2013

Basic Emergency and Surgical Skills (BESS) Course Team –

KasrAlainy Hospitals, Cairo University

Prepared By Revised By
Mohamed Mostafa Alasmar, MBBCh, MRCS Doaa Ahmed Mansour, MBBCh, MD, MRCS
General Surgery Resident General Surgery Lecturer – Cairo University
ATLS Instructor and National Coordinator - Egypt ATLS Instructor and Director - Egypt

Designed By
Yosra Saeed, MBBCh
General Surgery Resident

[A GUIDE TO HOUSE OFFICERS IN

SURGERY CASUALTY RECEPTION ]
Disclaimer: This guide contains general information about medical conditions and treatments. The information is not
advice and should not be treated as such as you have to treat according the situation and the advice of your senior
colleague. We do not warrant or represent that the medical information on this guide is complete, true, accurate, up
to date or non-misleading. You must not rely on the information on this guide as an alternative to senior advice. If
you have any specific questions, you should consult your senior. Nothing in this medical disclaimer will limit or
exclude our liability for death or personal injury resulting from negligence or limit or exclude our liability for fraud or
fraudulent misrepresentation.
Acute Abdominal Pain
History with Examination (Simultaneously)
General Examination. Pulse, temperature
Signs of hypovolemia or dehydration.
 Expose entire abdomen
 Look for movement with respiration “..‫ اشفط بطنك‬..‫”انفخ بطنك‬
 Look for distension
 Look for cough tenderness
 Ask him to localize the max. point of pain
 Look for hernia orifices and genitalia
 Auscultate the abdomen “the 4 quadrants” for the hyperaudible or absent bowel sounds
 Palpate
 Search for :
o Tenderness  pain with palpation
o Guarding  muscle contraction with palpation
o Rigidity  Muscle already contacted even without
palpation
o Rebound tenderness  pain with removal of your
hand “not usually recommended because it’s painful”
 DRE (Digital Rectal Examination)(chaperone) search for
o Stools “ indentation in a hard mass”
o Blood / Mass / Pain
 Percuss
 Percussion tenderness equivalent to rebound tenderness
 Shifting dullness “free abdominal fluid”
 Obliterated liver dullness “ air under diaphragm “
 History
 Personal
 Pain analysis
 GIT symptoms
o Do you have any problem in
- Digestion
- loss of weight
- difficulty in swallowing
- heart burn
- nausea, vomiting
- abdominal pain
- swelling
- change of bowel habits
- Rectal bleeding.

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  Genito Urinary symptoms
 Ask for other symptoms of other systems that may affect pt. fitness for operation
o CVS : Cardiac disease? Chest pain? Palpitation?
o Respiratory: Shortness of breath? Cough or sputum?
o DM
o Pregnancy? Menstrual disturbances?
 Past History
 Admission to hospital?
 Operation?
 Allergy?
 Drugs?

How to think? And what to do ?

1. Ask for senior consultation especially if you think the patient will be discharged
2. Buy Time
a. Ask for Investigations
 To guide you in diagnosis
 Erect and supine abdominal X-ray in IO
 US in acute pain
 Amylase for all abdominal pain unless clinically clear diagnosis
 Chest X-ray if you suspect perforated viscus
 CBC
 Routine labs.
PT, PC, INR
Na, K
ALT, AST
Creat, Urea
RBS
 ECG if pt. is cardiac or above 40 yrs
b. Ask for other consultations
- Like cardiology consultation in cardiac pt.
- Gyn/ob in female pt. with lower abd. Pain
3. Start immediate management
 Insert cannula labs.
 1-2 liters of (Lactated Ringer's)
 NG tube IO or perforated viscus
 urinary catheter
 Treatment : fluid + analgesics if ureteric colic
4. Inform the senior with full correct set of data, watch the senior while examining the pt. &
do what isrequested from you

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Most common causes of abdominal pain
 Think anatomically
 The classic picture is not usually common

Acute Cholecystitis

IOO
 4 cardinal symptoms: Pain , Vomiting, Distension, Absolute constipation
 Ask for previous abdominal Operation & Search for hernia orifices (also femoral)!
(2 most common)
 Consider CT scan especially if cause not obvious
 Decompress NGtube
 Resuscitate Cannula 1-2 L RL
 Monitor urinary cath.

