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:
a. 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.
17. 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.
18. 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.
19. 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.
20. Check the full blood count of all patients on the 3 rd postoperative day. In patients who bleed during operation and require
transfusion however, check the full blood count 24 hours after transfusion.
21. Investigate all cases of fever in the postoperative period (see Surgical infections, DVT, PE)

Prophylaxis against Deep Vein Thrombosis (DVT):

 DVT prophylaxis is indicated in the following;  Patients with a past history of DVT or pulmonary
 Obese patients embolism.
 Patients with malignant diseases  Elderly patients
 Immobile patients  Patients undergoing pelvic operations.
 Patients with a history of oral contraceptive pill  Patients undergoing orthopaedic operations of the
usage. lower limb.
 Patients with varicose veins undergoing major  Septic patients
surgery.

Methods
Mechanical  Low molecular weight heparin.
 Early mobilization  Enoxaparin (Clexane) 2000u subcut. Or
 Graded compression stockings [Antithrombosis  Dalteparin (Fragmin) 2500u subcutaneously daily.
stockings] e.g. T.E.D. (Thrombo-embolism  Dextran
Deterrent) stockings.  Heparinoids
 Intraoperative intermittent pneumatic compression.  Fundaparinux
 Effective pain relief  Melagatran
 Deep breathing exercises  A combination of the above methods reduces the
 Elevation of limb incidence of DVT to less than 5%.
 Aspirin? Aspirin prevents platelet aggregation and
Pharmacological hence clotting. It is, however, not useful in the
 Subcutaneous Heparin 5000units bid. This method acute prevention of DVT i.e. in patients admitted
has been shown to offer a clear advantage in for operation. It is, however, useful when taken
reducing the incidence of DVT and PE. over long periods.

SURGICAL INFECTIONS
Surgical infection is of particular importance to the surgeon for the following reasons;
1. Surgeons treat infections and abscesses
2. Patients who develop postoperative infections
a. are likely to remain in hospital for longer periods
b. require additional treatments e.g. operations, drugs
and dressings.
c. are delayed in the return to normalcy and work
d. may develop wound dehiscence
e. may develop incisional hernias
3. The implications of these are increased cost to both the
patient and the health system.
4. Prevention of postoperative infections is therefore of
paramount importance and will result in considerable
savings to the patient and the health system
5. Postoperative infections play a major role in the cause
of fever after operations. Investigation of infections in
the post operative periods is therefore a major activity
for all doctors in the surgical unit.

Preventable surgical infections

 Wound infection infections within loops of small bowel), pleural
 Deep infections eg. intraabdominal infections and infections etc.
abscesses ( subphrenic, subhepatic, pelvic and  Chest infections
 Urinary tract infections
  Infection of peripheral (thrombophlebitis) and
central lines

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.
 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.

Factors influencing increased wound infection o operating theatre personnel

Pre-operative factors  Poor tissue perfusion or hypoxia
 Obesity  Avascular tissue
 Diabetes mellitus  Necrotic tissue
 Malnutrition  Foreign body
 Alcoholism  Haematoma
 Shock, hypovolaemia
 Increasing 2. Chest infection
 Steroid Predisposing factors
 Cytoxic therapy  Anaesthesia
 Anergy to recall antigens  Upper abdominal incisions without inadequate
 Irradiation analgesia
 Advanced malignancy  Chest operations
 Impaired circulation  Immobility
 Re-operation  Pre-existing respiratory disease eg Asthma, COAD
 Prolonged pre-operative stay etc.
 Pre-existing infection or skin contamination  Others see above.

Intra operative factors 3. Urinary infection

 Contamination from  Predisposing factors
o opened viscus  Aseptic catheterisation
o patient skin  Prolonged catheterisation

Prevention
Wound infection  Closed drainage avoiding egress through wound
Preoperative  Monofilament sutures
 Antiseptic skin preparation  Closed wound dressing
 Unshaved skin  Delayed primary closure
 Adequate perfusion  topical antibiotics
 Aseptic technique
 Mechanical preparation of colon 2. Chest infection
 Gastric washouts in GOO  Early mobilisation
 Appropriate systemic antibiotics in contaminated  Breathing exercises
surgery either as prophylaxis or for treatment.  Adequate analgesia
 Antiseptic soap wash
3. Urinary tract infection
Intra-operative  Aseptic catheterisation
 Adequate tissue perfusion and oxygenation  Early removal of urethral catheters
(prevent hypovolaemia or shock and reduced 4. Thrombophlebitis of the intravenous catheter site
oxygen tension during operation.  Remove catheter
 Adequate lavage with normal saline

