GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.

) 1
Thingsyouneedtoknowinsurgicaldept
1. FluidandElectrolytes
(i) Contentineachpintofsolution
Sol. Content Na K Ca Cl HCO
3
NS NaCl9g(0.9%) 150 150
HS NaCl4.5g(0.45%) 77 77
D5% Dextrose50g/L
D10% Dextrose100g/L
HM NaCl+KCl+CaCl2
+Nalactate
131 5 2 111 29
3%Sal NaCl30g(3%) 513 513

(ii) Dehydration
Mild Moderate Severe
Adult 5% 7.5% 10%
Paeds* <3% 39% >9%
*accordingtoAcuteDiarrhoeaProtocol2011
(iii) Fluidrequirement
Total=Maintenance+Deficit+Ongoinglosses
Maintenance=40cc/kg/day
ForPaeds:(useHollidaySegarFormula)
4cc/kg/hfor1
st
10kg
2cc/kg/hfornext10kg
1cc/kg/hforsubsequentkg

Deficit=10%Bodywt
*replaceover12hrs

Ongoinglosses=lossesfromRTAspiration,
Drainage,thirdspaceloss,plasmalossetc
*usuallyreplacepershiftwithHM/NS

InallheadinjurypatientgiveonlyNS
InburnpatientParklandcorrectionbyHM
InpaedspatientusuallyuseNSD5%
(iv) Assessdegreeofdehydrationbasedon
Mentalstatus
Eyesunkeneye/cryingwithtears
Breathing
Mucosa/tongue
Skinturgor
Pulsevolume
PR/BP
CRT
Peripherywarm/cold
Urineoutput*goodUO=0.51cc/kg/h

(v) Narequirement
Totalrequirement=Maintenance+Deficit
Maintenance=23mmol/kg/d
Deficit(inmmol)=(140x)Wt0.6
*toconverttog,dividewith23.3
(vi) Krequirement
Totalrequirement=Maintenance+Deficit
Maintenance=0.51mmol/kg/d
Deficit(inmmol)=(4x)Wt0.4
*toconverttog,dividewith13.3
RulesofKcorrection:
Rateshouldnot>1.5gperhour
Concentrationshouldnot>3gin1L(1.5gin500ml)

IfhypoKuseMistKCl15mlTDS
Ifseverehypoload1gKClin100ccNSover1hr
Or2gKClin200ccNSover2hr
*makesuretakeECG/putoncardiacmonitoringduring
loadingANDrepeatRPpostloading2hrs
IfhyperKuseoralKalimate15gTDS
Ifseverehyperinsulinchase
IVCaGluconate10%10ccover25minthen
IVDextrose50%50ccthen
IVActrapid10unit
ECGchanges
HypoK HyperK
FlatTwave
NarrowQRS
STdepression
Uwave
SmallP
TalltentedTwave
WidenQRScomplex
Ventriculartachy/fibrillation

(vii) Hyperglycaemia
DKA HHS/HONK
Absoluteinsulindeficiency Relativeinsulindeficiency
Dx:
pH<7.3
Dxt>14
BloodKetone>2(geta
ketonestick)
Dx:
Serumosmolarity>320
Dxt>33

*Osm=2(Na+K)+Glu+Urea
Principleofmanagement:
1. Fluidresuscitation2largeboreIVcannula(green
18Gorgrey16G)in2antecubitalfossa1for
maintenance,1forbolus
2. Insulintherapy(nottostartfirstifKlessthan3.3),
targetDxtinDKA811,HHS1416thendoseof
insulin,ifhypodonotstopinsulin,insteadtouse
D10%drip
3. CorrectionofelectrolytesBUSE&VBG4hrly,
makesuregoodurineoutputandnoECGevidence
ofhyperKwhenplanningtoloadK
4. Treatunderlyingcauses(sepsis,MIetc)

*IndicationofHCO
3
ifHCO
3
<10,give100meq(10amp)

*ifresolvedandpatienttoleratingorallytochangetobasal
bolusregime0.50.8u/kg/dandtitratewithoverlapping1
2hrswithIVIslidingscale

(viii) PreparingDMpatientforelectiveand
emergencysurgery
Elective Emergency
Minor Major TreatDKA

PostponesurgeryuntilRBS<20
unlesslifethreatening

Aim711mmol/Lduringsurgery
GiveD5%orDS+20mmolKCl
8hrly+IVIinsulinslidingscale
OHAgive
normalregime