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Acute Pancreatitis

 Severe acute pain referred to the back

 Add amylase + Lipase, Ca, LDH, Alb, Bil. (D. & IND.) and ABG's
 Decompress (if vomiting) – Resuscitate - Monitor
 CT scan

Ranson’s Criteria of severity of acute pancreatitis :

non-gallstone pancreatitis
At admission: At 48 hours:
Age > 55 years Serum Ca < 8 mg/dl
TLC > 16,000 cells/mm³ Hematocrit fall > 10 mmol/L
Blood Glucose > 200 mg/dl Hypoxia PO₂ < 60 mmHg
Serum ASL > 250 IU/L BUN ↑by ≥ 5 mg/dl after IV fluid
Serum LDH > 350 IU/L Base ↓( -ve base excess) > 4mEq/L
Sequestration of fluids >6L

Ranson’s Criteria of severity of acute pancreatitis :

gallstone pancreatitis
At admission: At 48 hours:
Age >70 years Serum Ca < 8 mg/dl
TLC > 18,000 cells/mm³ Hematocrit fall > 10 mmol/L
Blood Glucose > 220 mg/dl Hypoxia PO₂ < 60 mmHg
Serum ASL > 250 IU/L BUN ↑by ≥ 5 mg/dl after IV fluid
Serum LDH > 400IU/L Base ↓( -ve base excess) > 5mEq/L
Sequestration of fluids >4L

If the score ≥ 3, severe pancreatitis likely.

If the score < 3, severe pancreatitis is unlikely
Or
Score 0 to 2 : 2% mortality
Score 3 to 4 : 15% mortality
Score 5 to 6 : 40% mortality
Score 7 to 8 : 100% mortality.

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Complicated hernias
 Swelling at site of hernia
 Irreducible
 IO
 Strangulated (Acutely Tense, tender, irreducible & NO impulse on cough)
 Taxis ??!!
 Cold fomentation may be of help
 Decompress – Resuscitate - Monitor

Acute appendicitis

ALVARADO SCORE (MANTRLES ) :

Symptoms: Signs: Investigations:
Migrating pain ..1 Rt iliac fossa Tenderness..2 Leucocytosis ..2
Nausea / Vomiting ..1 Rebound Tenderness..1 Shift to the left .. 1
Anorexia..1 Low Grade Fever ..1

MANTRELS - Migration to the right iliac fossa, Anorexia, Nausea/Vomiting,

Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever),
Leukocytosis, and Shift of leukocytes to the left
5-6 .. compatible
7-8 .. probable
9-10 .. nearly sure

 Do not forget Gyn/ob. Consultation in female pt.

Acute Cholecystitis
 US: wall edema – pericholecystic collection – stones – sonographic Murphy's

Ureteric colic
 History of urinary symptoms
 Pain in flanks referred to scrotum or inner aspect of the thigh
 No peritoneal irritation
 Severe colicky pain  patient is moving around
 Cocktail  500- 1000 cm of NS
+ amp. NSAID
Do not give antispasmodics

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Urine Retention or Anuria
 Examine pt.’s abdomen & take history
 Send pt. for US
Empty Bladder
Send for routine labs including Urea&creat.
If US hydroureter or hydronephrosis consult
urology
If creat. >7 or no signs of hydroureter or
hydronephrosis send pt. to internal medicine
Full bladder
Psychological support & trial of micturition in
front of running water
Consult Urology – consider Catheter
If relieved  should be gradual to prevent
hematuria then send pt. to urology clinic
If Not  consult urology

How To Write ttt, To admitted pt.

 Fluids for NPO pt.

GIVE
Daily Requirement

1mmol Na/kg if 70 kg pt.

