI
Clinical Predictors
- age (>55 is predictive of poor outcome)
- initial GCS post-resuscitation
- hypotension and hypoxia
Jeremy Fernando (2011)
-
pupil size and reaction to light
ICP
nature & extend of the intracranial injuries (worst to least, subdural -> extradural -> SAH)
co-morbidities
Radiological Predictors
-
presence of cisterns
midline shift
lesions
whether lesions evacuated
brainstem injury
- MRI @ 6-8 weeks: injuries to corpus callosum, corona radiate and dorsalateral brainstem ->
higher incidence of PVS
Plastic Surgery
Difficult airway
Long anaesthetics
Poor access to patient
Smooth emergence
Analgesia (mild to moderate pain + LA use)
High maintenance clients
R->L Shunt
Aim: optimise RV function and PVR
Low PVR
High SVR
Renal protection
1. Careful fluid management
2. Avoid nephrotoxic agents
3. Ensure adequate emptying
There are a number of other issues -> divide into pre, intra and post op
Scoliosis Surgery
Preop – assess patient, MSD,
Intraop – monitoring neurologically, bleeding, long, no relaxant
Postop – hyponatraemia, bleeding, neurological monitoring
Sitting Position
- long operation
- airway access
- airway swelling and trauma
Jeremy Fernando (2011)
-
hypotension
DVT cares
VAE
pressure cares
Tourniquets
Minimise time (max 2 hours)
UL = systolic + 50mmHg
LL = systolic x 2
Systemic
CVS – increased SVR, increased circulating volume, increased HR and BP -> hypotension and
vasodilation post deflation
RESP – increased PvO2, increased MV
CNS – increased CBF and ICP on release
HAEM – increased platelet aggregation, hypercoagulable, increased tPa -> systemic
thrombolysis post release, no increased in DVT
METABOLISM – increased catecholamines, isolated limb -> hypothermia, increased K+,
lactate, CO2 and O2 consumption
Local
Nerve injury
Muscle injury
Vascular injury
Skin injury
Trauma Intubation
RSI with inline immobilisation
If hypoxic bag
Relax CP if affecting view
1.
2.
3.
4.
5.
DL
DL with boujie
LMA or ILMA
Optical stylet
Surgical cricothyroidotomy
Trauma protocol (EMST)
Primary Survey – management of life threatening injuries + resuscitation
Airway with C-spine control (open, adjuncts, ETT)
Breathing with O2 (rule out life threatening chest injury)
Circulation with control of external haemorrhage (2 x large IV access, trauma bloods, IVF)
Disability with rapid neurological assessment (AVPU, pupils, glucose, limb movement)
Exposure with hypothermia care (undress, log roll and keep warm)
Investigations:
- xrays (lateral c-spine, CXR and pelvis)
Jeremy Fernando (2011)
-
cross match
FBC
U+E
LFT’s
amylase
Secondary Survey - head to toe assessment + definitive treatment
Transfusion Risks
Haemolytic
- ABO
- Rh
- Kell Duffy
Allergic
-
TRALI
transfusion reaction
anaphylactoid
anaphylaxis
graft vs host disease
purpura
Infective
- virus (HIV, Hep B and C)
- bacterial
- protozoan
Other
-
citrate toxicity
hyperkalaemia
massive transfusion
TACO
Vasospasm management
- prevention: removal of SAH at surgery, nimodipine, maintenance of euvolaemia, avoiding
hypotension
- monitoring: clinical, transcranial doppler, 4 vessel angio, CTA/MRI, EEG, SPECT/PET,
microdialysis catheters
- treatment: haemodynamic augmentation to reverse neurological deficits, endovascular
treatment (balloon angioplasty, papaverine, nicardipine), investigational therapies
Jeremy Fernando (2011)