Investigations
1. Full blood count 3. Blood cultures
2. Wound swab for culture and sensitivity 4. Urine culture and sensitivity
5. Infected catheter tips for culture and sensitivity
6. Sputum culture and sensitivity
7. Radiology
8. Chest X-Rays
Management
1. Drain pus by removing wound sutures or in deep
abscesses external (interventional radiology)aspiration
or open drainage Laparotomy/thoracotomy, transrectal
or through posterior fornix
2. Remove infected foreign materials and prosthesis.
3. 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.
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
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
orally continuously till the stools passed are clear. This
gives a good bowel clearance.
2. Magnesium Sulphate 2 satchet in warm sweetened
beverage. Magnesium Sulphate is bitter when taken on
its own and hence will not be tolerated. Check the
dosage for paediatric patients before administration.
3. Oral Picolax (Sodium Picosulphate) 2 satchet in water.
One satchet for the elderly.
Antibiotic prophylaxis:
1. Broad-spectrum antibiotics active against large
bowel organisms including anaerobes including
Bacteroides species must be used.
9. Abdominal ultrasound
10. CT scans and MRI
11. Scintigraphy WBC scans and Technetium scan
4. Mobilise
5. Encourage coughing and expectoration and institute
chest physiotherapy
6. 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
 A synthetic material is to be inserted e.g. vascular
prosthesis, mesh repair of hernia, orthopaedic
operation where metal prosthesis is inserted.
 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.
b. 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.
d. Ceftazidine 2g stat
e. Ciprofloxacin 400mg 12 hourly
f. Others include imipenem, piperacillin, which, are
all quite expensive and should only be used as
second or third line drugs in severe infections.
3. Prophylaxis should not continue beyond 24 hours
unless there is gross spillage of bile during operation.
4. Oral balanced electrolyte solution i.e. Klean prep or
GoLyTely 4.5 litres drank continuously till patient
passes clear fluid.
5. Others include colonic washouts and enemas, for lower
GI procedures and suppositories to evacuate the rectum
for anal procedures.
6. In all cases of oral bowel preparations the possibility of
dehydration and circulatory collapse must be borne in
mind. In such situations intravenous fluids (normal
saline or Ringers Lactate) must be set up.
2. 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.
Cefuroxime 750mg 8 hourly or
Ceftriazone 2g stat or Ceftazidine 2g stat.
c. Ciprofloxacin 400mg 12 hourly and
metronidazole 500mg 8 hourly.
d. Clindamycin 600mg 8-12 hourly and
Gentamycin 80mg 8 hourly
e. Erythromycin 1g 6hourly
Prophylaxis in Surgery on the Stomach and the Small Bowel:
1. No mechanical bowel preparation is required, an 2. Antibiotic prophylaxis follows the same guidelines as
overnight fast, however, ensures an empty stomach and those for large bowel.
very little small bowel content.

Prophylaxis during insertion of prosthetic material:

 These procedures include the insertion of pace  Antibiotic prophylaxis is therefore aimed at these
makers, arterial prosthesis and insertion of meshes organisms using mainly broad-spectrum
for hernia repair etc. antibiotics.
 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 4. Cefuroxime 1.5 g stat
500mg to be given 6 hourly over 24 hours. 5. Clindamycin 300-600mg stat.
2. Co-Amoxiclav ( Augmentin ) 1.2 G stat 6. Erythromycin 1g stat in the event of penicillin allergy.
3. Gentamycin 80mg and Penicillin 2-4g stat.

Prophylaxis during operations on patients with heart valve disease:

1. The organisms most likely to cause subacute 2. Give Ampicillin 1g and Gentamycin 80mg at induction
endocarditis under these circumstances are Staph. of anaesthesia and continue with Ampicillin 500mg 6
epidermidis or Strept. faecalis which are sensitive to hourly and Gentamycin 80 mg 8 or 12 hourly.
Ampicillin or Amoxycillin and Gentamycin.