Insulinomit
ondayof
surgery

DXTQID
OHAomit
longacting
(glibenclamide)

DXTQID
*IfRBS>15,to
startinsulin
slidingscale

GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.) 2

2. AcidBasebalance&Oxygentherapy
(i) ABGinterpretation
Norms
pH7.357.45
pO
2
80100mmHg
pCO
2
3545mmHg
HCO
3
2226
*ToconvertmmHgtokPadivide7.5

(ii) IfpH>7.45
pCO
2
<35 HCO
3
>26
RespiratoryAlkalosis MetabolicAlkalosis
Hyperventilation
stroke
SAH
meningitis
anxiety
hyperthermia
PE
salicylatespoisoning
profusevomiting
hypoK
burn

(iii) IfpH<7.35
pCO
2
>45 HCO
3
<22
Respiratory
Acidosis
MetabolicAcidosis
NAGMAHAGMA
Respiratory
failure

RTA
Diarrhoea
Addisonds
Pancreaticfistula
NH
4
ingestion
Drugacetazolaminde
Increaseinorganic
acidproduction
lactoacidosisshock,
sepsis,hypoxia
uricacid
ketoneDM,alcohol
drugmetformin,
metanol
*aniongap=[Na+K][Cl+HCO
3
]

(iv) Oxygendissociationcurve

LeftsideofcurvepHTDPG(2,3dephosphoglycerate)
RightsideofcurvepHTDPG(2,3dephosphoglycerate)
p50pointwheresaturationofHbreaches50%(atpO
2
=26.6)
ICUpoint(PaO
2
,SaO
2
)=(60mmHg,91%)=lowestacceptable
paO2inICUpatientbecausefurtherdropbeyondthispoint
leadtodrasticdropinSaO
2

MixedvenouspointatSaO
2
=75%
(v) Indicationforintubation
Todeliverpositivepressureventilation
Airwayprotectionfromaspiration
Duringsurgicalproceduresinvolvingneckand
headinnonsupineposition
Neuromuscularparesis
Proceduresincreasesintracranialpressure
Profounddisturbancenconsciousness
Severepulmonaryandmultisystemicinjury

3. Painmanagement
(i) Effectofpain
Hypoventilation
Secretionretention
Mentalunrest

(ii) WHOpainmedicationladder
Painscore03 46 710
Mild Moderate Severe
TPCM1gQID TPCM1gQID
+
CapTramadol
50mgQID
S/CMorphine5
10mg4hrly

TPCM/Cap
Tramadol
**UncontrolledtorefertoAPSforPCAorepiduraletc

Otheroptions:
TArcoxia(Etoricoxibe)90/120mgOD
TPonstan(Mefenemicacid)500mgTDS
IV/IMVoltaren(DiclofenacNa)75mgTDS
*forheadinjuryTPCMandTArcoxia
*forribinjurys/cmorphine

4. Operativecare
(i) Preoperativecare
Clinicalassessment,investigationandpreparation
Getinformedconsent
Hxtakingprevioussurgery,choiceofanaesthesia,
complicationofpreviousoperation
Underlyingcomorbid,smoking,alcoholic,
heart/respi/kidneydiseases
Currentmedicationtowithholdaspirin/warfarin
Physicalexaminationshortneck(difficultintubate),
obese,CVSRespistatus
Vitalsigns,sugarcontrol,bodyweight/height
FBC/Coag/RP/LFT/RBS/CXR/ECG
Correctionofcoagulationdisorder,electrolyte
imbalance,sugarlevel,bloodpressure
Prophylacticantibiotics
Anaestheticteampreopassessment

GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.) 3

Choiceofprophylacticantibiotics
Operation Preferredantibiotics
Laporopencholecystectomy
IVCefuroxime1.5g+
IVMetronidazole500mg
ERCP
Herniarepairwithmesh
Laparoscopicrepair
Breastsurgery
IVCefuroxime1.5g

PreferredantibioticinourdeptIVCefobid(Cefoperazone)
2g+Flagyl(Metronidazole)500mg