30ml/kg water
≈ 75 m mol Na
if 70kg pt.
If Potassium is required
So ≈ 2000ml/day
(usually in 3rd post. Op. day)

1 mmol Potassium/kg
Usually 10 mmol/ampoule but
READ
Rule of 40
Don’t give > 40 mmol/ hr
Don’t put > 40 mmol/ L
Don't give if urine output < 40 ml/hr
DO NOT give more than 4X40 (160 mmol/ day)

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 ‫‪‬‬ ‫? ‪IV Antibiotics‬‬
‫‪‬‬ ‫?‪Parentral Analgesia‬‬
‫‪‬‬ ‫‪Write instructions for your colleagues or nurses‬‬
‫‪‬‬ ‫‪Include the decision of the consultant in the pt.’s file and write the name of the‬‬
‫‪consultant‬‬

‫‪Example:‬‬

‫ض‪ .‬ن‪ .‬ح ‪.‬كل ؟؟ ساعات‬ ‫مالحظة‬

‫ال شىء بالفم ؟؟‬ ‫مالحظة‬
‫الخارج من قسطرة البول و الرايل و الدرانق لون و كمية مع التدوين‬ ‫مالحظة‬
‫محاليل‬ ‫مالحظة‬
‫‪ 055‬سم محلول جلوكوز ‪ %0‬زجاجة كل ‪ 6‬ساعات بالوريد‬
‫‪ 055‬سم محلول ملح زجاجة كل ‪ 21‬ساعة بالوريد‬
‫امبول بوتاسيوم على كل زجاجة محلول و يعطى خالل ‪ 05‬دقيقة على االقل‬
‫مالحظة عالج‬
‫فيال سيفوتاكس ‪ 2‬جم بالوريد كل ‪ 21‬ساعة‬
‫او فيال يوناسين ‪ 2.0‬جم بالوريد كل ‪ 21‬ساعة‬
‫او فيال سلبرازون ‪ 2.0‬جم بالوريد كل ‪ 21‬ساعة‬
‫او فيال روسيفين ‪ 1‬جم كل ‪ 12‬ساعة‬

‫امبول ديكلوفين على المحلول كل ‪ 8‬ساعات بالوريد‬

‫امبول زانتاك كل ‪ 8‬ساعات بالوريد‬

‫زجاجة فالجيل ‪ 055‬ملجم بالوريد كل ‪ 8‬ساعات‬

‫قياس السكر عشوائى بالدم كل ‪ 6‬ساعات و اعطاء انسولين مائى بالوريد حسب الجدول‬
‫اقل من ‪ 155‬ملجم الشئ‬
‫من ‪ 105 – 155‬اعطاء ‪ 0‬وحدات‬
‫من ‪ 055 – 105‬اعطاء ‪ 25‬وحدات‬
‫من ‪ 005 – 055‬اعطاء ‪ 20‬وحدة‬
‫من ‪ 255 – 005‬اعطاء ‪ 15‬وحدة مع ابالغ الطبيب و عمل اسيتون فى البول‬

‫‪Acute Mesenteric Vascular occlusion‬‬

‫‪‬‬ ‫‪Pain out of proportion to the abdominal signs‬‬
‫‪‬‬ ‫‪History of source of emboli‬‬
‫‪‬‬ ‫)‪full labs + serum amylase + ABG (metabolic acidosis‬‬
‫‪‬‬ ‫‪CT with IV contrast‬‬

‫‪8‬‬
Vascular emergencies
Acute ischemia "6 Ps" Pain, Paralysis, Paraesthesia, Poikilothermia (Coldness), Pallor
and Pulselessness
Differentiation of embolus and acute arterial thrombosis (thrombosis in situ)
Embolus Thrombosis
Onset Seconds or minutes Hours or days
Embolic source Present (usually atrial Absent
fibrillation)
Previous claudication Absent Present
Contralateral leg Present Absent
pulses

Deep venous thrombosis

 History of predisposing factor
 Triad of Pain + tenderness + swelling
Send the patient for duplex scan and consult vascular surgeon

Diabetic foot:
- Signs of sepsis?
- DKA?
- RBS? ABGs? Urinary Acetone?
- Assess: Tissue loss, collection, crepitus, odour
- No pulse  vascular surgery
- Intact pedal pulsations  general surgery
- X- ray foot

If DKA
1 Consult internal medicine / ER / ICU
2 Start 1 L/ hr of 0.9% NaCl for first 3hours.
3 Insulin 0.1 units/kg IV bolus, then start a continuous IV infusion 0.1 units/kg per hour
4 Check RBS every hour by finger prick
5 ABGs, Na, K
6 Consider administration of K via central line
If serum K is < 3.3 mEq/L, give 20-30 mEq of K/hr until K > 3.3 mEq.
If serum K is 3.3 - 5.3 mEq/L, give 10-20 mEq/hr of K to keep serum K between 4-5 mEq/L.
If serum K is > 5.3 mEq/L, do not give K but check serum K Q2hr.