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 3. Liver function tests
2. Blood urea and electrolytes and serum creatinine (BUE 4. Ultrasound scan of the upper abdomen
and Creatinine) 5. 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 5. Sepsis: Pooled bile in the biliary tree is a good culture
of poor vitamin K absorption. medium and hence patients with obstructed jaundice
a. To rectify this give 10 mg of Vitamin K are prone to develop septicaemia especially when the
intramuscularly daily for 3 to 5 days. biliary tree is opened during bypass operations, ERCP
b. In the emergency situation, however, 2-4 units of and stenting and also during percutaneous transhepatic
fresh frozen plasma should be given at most an cholangiography (PTC).
hour before operation. a. Antibiotic prophylaxis with broad-spectrum
2. Hepato-renal failure; this is a real problem especially antibiotics, which are active against gram negative
during the post operative period. and gram positive gut organisms for example, a.
a. It is related to dehydration leading to poor renal Gentamycin b. Cefuroxime or c. Ciprofloxacin etc.
function. are given.
b. It may also be related to sepsis.
c. To prevent this, the patient must be
i. adequately rehydrated prior to surgery.
ii.given an infusion of mannitol 200 to 500 ml of
the 10% immediately preoperatively or during
operation to induce diuresis,
iii. given prophylactic broad spectrum
antibiotic.
3. Anaemia which should be corrected preoperatively.
4. Hypoglycaemia resulting from the inability of the liver
to store glycogen.
a. It is therefore necessary to infuse at least 1-2
litre(s) of 10 % dextrose daily to prevent this
complication.
THE DIABETIC SURGICAL PATIENT
Pre operative preparation of the Diabetic patient: The following scenarios may be encountered;
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 5. Start intravenous 5 or 10% dextrose alone or with
2. overnight fast insulin and potassium using the Alberti regime or any
3. check the blood glucose level on the morning of the of its modifications. (see below)
operation 6. Plan to continue the Glucose, insulin, and Potassium
4. omit oral antidiabetic on the morning of operation and regime postoperatively.
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.
4. Start 500 ml of 10-20% glucose with 10mmol
potassium and insulin depending on the blood glucose
level. (see Alberti regime below)
5. 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.
2. Inform the Anaesthetist and involve him in the initial
management
3. Reschedule all elective operations until diabetes is
controlled.
4. In the emergency situation aim to bring blood glucose
to below 14mmol/l or ideally around 10mmol/l and
correct any attendant fluid, electrolyte, and acid/base
imbalance.
5. Check blood glucose, urea and electrolytes and
depending on the patients condition the arterial blood
gases and pH.
6. Insert a wide bore cannula, 2 cannulae if possible.
7. Rehydrate the patient with normal saline or Ringers
lactate.
8. Start patient on the glucose, insulin, potassium regime (
Alberti see below)
9. Continue to monitor blood glucose every 2 -4 hours.
10. Catheterise the patient.
11. start the patient on broad spectrum antibiotics

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
circumstances. 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

Diabetic for minor operation under local anaesthetic;

Action;
1. Patient need not starve 3. If there is a long wait before operation set up 5%
2. Early breakfast with oral antidiabetic agent or insulin Dextrose infusion with or without insulin depending on
as usual. 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.

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. of insensible loss, the urine output and other losses e.g.
2. Monitor the urine output by inserting a urethral NG aspirations.
catheter. This helps to determine the amount of fluids 3. Insert central venous catheter if available.
to be administered since daily requirement is made up

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 used.
potassium 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.
5. Intussuception; Colicky abdominal pain, abdominal
mass, red currant jelly stool, rarely mass at the rectum.
6. Worms; only seen in children with heavy worm
infestation.
7. Gallstone ileus; Very rare in our environment.
Characteristic x-ray finding of small bowel obstruction
and gas in the biliary tree.

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. 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.
6. 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:
1. Nil by mouth 4. Pass urethral catheter and monitor the urine output
2. Start intravenous fluids Normal saline or Ringers aiming at 30 - 50 ml/hr in the adult or 1 - 2 ml/kg/hr in
lactate. Give the initial one litre over at least 45 the Paediatric patient.
minutes to 60 minutes. 5. Start patient on broad-spectrum antibiotics.
3. Pass a nasogastric tube (Gentamycin or Ciprofloxacin or Cephalosporins, and
 metronidazole). Bacteria always translocate through
the bowel wall when it is obstructed.
6. Prepare the patient for operation by explaining the
operation and obtaining informed consent from the
patient or his relatives.
7. 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.
8. 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 Investigation;
1. Acute cholecystitis 1. Full blood count and sickling.
2. Acute appendicitis 2. Blood urea and electrolytes, creatinine and blood
3. Acute diverticulitis glucose.
4. Salpingitis 3. Ultrasound scan (cholecystitis and salpingitis)
5. Inflammatory bowel disease e.g. Crohn’s disease rare. 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 4. Start intravenous antibiotics using broad-spectrum
envisaged, however, sips of water can be allowed. antibiotics including metronidazole. In Acute
2. Start intravenous fluids dextrose saline or normal saline cholecystitis, however, metronidazole is not required
or Ringers lactate. routinely except in diabetics.
3. Nasogastric tube is required in those who are vomiting.

The following combinations are useful;

 Gentamycin and Metronidazole or Clindamycin.  Ciprofloxacin and Metronidazole or Clindamycin.
 Cefuroxime or Cefotaxime 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 5. Antibiotics? Controversial. Advocates of antibiotic
appendix mass. therapy, however, abound. Follow what your
2. Nil by mouth Consultant recommends. I advocate antibiotics and I
3. Intravenous fluids recommend metronidazole or Clindamycin with
4. Analgesics 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.
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.
 10
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 3. Erect chest X-Ray (May show gas under the diaphragm
2. BUE if there is perforation)
4. Plain abdominal X-Ray

Action;
1. Nil by mouth 4. When the condition settles, arrange a Barium enema to
2. Intravenous fluids confirm the diagnosis and rule out left sided or sigmoid
3. Intravenous antibiotics metronidazole or clindamycin carcinoma.
and gentamycin or cefuroxime or ciprofloxacin.