(ii) Postoperativecare(complications)
PODfever >38.5C Prevention
1 Wind Atelectasis Incentivespirometry,chest
physiotherapy,ambulate
3 Water UTI/Pneumonia EarlyoffCBD,propuppatient,
sitpatientonchair,hand
washingonhandling,RT
insert,oral/trachytoileting
5 Walk DVT Encourageambulation,S/C
Clexane0.4mgOD,TED
stocking
7 Wound Woundinfection,
abscess
Preopshowerandskinprep,
continueantibioticspostop,
dressingofwound
10 Wonder Drugs

Preopbowelprep(Fleet/Foltran)toprevent
intraoperativecontaminationbyfaecalmasses

OPSIpreventionpenicillin(age<21),vaccinationpost
splenectomy(Haemophilusinfluenzab,meningococcal*,
pneumococcal)*pthavetoselfpurchase

Onceevidenceofbowelmovement(bowelsounds,
flatus/BO)encourageorallyASAPtoprevent
Refeedingsyndrome
Identifyrisk:malignancy,anorexia,alcoholism,GI
surgery,starvation
Closemonitoringduringperiodofrefeedingwith
involvementofnutritionist
Parenteralphosphateadministration18mmol/din
additiontooralsupplement

5. PrimaryandSecondarySurvey
(i) PrimarysurveyABCresuscitation
Airway
Ifpatientgag/talk/coughairwaypatent
Cervicalcollarforallheadinjury
Sxofairwayobstruction:stridor,hoarsenessofvoice
LookforFBinthethroat
Performsuctionandcheckgagreflex
Ifgag,nasopharyngeal(notforbasalskull
fracture)/oropharyngealtubeorintubation
Breathing
Lookforchestexpansionsymmetry?
Pneumo/haemothorax?
Flailchestparadoxicalbreathing
RecheckETT,CXR
Tensionpneumothorax
Thoracocentesisifpneumothoraxchesttube
insertion
Oxygentherapy
Circulation
Listentoheartlookformuffledheartsound
Correcthypotension
Intraabdominalinjury
Abnormalbruits
CardiacBP/PRmonitoring
Beckstriad(muffledHS,JVP,hypotension)
Disability*
GCSassessment
1315mildheadinjury
812moderateheadinjury
<8severeheadinjury
Neurologicalassessmentcranialnerve,power,tone,
reflexes,sensation
Longbonefracturestenderness,crepitus
Pupilreflexes
ConsciousnessAlert,Verbalise,Pain,Unresponsive
Cervicalspineinjury
CTBrain/CervicalspineICB,pneumocranium,spine
disarticulation,fractures
Exposure*
Otherinjuries
Abrasion/lacerationwounds
Checkperineumbloodinurethralmeatus
Logrollstepdeformities,analtone,DPRexamination,
spinedeformities
Chestspring/pelvicspring
LifethreateninginTrauma
Trachea
Chest
expan
sion
Breathing Mx
Tension
pneumo
thorax
Deviate
away

BPlow
venou
sreturn
IVC
Thoraco
centesisthen
chesttube
Flailchest Central

parado
xical
lung
contusion
Pain
scareto
breath
Analgesiaand
oxygen
Open
pneumo
thorax
Central
3sidedflap+
chesttube
PEEP
Cardiac
tamponade
Central
Heart
cannot
expand
Pericardio
centesis

ShorthistoryAMPLE
AllergyMedicationPMHxLastmeal
Eventsurroundinginjury

Afterprimarysurvey
Monitorcardiac,SPO
2
,BP,Urineoutput
LabGXM,ABG,toxicologyscreening,urine
analysis,UPT,otherbaselineIx
Adequateresusbasedonbloodgasandu/o
RadiographicIxCXR,PXR,FAST

GCSScore
Eye Verbal Motor
6 Obey
5 Orientated Localisepain
4 Spontaneous Confuse
Withdraw
pain
3 Tocall
Inappropriatebut
comprehensible
Flexion
2 Topain Incomprehensible Extension
1 Close Mute Nomovement
FASTscan(FocalAbdominalSonographyforTrauma)
6areasoffocalscan:
Morisonpouch(betweenliverandRtkidney)
SpacebetweenspleenandLtkidney
Leftparacolicspace
Rightparacolicspace
PouchofDouglas/Rectovesicalpouch
Pericardialcavity
GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.) 4
Safetytriangleforchesttubeinsertion

(ii) Secondarysurvey(*)
=headandtoecompleteexaminationafter
primarysurvey

Signofbasalskullfracture
Periorbitalhaematoma(racooneyes)
Mastoidhaematoma(battlesign)
Haematympanum
CSFrhinorrhoea
CSFotorrhoea