9
Differential diagnosis of different scrotal presentations
Causes of painful scrotum
o Strangulated hernia
o Fournier's gangrene
o Testicular torsion
o Epididymo-orchitis

Differences between torsion of testis and acute epididymo-orchitis

Torsion of testis Acute epididymo-orchitis
Age Usually adolescents and Usually adults or elderly
children
History Sometimes mild trauma Usually UTI symptoms
Temperature Normal or slightly elevated Elevated
Elevation of scrotum Does not alleviate the pain Partial pain relief
Urgent urine analysis Free May show pus cells
Urgent Doppler or Obstructed testicular vessels Patent testicular vessels
duplex
- Consult your resident
- Send pt. to andrology department.

Differential diagnosis of different anal disorders and approach

for diagnosis
 rectal bleeding
- assess patient haemodynamic stability
- stable refer to internal medicine or outpatient clinic and consider medical ttt
o Daflon tap 2×3×4 days, 2×2×3 days then 1×3 for a week
o Konakion amp. once
o Dicynone amp. once
o Kapron amp. once
- If unstable  resuscitate, CBC, Blood, consult your resident / internal med.
 Diagnosis of conditions which present with pain
Pain Fissure (pain after defecation) lignocaine cream or GTN /
laxative
Anorectal abscess  Drainage
Pain and lump Perianal haematoma  lignocaine cream / Lead Acetate
fomentations
Pain, lump and Prolapsed haemorrhoids
bleeding Carcinoma of the anal canal
Prolapsed rectal polyp or carcinoma
Prolapsed rectum

10
Swallowed Foreign Body
 Talk to the pt.
 If pt. responds so most probably airway is Ok.
- Send pt. to Do x-ray ( neck &chest or Abdomen) AP & lat. View
- If FB above clavicle  sent to ENT
- If FB in chest & below clavicle  consult cardiothoracic surgeon
- In FB in the abdomen
Examine Pt. abdomen
Reassure the pt.
You may need to consult your resident if there are warning signs
Send him for follow up in outpatient clinic
Instruct him about warning signs of complications like perforations or IO
Acute abdomen
Absolute constipation
Repeated vomiting
- Instruct Pt. to Ingest fluids and food
Normally without any change and there is no specific regimen or treatment

 If not
- Shout for help  send pt. to resus. Room.

WOUND
MANAGEMENT

REMEMBER

 Simple wounds may be not simple at all

 “Good surgeons know how to operate, Better surgeons when to operate, and the Best when NOT to operate”.

11
 PLAN

12
Assessment Preparation Procedure After-care

General  Consent (options - complications)  Dressing

 Prepare your stuff (dressing – instruments - …..)  Medications (antibiotics
 Anesthesia (local – regional - general) - analgesics - others)
 Cleaning (tap water , saline, DO NOT use  Immunizations (tetanus -
 Talk to the antiseptics) rabies vaccine)
patient   Skin preparation (shaving - disinfection)  Suture removal
assessing ABCs – Regional
 Draping
gaining patient
 Wound examination: DON’T close upon: F.B. ,
confidence.
Hematoma, Edema & potentially infected ( after
 Mode of trauma
6 hours delayed 1ry closure )
 Co-morbidities
 Position & light
 Vital signs (esp.
the pulse and
Ask & Examine You may need to You may need to
conscious level )
order Consult
 Any tachycardic,
cold patient Head  Loss of consciousness CT scan Neurosurgeon
considered  Vomiting
 Persistent headache If the previous
shocked until
 Blurring of vision symptoms are +ve
proved
otherwise  Chest  Inspection, palpation, percussion Chest x-ray Cardio-thoracic surgeon
Resus. Room and auscultation
 NECK (veins – trachea)
Abdomen  Inspection, palpation, percussion  Abdominal U/S General surgeon
and auscultation  Chest x-ray
Extremities Look, feel, move and special tests X-ray Orthopedics, plastic
 Bone, joints, muscles and tendons, surgeon or vascular
nerves and blood vessels. surgeon
Local anesthesia