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 abscess, spreading peritonitis or pelvic
appendicitis and prepare for operation.
3. 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. 5. Blood culture
2. Group and crossmatch 2 units of blood. 6. Erect chest x-ray (gas under the diaphragm)
3. Blood urea and electrolytes and creatinine and serum 7. Supine abdominal x-ray (dilated paralysed bowel).
amylase. 8. Electrocardiogram (ECG) in old individuals.
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.
b. 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.
4. All losses from the nasogastric tube or diarrhoea must
however, be replaced volume-for-volume with normal
saline containing potassium or gastrointestinal
replacement fluid.
5. Potassium deficit can usually be corrected by adding 20
millimoles of potassium to each litre of intravenous
fluids once urine output exceeds 30ml/hr.
6. Pass a nasogastric tube
7. Pass a urethral catheter and monitor urine output hourly
aiming at 30 - 50 ml/hr or 1-2-ml/kg/hr.
8. Relieve pain.
9. Change all oral medications to intravenous, rectal or
sublingual forms.
10. Start intravenous broad-spectrum antibiotics.
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a. Metronidazole in combination with Gentamycin or c.In typhoid fever use a combination of
Ciprofloxacin or Cefuroxime or Ceftriazone. Metronidazole and Ciprofloxacin or Ceftriazone
b. Clindamycin and Gentamycin 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 6. Stress ulcers following severe burns or trauma or
2. Erosive Gastritis secondary to NSAID, steroids, aspirin severe sepsis.
usage, and alcohol abuse. 7. Mallory Weiss tears.
3. Gastric ulcers. 8. Blood dyscrasias.
4. Oesophageal and gastric varices 9. Others including Dieulafoy syndrome
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.
9. Take a good history asking about peptic ulcer disease,
NSAID use, alcohol abuse (oesophageal varices, acute
gastric erosions), abnormal bleeding.
10. 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.
11. 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.
12. Prepare patient for possible endoscopic injection
sclerotherapy or injection of bleeding ulcer or operative
intervention.
13. 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 8. Solitary rectal ulcer etc.
2. Carcinoma 9. bleeding may also come from the small bowel where
3. Polyps the commonest in our environment is bleeding from the
4. Diverticular disease Peyers patches secondary to typhoid fever.
5. Colitis infective or ischaemic. 10. Occasionaly bright red bleeding from the rectum is
6. Fissure in ano secondary to massive upper gastrointestinal bleeding.
7. Angiodysplasia in the elderly.

Action
1. Follow the same procedure as for upper GI bleeding in bowel secondary to typhoid ulcer may present as lower
your resuscitative effort. GI bleed with the passage of bright red bleeding.
2. Remember that massive upper GI bleed eg bleeding
DU, bleeding varices and bleeding from the small

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

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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 5. Other special investigation usually requested by more
2. Sigmoidoscopy Rigid or flexible senior personnel.;
3. Colonoscopy a. Red cell scan
4. Barium enema 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 6. Erect Chest X-Rays look for effusions and atelectasis.
2. Blood urea and electrolytes and creatinine and 7. Plain abdominal x-ray. Look for sentinel jejunal loop,
Calcium. colonic cutoff, and pancreatic calcification.
3. Serum amylase 8. Others include arterial blood gases which usually
4. Blood glucose. abnormal in severe cases.
5. Liver function tests.

Action;
1. Insert a large bore cannula 5. Relieve pain with Pethidine, or morphine with an
2. Nil by mouth antispasmodic.
3. Intravenous fluids start with Normal saline or Ringers 6. Pass a nasogastric tube.
lactate. Do not use 5% Dextrose. 7. Note that the treatment of acute pancreatitis is mainly
4. Pass a urethral catheter to monitor the urine output and symptomatic and is aimed at the correction of shock,
aim at an hourly output of 30 - 50 mls with your pain relief and prevention and treatment of respiratory
infusions. 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. Chronic doudenal or prepyloric ulcer - due stricture or 4. Leiomyoma of the antrum and duodenum
oedema. 5. Carcinoma of the head of the pancreas
2. Hypertrophic pyloric stenosis (Congenital and adult) 6. Pancreatic pseudocyst.
3. Carcinoma of the antrum

Problems;
1. Dehydration and electrolyte and acid base imbalance. 3. Metabolic alkalosis
2. Shock leading to renal failure 4. Hyponatraemia, hypokalemia, hypochloraemia.

Investigation;
1. Full blood count and sickling 4. Erect chest x-ray to rule out aspiration pneumonia.
2. Group and crossmatch at least 2 units of blood for 5. Plain abdominal x-ray and barium meal.
operation. 6. Upper GI endoscopy.
3. Blood urea and electrolytes and creatinine and blood
glucose.

