Indications In Srgery

INDICATIONS IN SRGERY Dr. Hiwa Omer Ahmed Assistant Professor in General Surgery

(‘a living problem is better than a dead “cert”’ ) Grey Turner

BURN

• The indications for admission include: • (1) All patients liable to shock (that is all burns over 10%). • (2) Any patient who has burnt his face, eyes, hands, feet or perineum, whatever the size of his burn. ALWAYS admit a child with a burnt hand size. • (3) All patients who have inhaled smoke. If possible, refer all these patients • 4. Electrical and Chemical burn • 5. cold burn • 6. pregnant ladies

HEAD injury

• A head injured patient should be referred to hospital if any of the following is present: Impaired consciousness (GCS (15/15) at any time since injury – Amnesia for the incident or subsequent events – Neurological symptoms, e.g. • • • •

severe and persistent headache nausea and vomiting irritability or altered behaviour seizure

– Clinical evidence of a skull fracture (e.g. CSF leak, periorbital haematoma) – Significant extracranial injuries

– A mechanism of injury suggesting: • a high energy injury (e.g. road traffic accident, fall from height) • possible penetrating brain injury • possible non-accidental injury (in a child)

– Continuing uncertainty about the diagnosis after first assessment – Medical comorbidity (e.g. anticoagulant use, alcohol abuse)

Indication of skull x ray • • • • • • • •

History of ^ ICP Features of ^ ICP Suspected # skull Penetrating wounds of head HVM wounds of head Severe facial-maxillary injuries Unconscious patient with trauma Deteriorating patient

INDICATIONS OF Head CT scan

• CT remains the investigation for the diagnosis and management of many central nervous system diseases. • MRI is superior in the posterior fossa and parasellar region and for the assessment in multiple sclerosis, epilepsy and tumours. • CT is superior to MRI in the assessment of head injury. • Indications for CT imaging, CT Angiography, and CT venography include

CT Scan in Head Injuries Selection of adults for CT Scan • Urgent Scan if any of the following (results within 1 hour) – GCS <13 when first assessed or GCS<15 two hours after injury – Suspected open or depressed skull fracture – Signs of base of skull fracture** – Post-traumatic seizure – Focal neurological deficit – >1 episode of vomiting – Coagulopathy + any amnesia or LOC since injury

• A CT scan is also recommended (within 8 hours of injury) if there is either: – More than 30 minutes of amnesia of events before impact – Or any amnesia or LOC since injury if • Aged ≥65 years • Coagulopathy or on warfarin • Dangerous mechanism of injury – RTA as pedestrian – RTA - ejected from car – Fall > 1m or >5 stairs

Selection of children (under 16 years) for CT Scan • Urgent scan if any of the following: – Witnessed loss of consciousness >5 minutes – Amnesia (antegrate or retrograde) >5 minutes – Abnormal drowsiness – ≥3 Discrete episodes of vomiting – Post-traumatic seizure (no PMH epilepsy)

– GCS <14 in emergency room (Pediatric GCS<15 if aged <1) – Suspected open or depressed skull fracture or tense fontanels – Signs of base of skull fracture** – Focal neurological deficit – Aged <1 - bruise, swelling or laceration on head >5cm

• Dangerous mechanism of injury (high speed RTA, fall from >3m, high speed projectile).

Indication of anti-tetanus

• Every simple wound in patient not

immunized in the previous 5 years Give ATS

• Every laceration or maceration or deep wounds in patient not immunized in

the previous 5 years Give ATS & Toxoid

Indications for snake antivenin

• • • •

G 1; 1-2 AMPULES G2 ; 2-3 G3 ; 5-15 G4 ; FREELY IN DRIP TILL NEUTRALIZATION

Not need admission and sent home

Advice for the person taking a patient home from the A&E Department • [Name] ........................... has suffered a head injury, but does not need to be admitted to a hospital ward. We have examined the patient, and believe that the injury is not serious. Very rarely complications can develop as a result of the injury, so please watch the patient closely over the next day or so and rouse gently every couple of hours, and follow this advice:

– Do not leave the patient alone in the home. – Make sure that there is a nearby telephone, and that the patient stays within easy reach of medical help. – Symptoms to look out for: • Is it difficult to wake the patient up? • Is the patient very confused? • Does the patient complain of a very severe headache?