6. Managementofdrowsyandunconscious
patient
(i) Causes
1. Bilateralcorticaldiseases/processes
a. Traumaheadinjury
b. HypoxiaHIE,sinusthrombosis,CVA
c. Infectioncerebralabscess,meningitis,
encephalitis
d. HaemorrhageSAH,SDH
e. MetabolicDKA,HHS,hypoorhyperNa/K,
hypoglycaemia
f. Organfailureliverorrenal
g. Postictal
h. Endocrinethyroidstorm,myxoedema,Addison
crisis
i. Drugsopiates,alcohol,opioid,alcohol,cocaine,
benzodiazepine,antidepressant
2. Brainstemdisorder~Supratentoral/infratentoral
lesionsSDH,EDH,ICB

(ii) Diagnosisandmanagement
PriorityshouldbegiventoABCresuscitationandperform
examinationsimultaneously,then:
1. Obtainquickhistoryfromwitness
a. Onsetabrupt/gradual
i. Acute(sec/min)CVA,cardiacarrest,SDH,
headinjury
ii. Subacute(minhrs)sepsis,infections,drug,
hypo
iii. Protracted
b. Recentcomplaintsheadache,depress,weakness,
vertigo
c. Recentinjury
d. Previousmedicalillness
2. Examination
a. VitalsT,PR,BP,RR
b. Skinpetechialrashes,ecchymosis
(meningoencephalitis)
c. Neurologicalassessment
i. Posture
Lackofmovementofoneside
Intermittenttwitching
Multifocalmyoclonus
Decortication
decerebration
ii. Levelofconsciousness
iii. Neckrigidity
iv. PupilsizesHornerSyndrome(ptosis,myosis,
anhydrosisandenophthalmus),atropine
overdose,opioidpoisoning,ICBetc
v. Funduscopy
vi. Brainstemreflexpupilreflexes
vii. Cornealreflex
viii. Dollseyereflex(eyemovetooppositesideof
movementsoitalwaysgoestocentre)if
negativebrainsteminjured
d. Racooneyes~basalskull#
e. Otorrhoea/rhinorrhoea
f. Nails,dxtmarks
g. Breathing
i. CheyneStrokerapid,shallowwithperiodic
apnoeicepisodesheartfailure,strokes,
traumaticbraininjuries,tumours,COpoisoning,
morphine,toxicmetabolicencephalopathy
ii. Kussmauldeeplabouredbreathing(usuallymet
acidosis)e.g.DKA,renalfailure
iii. Biotbreathingclusterpattern~pontine
malfunction
iv. Gaspingseverehypoxia

3. Ix
FBC
RBS
ESR/CRP
LFT/RP
BloodC+S
ECG/CXR
Urinetoxicology
ABG/VBG/Lactate
KIVLP
Serumtoxicology
CTBrain
SkullXrayetc.
4. ImmediateMx
MaintainIVline,O
2
therapy
BloodsampleforRBS
Controlseizures
ConsiderIVglucose,thiamine,naloxone,flumazenil
5. FurtherMx
DependingontheHxandexaminationfindings,TFT,
carboxyHblevels,BFMPandplasmaosmolarity
(increasedinmethanol,ethyleneglycolandisopropyl
alcohol)mayberequired.
6. DefinitiveMxdependsonthecause.
However,whilethepatientisundergoingevaluation,it
isessentialto:
pressureareacare
careofthemouth,eyesandskin
physiotherapytoprotectmusclesandjoints
risksofdeepveinthrombosis
risksofstressulcerationofthestomach
nutritionandfluidbalance
urinarycatheterization
monitoringoftheCVS
infectioncontrol
maintenanceofadequateoxygenation,withthe
assistanceofartificialventilationifnecessary

Algorithm
ABCoflifesupport

OxygenandI.Vaccess

Stabilizecervicalspine

Bloodglucose

Controlseizures

ConsiderI.Vglucose,thiamine,naloxone,flumazenil

Briefexaminationandobtainhistory

Investigate

Reassessthesituationandplanfurther
Anteriorborderof
mlatissimusdorsi
(anterioraxillary
line)
Lateralborderof
mpectoralismajor
46
th
rib
GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.) 5
7. Approachtopatientinshock
(i) Differencebetweenseptic,spinaland
hypovolaemicshock