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.
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3. Pass a urethral catheter to monitor urine output aiming 6. Remember that until the serum electrolytes are within
at 30 - 50 ml / hour. the normal range the patient electrolyte derangement is
4. Pass a nasogastric tube. This helps make the diagnosis, not corrected and hence fluid prescription should not
help keep track of continued losses, and also help to include 5% dextrose or maintenance fluid.
prevent vomiting and its attendant aspiration 7. All continued losses from the Nasogastric tube must be
pneumonia. replaced volume for volume with normal saline or
5. Check urea and electrolytes regularly and correct any dextrose saline containing at least 10mmol of
abnormality. potassium/litre.
8. 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 Pyomyositis:
aspiration through a wide bore needle or cannula These patients are usually very ill with deep abscesses
and affecting the big muscle masses.
b. Antibiotics, which are active against Staph.
Aureus. Investigations;
3. In the middle aged and elderly an underlying 1. Full blood counts and sickling
Carcinoma of the breast must be suspected and biopsies 2. Blood urea and electrolytes
taken during incision and drainage. 3. Blood glucose
4. Blood cultures.
Investigation;
1. Full blood count and sickling Action;
2. Blood urea and electrolytes. 1. Start intravenous fluids normal saline or dextrose
3. Blood sugar saline.
4. Prepare the patient for operation. 2. Start intravenous antibiotics use Benzylpenicillin and
gentamycin or Flucloxacillin or Cloxacillin or
Perianal abscess Augmentin or Cefuroxime.
Investigation; 3. Prepare the patient for incision and drainage.
1. Full blood count and sickling. 4. Relieve pain
2. Blood urea and electroytes.
3. Blood glucose or urine glucose. Gluteal abscess (Injection abscess);

Action; Investigations;
1. Best treatment is incision and drainage. 1. Full blood count and sickling
2. Antibiotic treatment is only indicated in diabetics, 2. Blood urea and electrolytes
patients with immune suppression or those who are 3. Blood/urine glucose
septicaemic. Use gentamycin or ciprofloxacin or
cefuroxime and metronidazole or clindamycin. Action;
1. Best treatment is incision and drainage.
2. Antibiotics needed in Diabetics, the immunosuppressed
or patients who are septicaemic.

Cellulitis;
The usual organisms involved are Strept. pyogenes and Examine all peripheral pulses to rule out arterial
Staph. Aureus. insufficiency as a predisposing factor.
Rule out diabetes mellitus.

Investigation; Action;
1. Full blood count and sickling. 1. Intravenous antibiotics Benzylpenicillin and
2. Blood urea and electrolytes gentamycin or Benzylpenicillin and flucloxacillin or
3. Blood glucose cloxacillin or coamoxyclav.
4. Blood culture in the severely ill. 2. Elevate the affected limb.
3. Incision and drainage if subcutaneous abscess forms.
4. Give prophylaxis against DVT

UROLOGICAL EMERGENCIES
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Acute Retention of Urine:
Causes;
1. Benign Prostatic Hyperplasia (BPH) Action;
2. Carcinoma of the Prostate 1. Relieve pain by giving IM Pethidine 75-100 mg.
3. Urethral Stricture 2. Catheterise patient with Foley’s catheter Ch 14 or 16.
4. Hypertrophic bladder neck 3. Anaesthetise the urethra with 5-10 ml of 2% lignocaine
5. Posterior Urethral Valves in children. gel and hold or clamp the penis for 2-5 minutes to
6. Clot retention facilitate easy catheterisation.
4. Give patient antibiotics eg. IV Gentamycin 80 or 160
Investigations; mg stat, IV Ciprofloxacin 200mg stat, or Oral
1. Full Blood count and Sickling Ciprofloxacin 500mg stat or iv Cefuroxime 1.5g stat..
2. Blood urea and electrolytes and serum creatinine 5. If catheterisation fails or is unduly traumatic then a
3. Urine for culture and sensitivity once catheter is urethral stricture may exist hence a suprapubic catheter
inserted. is required. Call the Urology Resident.
4. Serum PSA

Chronic urinary retention;

Presentation of this condition can be varied and include; a. Problems expected after catheterisation;
1. Overflow incontinence i. Excessive diuresis leading to dehydration and
2. Inability to pass urine with no pain. hyponatremia.
3. Lower abdominal mass ii.Bleeding from the urinary tract. Slow
4. Uraemia and confusion i.e. signs of renal failure. decompression of the bladder therefore
Investigations; advocated.
1. Full Blood Count and sickling 3. Give broad-spectrum antibiotics as for acute urinary
2. Blood urea and electrolytes and serum creatinine. retention.
3. Blood sugar 4. Set up intravenous fluids eg. Normal saline since the
4. Blood for PSA (consider the cost of this procedure. patient may pass large amounts of isotonic urine post
Hence discuss with the Resident) catheterisation and will become dehydrated.
5. Assess the prostate gland.
Action; 6. If catheterisation fails call the Resident to perform a
1. Admit the patient. suprapubic catheterisation.
2. Catheterise the patient and put him on slow
decompression of the bladder after the BUE and
Creatinine results are known.