• Has the patient: – – – –

vomited? had any fits? lost consciousness? complained of weakness or numbness in an arm or a leg? – complained about not seeing normally? – had any watery fluid coming out of their ear or nose?

• If the answer to any of these questions is 'Yes' or you are worried about anything else, you should telephone the Accident and Emergency Department on:

SRGERY in Acute abdominal pain

• represents 1% of hospital admissions and 6% of emergency visits 1. These cases cause a burden on the hospital and physician especially the nonspecific abdominal pain, which is defined as acute abdominal pain of less than 7 days‘ duration, and for which there is no diagnosis after examination and baseline investigations 2. Challenging as it is, a careful history-taking, thorough evaluation of symptoms, head-to-toe physical examination, and judicious use of laboratory tests can simplify the evaluation of this complaint.

However, some cases still remain confusing after all diagnostic tools have been utilized. An option that is taken is "wait and see" by hospitalizing the patient and performing frequent examinations when they have non-typical signs. The predictive value of this method was estimated between 68-92%. This method may pose undue risk upon the patient from complications such as peritonitis, hemorrhage, or infertility. However, if active measures are taken, laparotomy may be performed unnecessarily. So Laparoscopy indicated:

LAPAROSCOPC FNDNGS N THESE CASES • • • • • • •

Laparoscopic finding Number of patient Appendicitis 73 Pelvic inflammatory disease 14 Significant ovarian cysts 7 Endometriosis 3 Ectopic pregnancy 2 Meckel’s diverticulitis 1

SURGERY IN THYROID

Surgery is indicated in

simple goitre if: • There is clinical or radiological evidence of compression • Substernal goitres: are best removed surgically, as biopsy is difficult and clinical observation without frequent CT or MRI scans is impossible • The goitre continues to grow • Cosmetic reasons if large or unsightly.

Thyrotoxicosis • Indications for thyroidectomy are 1.Patient preference, e.g. fear of radio-iodine 2.Children (radio-iodine or prolonged drug treatment remain an option) 3.Pregnancy (medical treatment is usually preferred) 4.Large goitre (particularly multinodular goiter, with local compressive symptoms) 5.Severe reaction to anti-thyroid drugs (but radio-iodine remains an option) 6.Severe ophthalmopathy (medical therapy remains an option) 7.Suspicious nodule plus hyperthyroidism (perform fine needle aspiration cytology first) 8.Complex situations, e.g. poor compliance with antithyroid drugs and radio-iodine is refused.

Thyroid nodules • Indications for surgery : 1.Malignant or suspicious fine needle aspiration cytology 2.Larger nodule with repeated non-diagnostic fine needle aspiration 3.Continued growth of nodule after fluid removal and thyroid hormone therapy 4.Symptomatic nodules (pain or pressure) 5.Continued patient anxiety 6.Some clinicians recommend surgical removal of all nodules of diameter over 4 cm 7.Hot nodules: a hyperthyroid hot nodule should be treated with radioiodine or surgery. Surgical thyroid lobectomy is effective and safe therapy for hot nodules, and the risk of hypothyroidism after a hemithyroidectomy is low.

Urinary catheter

Urethral catheterization is contraindicated in • the presence of traumatic injury to the lower urinary tract (eg, urethral tear). • This condition may be suspected in male patients with a pelvic or straddle-type injury. • Signs that increase suspicion for injury are a 1.high-riding or boggy prostate 2. perineal hematoma 3. blood at the meatus. When any of these findings are present in the setting of concerning trauma, a retrograde urethrogram should be performed to rule out a ureteral tear prior to placing a catheter into the bladder

Chest tube

1. 2. 3. 4. 5. 6.