Septic
EarlyLate
Spinal Hypovolaemic
Skin Warm
Pink
Cool
Pale
Warm
Pink
Cool
Pale
JVP
Cardiac
output

Systemic
vascular
resistance

Mixed
venous
O
2

content

Inotropes Dopamine Dopamine Noradrenaline
Mx
IVAbx
Methypred
*unrespons
ivetofluid
resus
Fluid
resus/blood
transfusion

Hypovolaemicshock("Tennis"staging)
I II III IV
<15% 1530% 3040% >40%
750ml 750ml1.5litre 1.52litres >2litres

(ii) Conceptof:
a. Thirdspaceloss
Fluidaccumulationininterstitial
tissue/lumenofparalyticbowels
egpostGITsurgery,pancreatitis
(acuteparapancreaticfluid
collection)
Tendstomobilisebackto
intravascularspaceinPOD3
Bewareoffluidoverloadsign

b. Plasmaloss
Occurafter1
st
12hrspostburn
injury
Slowlydecreaseatthe2
nd
12hrs
Plasmalosscausesoedemaof
tissueinvolved
c. Acutebloodloss
d. Spinalshock
Lossofsensationaccompaniedby
motorparalysiswithinitialloss
andgradualrecoveryofreflexes
followingspinalcordinjury
Phase1(01day)
arreflexia/hyporeflexia,lossof
descendingfacilitation
Phase2(12day)initialreflex
retain,denervation,
supersensitivity
Phase3(14wks)hyperreflexia,
axonsupportedsynapsegrowth
Phase4(112mths)
hyperreflexia,spasticity,soma
supportedsynapsegrowth

8. Managementofwound
(i) Typesofwoundsbydegreeof
contamination
a. Clean
Nontraumaticwithoutinflammation
e.g.vascular,endocrine,eye
procedure,withoutinvolving
respiratory,GIT/GUT
b. Cleancontaminated
Highpotentialforinfection
GIT/GUT/Respiprocedurewithout
spillage
Woundopenfordrainage
c. Contaminated
SpillagefromGIT/Biliary/GUT
d. Dirtyinfected
Traumaticwoundfromdirtysource
Woundembeddedwithforeignbody
Indicatedforwounddebridementto
removenecrotictissues

(ii) Woundclosure
a. Primarywoundclosure
woundclosedimmediatelyafterop
b. Secondarywoundclosure
woundleftopenandletithealed
overtime
c. Delayedprimaryclosureorsecondary
suturing
Duetoinfected/contaminatedwound,
unabletocloseatthetimeafterop
done
Doneafterwoundisclean

(iii) Stagesofwoundhealing
a. Early(D1)haemostasisand
inflammatorystage
b. Intermediate(D2D3)proliferative
withmigrationofmesenchymal
tissues,angiogenesisand
epithelisation
c. Late(D45)woundcontractionand
scarring(D21)

GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.) 6

9. Burnresuscitation
(i) Pathophysiologyofburn

Zoneofcoagulation:irreversibletissueloss(necrosis)
Zoneofstasis:reducedtissueperfusion,potentially
salvageabletissue(lossoftissueinthiszonecanlead
towounddeepeningandwidening)
Zoneofhyperaemia:increasedtissueperfusion,
mostlikelyrecovertissueunlessuntreatedsevere
sepsisandprolongedhypotension

Systemicresponsedevelopedoncetheburn
reaches30%ofTBSA,asaresultofcytokinesand
otherinflammatorymediators
CVS
(i) increasedcapillarypermeabilityleadsto
lossofintravascularproteinandfluidinto
interstitialcompartment
(ii) peripheralandorganvasoconstriction
causedbyTNFmyocardialcontractility
systemichypotensionandorgan
hypoperfusion
RespibronchoconstrictionALI
MetabolicBMR3,catabolism
Immunedownregulating

(ii) Burnclassification
Accordingtodepth(degree)
Isuperficialepidermis:onlyerythema,noblister,healin34
days
IIAsuperficialpartialthicknessinvolvedpapillarydermis:
redwarm,oedematous,blistered,sensoryintact,healless
than2weeks
IIBdeeppartialthicknessinvolvedreticulardermis:damage
dermalappendages,sweatgland,nerves,hairfollicles,heal
atleast3weeks
IIIfullthicknessburninvolvedalllayersofskinandsome
subcutaneoustissueinitiallypainlessinsensatedrysurface
thatappearwhitecrackwithexposedunderlyingfat
IVfullthicknesswithinvolvementoffascia,muscles,and
bones