Ureteric Colic
Diagnosis is made by;
1. Colicky loin pain radiating to the groin or scrotum or
labium majus.
2. Tenderness in the renal angle, or in the right iliac fossa
(RIF) if the stone is held up at the point where the
ureter crosses the common iliac artery.
3. Microscopic haematuria.
Investigation;
1. Urinalysis i.e. Urine R/E or Dipstick examination of
urine.
2. Plain abdominal X-Ray (KUB) this can be followed by
a formal IVU or ultrasonography after review by the
resident or Consultant.
3. Full blood count and sickling
4. BUE, serum creatinine and serum calcium.
5. Urine calcium and phosphate (Consult the urological
team before ordering this test.)
Action;
1. Admit the patient.
2. Relieve pain give IM Pethidine 50 - 100mg and IM
Buscopan 20-40mg stat. or Suppository Diclofenac
100mg 18 hourly
3. Strain all urine passed to recover stone since most
stones less 6mm in diameter will pass spontaneously.
4. Refer the patient to the Urologist for further
investigation and management.

Haematuria;
Haematuria must be taken seriously and fully investigated 2. Ureter
since it may herald the presence of serious conditions like a. Calculus
carcinoma, schistosomiasis etc. b. Transitional cell carcinoma of the ureter
Causes 3. Bladder
1. Renal a. Schistosomiasis
a. Renal cell carcinoma b. Carcinoma of the bladder TCC or Squamous cell
b. Transitional cell carcinoma (TCC) of the renal carcinoma
pelvis c. Calculus
c. Renal calculus d. Cystitis
d. Analgesic nephropathy (analgesic induced 4. Prostate
papillary necrosis.) a. Benign prostatic hyperplasia (BPH)
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b. Carcinoma of the prostate 7. Intravenous urogram (IVU)
c. Prostatitis 8. Cystoscopy
5. Urethra 9. CT Scan to be ordered only by a senior person.
a. TCC
b. Urethritis Action;
1. Admit the patient
Severe bleeding from the bladder and the prostate can lead 2. Relieve pain by giving 50-100mg of pethidine
to clot retention and acute urine retention. intramuscularly.
3. Pass a wide bore urethral catheter 20ch or above
Investigations; preferably a whistle tipped catheter to facilitate the
1. Full blood count (FBC) sickling and clotting screen. washing out of clots. A three way catheter for the
2. Blood for grouping and x-matching irrigation of the bladder must be passed if bleeding is
3. Urinalysis i.e. Urine for routine examination. very heavy.
4. Urine for culture and sensitivity. 4. Give antibiotics initially intravenous (use cefuroxime
5. Urine for cytology. or Ciprofloxacin etc)
6. Plain abdominal x-ray (KUB) if calculi are suspected. 5. Continue further investigations

VASCULAR EMERGENCIES

Acute arterial occlusion

Causes
 Embolism  Raynauds disease and phenomenon
 Thrombosis  Vasoconstrictor drugs e.g ergot
 Trauma

Types.
 Thrombi and clots
Embolism (Mainly thromboembolism)  Gas
An embolus is an abnormal mass of undisclosed material  Fat
which is transported from one part of the circulation to  Tumour
another.  Miscellaneous (septic etc
Source of emboli
Heart o Congenital
 Atherosclerotic heart disease o Bacterial
 Coronary artery disease o Prosthetic
 Acute MI Artery-to-artery
 Arrythmia (atrial Fibrillation)  Aneurysm
 Valvular disease  Atherosclerotic plaque
o Rheumatic  Idiopathic
o Degenerative Paradoxical

Arterial thrombosis
 Atherosclerosis  Hyper coagulation (polycythaemia, activated
 Low flow states protein C resistance [factor V Leiden], protein
o CCF S&C,& antithrombin III deficiencies)
o Hypovolaemia  Vascular grafts
o Hypotension  Intimal hyperplasia

Arterial trauma
Penetrating trauma  Intimal flap
 Direct vessel injury  Spasm
 Indirect injury Iatrogenic
 Missile emboli  Intimal flap
 Proximity of injury to arteries  Dissection
 Presence of medical device
Blunt trauma
Drug abuse
Other causes of acute arterial occlusion  Intraarterial administration
External compression  Drug toxicity
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 Contaminant
 Microembolization
Outflow venous occlusion
 Compartment syndrome
 Phlegmasia caerulea dolens
Drug effect
 Ergot

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Clinical manifestation
Acute embolisation
 Sudden onset
 Pain  Perishing cold (Poikilothermia)
 Paraesthesia  Paralysis
 Pallor In thrombosis there is less pronounced injury to tissue due
 Pulselessness to previous collaterals formation. Prolonged ischaemia
leads to cellular swelling. Muscle is stiff and wooden.