Postoperative Prophylactic (pneumothorax) (hemothorax) (pneumothorax or hemothorax) lung abscesses or pus in the chest (empyema).

NG tube

1. DIAGNOSTC • to drain gastric contents • assessment of GI bleeding • obtain a specimen of the gastric contents decompress the stomach • Administration of radiographic contrast to the GI tract

2. THERAPUTIC • Administration of medication • drainage and/or lavage in drug overdosage or poisoning. • In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration • MANAGEMENT of GI bleeding. • NG tubes can also be used for enteral feeding initially. • Comatose patients have the potential of vomiting during a NG insertion procedure, thus require protection of the airway prior to placing a NG tube • GASTRIC Irrigation before operation

CONTRAINDICATONS • Absolute contraindications – Severe midface trauma – Recent nasal surgery

• Relative contraindications – Coagulation abnormality – Esophageal varices or stricture – Recent banding or cautery of esophageal varices – Alkaline ingestion

The indications for central lines 1.Measurement of CVP 2. Central venous access devices (CVADs) are used to deliver larger volumes of irritating solutions, such as antibiotics, blood products, parenteral nutrition media, and sclerosing chemotherapeutic agents. 3.If patients need prolonged IV access, a CVAD is preferred to a peripheral IV line. 4.Central access is also indicated when peripheral access cannot be achieved; however, in an emergency situation, an intraosseous needle is probably the primary choice according to Pediatric Advanced Life Support (PALS) guidelines.

Peripheral intravenous central catheters

Although the lines are placed peripherally, usually in the antecubital or superficial saphenous vein, the distal tip remains in a large central vein. • PICC lines are indicated in children who require intermediate-term IV access for prolonged home or hospital therapy, such as those with human immunodeficiency virus (HIV) infection, cystic fibrosis, osteomylitis, meningitis, or cancer. • The success of introducing the PICC line is greater if attempts at inserting noncentral peripheral lines are limited. Therefore, PICC placement should be attempted as soon as the need for intermediate-term access is apparent.

Umbilical artery catheters and umbilical vein catheters • Useful in the first few days of life. • The umbilical vein can be used for access during the first 5-7 days but is rarely used beyond 7 days. • Both and UACs and UVCs can be used: UAC is used for blood pressure monitoring, and UVC is used for central venous pressure monitoring.

VENUS CUT DOWN • Emergent venous access, when attempts to gain access by the peripheral or percutaneous routes have failed.

contraindications • Coagulopathy or bleeding diathesis • Vein thrombosis • Overlying cellulitis

Surgery and Antibiotics

• • • •

Clean Clean contaminated Contaminated Dirty

nil periop. periop. therap.

• Clean wounds in the following groups must receive perioperative antibiotics; • Cancer • Immunodefiecent • have foreign bodies • With DM and Coagulopathy

INDICATIONS FOR SKIN TEST

• EVERY ANTITOXIN • EVERY NEW PARENTRAL DRUGS • EVERY CONTRAST MEDIA

INDICATIONS TO STOPE DRUGS

Examples

• Antithyroid day before OP • beta blockers in toxic goiter 7-10day postOP • Contraceptive 3 weeks pre OP in 1.operations on pelvis 2.operations on lower limb 3.using of tourniquet • Oral antidiabetics day before OP and replaced by soluble Insulin

DON’T GIVE

• Don’t give steroid in acute head injury • Don’t give opiate in biliary disease and surgery • Don’t give opiate in head injury • Don’t give analgesia in undiagnosed acute abdomen before decision • Don’t suture wounds (except facial and scalp) after 6 hours from the injury • Don’t give heparin I.M. • Don't give PP I.V.