Accordingtothesurfacearea:
Smallarearulesofpalm(1%patientspalmSA)
Largearearulesofnine

AccordingtoLundandBrowder

(iii) Fluidresuscitation
IVfluidinexcessofmaintenanceisgiventoallpatientwith
burn>20%bodysurfaceareausingParklandformulafor
reducingtheoccurrenceofburninducedshock

Choiceofsolution=Ringerlactate/HM(crystalloid)

ParklandFormula=4BWBSA%.
*Firsthalftobegiveninfirst8hrsafterinjury
*Secondhalftobegiveninnext16hrsafterinjury
*Colloidshouldnotbeusedin1
st
24hrspostburnbecauseit
mayleadtoseverepulmonarycomplication(ARDS)dueto
excessivecapillaryleakage

GKS2012/9r Page Together in Delivering Excellence (T.I.D.E.) 7

10. Bloodandbloodproduct
(i) ABOandRhesusgroup
a. UniversaldonorforFBCOnegative
b. UniversaldonorforFFPAB

1unitPCexpectedtoincrease24%
Haematocrite

Hb 3=Hct

(ii) Typeofcrossmatching

GSH(GroupScreenHold)
Patientsbloodtypeisdetermined,
bloodisscreenedforantibody
Typeandcrossfromthesamplecan
beorderedifneededlater

GXM(Groupcrossmatch)
Patientsbloodsenttobloodbankand
crossmatchforspecificdonorunitfor
possiblebloodtransfusion

(iii) Typeofbloodproductandindication
Packedcell1unit=350450cc
Indicatedatacutebloodloss
Hb<10forpatientwithh/oCAD/COPD
HealthysymptomaticpatientwithHb<8
1unitPCexpectedtoincrease11.5gofHb

Plateletindicatedif<20
1unitshouldincrease>20
Plateletcountbeforesurgeryhavetobe>50

FFPtoreplaceclottingfactor
Incaseofwarfarinoverdose,DIVC,liverdisease,
TTP

Cryoprecipitatetoreplacefibrinogen,vWF,and
otherclottingfactors

HAS4.5%or20%
Temporarilyforpatientwith
hypoproteinaemia(liverds/nephrotic)with
fluidoverload
Replaceinabdominaltapping

1DIVCregime=2platelet,4cryoprecipitate,6
FFP

(iv) Rateoftransfusion
1pintpackedcellusuallytransfusedover4hrs
withIVfrusemide30mginbetweentransfusion

(v) Transfusioncomplication
Early
(Within24hrs)
Late
(>24hrs)
Acutehaemolyticreaction
Anaphylaxis
Bacterialcontamination
Febrilereaction
Allergicreaction
Fluidoverload
Transfusionrelatedacutelung
injury
Infection(Hep
B/C/HIV/protozoa
/prion)
Ironoverload
Posttransfusion
purpura

11. Acuteabdomen
(i) Definition
Acutesevereabdominalpainthatcausespatienttoseekfor
medicalattention

Peritonealsign
Tendernessonpalpation
Percussiontenderness
Voluntaryguearding
Involuntaryguarding
Rigidity
Reboundtenderness

Inspectionsurgicalscar,distention
Palpationtenderness,hernia,motiontenderness,CVAP
(costovertebralanglepain)
Auscultationbowelsoundsandbruises
Percussionliverandspleensize

Peritonismmotionless,oftenwithkneeflex
(ii) Indicationofsurgicalreferral
Ruptureoforgan
Peritonitis
Colic
Obstructionofboweletc
(iii) Management
ABCresuscitation
Treatshock
Antibiotic
IVfluidresuscitation
Analgesics
KeepNBM
BloodIx:FBC,RP,LFT,CRP,Amylase,ABG,
UFEME,BloodC+S
US/CTtolookforfreefluid
AXR/ECG
Consent

(iv) Painrelief
NonopioidPCM,ibuprofen,diclofenac,aspirin
(musculoskeletalpain,renal,biliarycolic)
Contraindication:pepticulcer,floatingdisorder

OpioidMorphine,dimorphine,pethidine,tramadol
Contraindication:notusedintraumaticheadinjuryorhepatic
failure