Investigation
 There is usually no time  Urine myoglobin
 FBC, Sickling  Arteriography
 Clotting profile o Usually there is no time for this patient
 Fibrinogen and fibrin degradation products may be unduly held in the X-ray unit.
 BUE and Creatinine Useful in trauma when ‘soft signs’ are
 Blood glucose present.
 ECG o May be of use in theatre as completion
 Chest X-Ray angiograms.
 Creatinine phosphokinase  Duplex scanning

Action
 Anticoagulate the patient  Delayed embolectomy
 Give a bolus of IV Heparin 10,000U o Delayed diagnosis with the limb still
 Then follow up with IV Heparin 500-1500u/hr by viable
continuous infusion  Thrombolysis
 Nonoperative o TPA
o High dose anticoagulation o Urokinase
 Prepare the patient for Emergency Embolectomy o ? Streptokinase

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
 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 Hypertension 2-3 fold increase in risk
o Senility Prevalence increases with age o Abnormalities of homocysteine
such that 20% of people over 70 years of metabolism
age have the disease. o Low levels of oestrogen
o Diabetes melitus 2-4 fold increase in risk)  Popliteal entrapment
o Hyperlipidaemias  Aneurysms
 Hypercholesterolaemia  Vasculitides (Raynauds phenomena etc.)
 Elevated triglycerides  Buergers disease
o Cigarette smoking

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,
17

 Skin changes: Skin is thin and atrophic with loss of
hair. The nails are thickened and ridged
 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.
18
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
 Pulses by palpation:
 Palpate and comment on the nature of the arterial
wall which may be calcified in senile
atherosclerosis or in diabetics. Compare pulses of
the right to the left and also the lower limb pulses
to the upper limb pulses and note any delays.
 Palpate for aneurysms
o Aorta in the epigastrium slightly to the
left of the midline, iliac arteries in the
iliac fossae, femorals and popliteal
 Auscultate
o The carotids, the abdominal aorta, the
renal arteries (epigastrium and renal
angles), the femorals for bruits. This may
indicate strictures or aneurysms of the
involved vessels.
 Pulses by Doppler studies
 Ankle Brachial Pressure Index (ABPI)
 Systolic pressure in the posterior tibial or
dorsalis pedis arteries is divided by the
systolic pressure in the brachial artery.
 Normal 0.9-1.2

Investigations
General
 FBC Sickling  Serum lipids  Chest X-Ray
 BUE and Serum creatinine  Cholesterol  ECG
 Fasting blood sugar  Triglycerides

Vascular laboratory
Treadmill Exercises with Doppler Studies, ABPI)
Bicycle Ergometer exercises Doppler Studies, ABPI)

Radiology
Noninvasive
 Waveform analysis Invasive
 Duplex scan  Angiography
 Triplex (Duplex + colour Doppler)  Standard
 Arterial Digital Subtraction angiogram (DSA

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Treatment
Conservative
 Encourage exercises. Graded exercises. Improves  Control hyperlipidaemias (diet and Statins HMG-
the formation of collaterals CoA reductase inhibitors)
 Stop smoking will arrest progression of disease  Control diabetes
esp. Buergers.  Antiplatelet therapy (Aspirin, Clopidrogel,
 Control hypertension Cilostazol)

Interventional radiology
 Percutaneous Angioplasties  Short single strictures
 Stenting

Surgical operations
These are undertaken usually after angiograms when the Methods
site and extent of the arterial occlusion is demonstrated and  Endartectomy
also when the vessel or vessels distal to the occlusion are  Bypass operations
found to be patent.

Amputation
Are necessary when the limb is not viable either because of  Below knee
overt gangrene or when the limb has been deprived of its  Above knee
arterial blood supply for more than 6 hours and is cold and  Disarticulation at the hip
paralysed. Amputation is life saving in such circumstances.

Sympathectomy
 Improves blood supply to the skin by causing benefit from angioplasty or bypass operations
vasodilatation of the arterioles and hence may help because of poor run-offs.
in relieving pain and promoting wound healing. It  Chemical
is usually reserved for the elderly who will not  Operative

Venous thromboembolism
 A thrombus is basically a clot formed in the
cardiovascular system in the living person.
 Thrombi are composed of fibrin and blood cells
formed in any part of the cardiovascular system.
 In thromboembolism clots which are formed in one
part of the cardiovascular system are transported to
other areas of the same system and may result in
severe morbidity or mortality to the patient.
 Venous thrombi are formed in areas of stasis and
are composed mainly of red cells with large
amounts of interspersed fibrin with relatively few
platelets
 Two types of venous thromboembolism are
recognised
o Deep vein thrombosis (DVT)
o Pulmonary embolism (PE)
 The triad of venous stasis, hypercoagulability of
blood and venous endothelial damage (Virchow’s
triad) is recognized as the basis for venous
thrombosis. The various clinical risk factors are
related to this triad.