• Don’t give blood unless indicated • Don’t give antibiotics unless indicated • Don’t give K+ unless there is normal urine output ( 30-50ml/ hr )

DON’T FORGET

• Don’t forget that 15-20 of all suspected acute appendicitis there is normal appendix, and this well accepted scientifically • Don’t forget to give antispasmolytics in biliary disease and surgery • Don’t forget to search for features of hypocalcemia in scorpian stings • Don’t forget to ask every patient about allergy to any drug, contrast or anasthetic agents • Don’t forget to remove any torniquet within 45 minutes

• Don’t forget that 50% of surgical diseases not need surgery • Don’t forget to mark with skin pencil the side of OP in double organs in the body • Don’t forget to sign informed consent and sign by your patient • Don’t forget that adult patients are free not to any treatment ,drug, investigations ,imaging or OP • Don’t forget that every inpatient / day costs 380 $

The indications for thoracotomy following blunt thoracic trauma

• are the following: 1. 50—1000 ml of blood at the time of initial drainage is common and may need no further action, but greater volumes, especially if the blood is fresh, require intervention; 2. continued brisk bleeding (>100 mI/15 minutes) from the intercostal drains indicates a serious breach of the lung parenchyma and urgent exploration is required; 3. continued bleeding of >200 ml/hour for 3 or more hours may require thoracotomy under controlled conditions; 4. rupture of the bronchus, aorta, oesophagus or diaphragm; 5. cardiac tamponade (if needle aspiration is unsuccessful).

INDICATIONS OF SURGERY IN PEPTIC ULCERS

1.ulcer resist treatment for 5 years 2.Complicated PU as; • Perforation • Bleeding • Obstruction • Suspicion of malignancy

Priority in surgical lists • • • •

Child first Major OP first Co-morbidity first Clean first

universal precautions for HIV & HEPATITIS • wearing either safety spectacles or a face mask • a gown which provides waterproof protection to the sur-geon’s anterior trunk and arms. • boots rather than open-toed shoes should be worn to improve protection to the feet should something sharp be dropped.

• wearing two pairs of gloves: it is usually more comfortable if the larger-sized glove is worn on the inside next to the skin and a half-size, smaller glove is worn as the outer second layer • carry out the procedure in an orderly manner. • Surgical assistants should be kept to a minimum and should be instructed not to move while the operation is proceeding.

• The operation should proceed in a slow and methodical manner with meticulous attention to haemostasis, taking care to avoid unexpected rapid bleeding which changes the tempo of the procedure and increases the risk of inadvertent injury to the operators • No sharp instruments or scalpels should be passed across the operative field from hand to hand. All instruments are passed from the scrub nurse to the surgeon and back to the scrub nurse in a dish • • • • •

high risk patients are: homosexual lifestyle; a history of intravenous drug abuse; a history of haemophilia treated with factor VIII; residents of sub-Saharan Africa; the partners of the above, higher risk groups.

0n exposure what to injury what to do ? • immediately clean the contaminated area by washing under running water. • postexposure prophylaxis to HIV should be started within 1 hour of the injury where possible • zidovudine 250 mg twice daily, lamivudine 150 mg twice daily and indinavir 800 mg three times daily for I month. • The surgeon should then be given hepatitis prophylaxis • A baseline HIV test should be carried out immediately since seroconversion will not have occurred immediately after injury. • The HIV test should then be repeat-ed approximately 12 weeks after contamination to determine whether seroconversion has occurred.

ATLS component steps

• Primary survey — identify what is killing the patient • Resuscitation — treat what is killing the patient •Secondary survey — proceed to identify all other injuries • Definitive care — develop a definitive management plan

Elements of the primary survey

• Airway with cervical spine control • Breathing and ventilation • Circulation with control of haemorrhage • Dysfunction of the central nervous system • Exposure in a controlled environment

Criteria of discharge

1.Stable vital signs 2.Up to Mild pain & nausea 3.Could move alone and walk 4.Could dress him self 5.Not needs parentral drugs 6. There are some one to take care of him at home 7.Not far more than 60 minutes drive 8. Could take orally