Deep vein thrombosis

Acquired factors
 Surgery (orthopaedic operations of the lower limb,  Nephrotic syndrome
pelvic and general abdominal operations)  Oral contraception & (HRT)
 Trauma and sepsis through hypercoagulabilty  Antiphospholipid antibody syndrome
 Immobilisation mainly due to stasis  Hyperhomocysteinaemia
 Obesity through stasis  Dehydration as in patients with intestinal
 Cancer especially abdominal cancers but all obstruction and peritonitis
cancers increase the risk of DVT  Age greater than 45 years
 Pregnancy

Genetic factors (Thrombophilia)

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 Factor V Leiden (activated protein C resistance  Antithrombin III deficiency
[APC resistance])  Protein C deficiency
 Prothrombin G20210A mutation which leads to  Protein S deficiency
increase of prothrombin level in blood  Hyperhomocystenaemia

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  Minor surgery (<30 minutes)
paraplegia.  Minor trauma or medical illness
 Major limb amputation  Young patients
 Will need all the prophylactic regimes discussed  May require only graded compression stockings
below. and other mechanical prophylaxis

Moderate risk
 Other major surgery and another risk factor such as
varicose veins, immobility
Clinical features
 Common o Phlegmasia alba dolens white limb
 Pain full limb secondary to arterial spasm in the face of
 Tenderness acute DVT
 Swelling and oedema of the limb. Usually starts o Phlegmasia cerulea dolens the ‘blue’ lim
from the ankle and spreads upwards. which results from extensive venous
 Differential warmth. The affected limb is warmer thrombosis in which all the tributary veins
than its fellow. The limb is not cold and must of the femoral vein are blocked. This is
therefore not be confused with acute arterial the beginning of venous gangrene.
occlussion  Clinical signs are non specific and not reliable
 There may be low grade fever because the are not very different from other cause
 Occasionally there may be prominent superficial of swollen painful lower limb like cellilitis,
veins of the limb. lymphangitis and ruptured Baker’s cyst etc or non
 Less common painful conditions like lympoedema and oedema
secondary to cardiac failure. Hence a high index of
suspicion is required to make the diagnosis.

Investigations
 Doppler ultrasonography  Venography
 Duplex and colour duplex  D-dimer test
 Plethysmography

Treatment
1. Prophylaxis 2. Treatment of established cases

Prophylaxis
Mechanical
 Mobilisation  Intermittent pneumatic compressions
 Elevation of limb  Effective pain relief
 Graded compression stockings  Deep breathing exercises

Pharmacological
 Unfractionated heparin (5000u subcut bd)  Fundaparinux
 Low molecular weight heparin  Heparinoids
 Dalteparin (2500-5000u Subcut. Daily)  Dextran
 Enoxaparin (2000-4000u Subcut. Daily)  Melagatran

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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 28-
40,000units/24hrs with an infusion pump
o Or IV 1000-1500units/hr
o Alternatively Subcut. Heparin 15,000-
17,500u 12hrly if continuous infusion
pump is not available
o Check APTT daily and maintain between
1.5 and 2.5 of the control
 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  Agents rTPA, Urokinase, ?Streptokinase
dolens. Thrombectomy
 Complications of bleeding very high.  Only indicated in phlegmasia cerulea dolens with
eminent venous gangrene.

Pulmonary embolism
 Clinical diagnosis highly non specific  Haemoptysis
 cardiorespiratory, musculoskeletal conditions may  Severe shortness of breath
mimic the condition  Associated right-heart failure
 Transient shortness of breath  Hypotension
 Sharp localised chest pain aggravated by  Syncope
inspiration (pleuritic-type pain)  Peripheral circulatory collapse

Pulmonary angiogram best

 Ventilation/perfusion scans  D-dimer test if available
 Chest X-ray not diagnostic but rules out  Arterial blood gases
differential 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.
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 Treatment must start if there is any index of suspicion

Appendix

Salivary gland operation group and save only Cholecystectomy group and save
Thyroidectomy x-match 2 units blood Gastro-jejunostomy group and save
Mastectomy x-match 2 units blood Strangulated hernia x-match 2 units blood
Bowel resection x-match 2 units blood Amputation x-match 2 units blood
Gastrectomy x-match 2 units blood Nephrectomy x-match 2 units blood
Vagotomy and drainage x-match 2 units blood Partial nephrectomy x-match 4 units blood
Hemicolectomy x-match 2 units blood Open prostatectomy x-match 4 units blood
APER x-match 2-4 units blood Operations for priapism x-match 2 units blood
Splenectomy x-match 2 units blood Total cystectomy x-match 4 units blood
Pancreatectomy x-match 4-6 units blood

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