Xylocaine
 Mode of administration: Subcutaneous local infiltration
 Complications : 1st symptom of toxicity circum oral numbness
 CNS convulsions  coma
 CVS arrhythmia  arrest
So,,
- Antidote  NONE thus supportive ABC so, DO NOT give where support is not
available.
- Aspirate before injection
- Max. safe dose  3mg/kg
In 70kg adult  200 mg
In conc. 2%: 2gm/100gm water
2gm/100cm³ or ml or cc water
2000mg/100ml
20mg/ml
So. In 70kg adult it is 10 cc of the 2%
Or 20 cc of 1%
Or 40 cc of 0.5%
Start acting after 3min so wait
Lasts for 3 hours
The effective volume = length of the wound x 3
So if 5sm wound prepare 15cc of LA
1cm on each 1 cm of the edge of the wound & 1cm spare if the patient still in pain
So 10 cc in wound & 5cc spare
From inside or from outside & minimize number of punctures
Role of 3’s
- 3mg/kg (Maximum safe dose)
- 3min to start
- 3hours duration of Action
- 3cc /cm wound

 With adrenaline 1:200,000 (one amp. 1mg on 200cc saline)

Maximum safe dose will be approximately doubled (7mg/kg)
 But be aware
Do not give in finger, toes, nose, ear and penis.
 No topical xylocaine except on mucosa.

13
How to select proper suture material & needle?

 Suture material
Absorbable Nonabsorbable
- We need suture till healing, and not after that so we remove it as early as possible
Outside body  we have the both options
So inside body  absorbable except
o Closure of abdomen
o Hernia repair
o Vascular anastomosis
o Tendons
o Nerves

Monofilament Multifilament (braided)

Difficult handling Easy handling
Memory Less memory
insecure knot Secure knot
Lower risk of infection Microabscesses formation

Natural Synthetic
Antigenicity Inert
Cheap More Expensive
Theoretical risk of transmission of diseases e.g.
prions
Usually we prefer synthetic suture

14
  Needles

Rounded needles Negotiate with collagen fibers as passing a needle through cloth
It can not negotiate with tough tissues like skin so we use cutting needles with skin

 Sizes
o Length 75cm or 45cm
o Gauge
3 , 2 ← 1 → 0 , 00 , 000 , -------
0.35 mm 2/0 3/0 ------- 12/0 or less!
There is No. 1/0 ?!

 Examples
Silk Natural Nonabsorbable Multifilament
Catgut Natural Absorbable Monofilament
Prolene Synthetic Nonabsorbable Monofilament
vicryl Synthetic Absorbable Multifilament

 Usually skin we use 3/0 prolene

 Face 5/0 prolene
 Scalp for the sake of hemostasis 0 or 1
 Closure of abdomen prolene 1 or 0 or PDS loop
 Subcutaneous vicryl 2/0 or 3/0

15
 Examination of an injured patient
PRIMARY SURVEY OF INJURED PATIENTS

 Safety (gloves, coat...) – Shake and shout (talk to the patient) - if No response Shout for
Help – look, listen & feel

 If the patient is responsive or brathing and has intact central pulsation proceed with:
• Simple Combined Assessment (history, examination) and Management.
• ABCDE

Airway You may need the help of Anesthetist

Clear airway Protect airway Cervical spine control Oxygen mask

Manually, Oropharyngeal airway, Backboard / High flow O2

Suction or Chin Nasopharyngeal airway, semirigid collar >11L/min
lift or jaw thrust / Manual inline
Definitive Airway immobilization
Tracheal intubation,
Cricothyroidectomy
16
 You may need the help of
cardiothoracic surgeon
Breathing

Assessment Management of the 5 killers

Inspection Respiratory rate, Movement,
Chest expansion, Accessory
muscles of respiration,
Cyanosis, Tracheal shift,
Jugular venous distension
and Open chest wound
Palpation Subcutaneous emphysema
and Flail segment
Auscultation Upper airway sounds and
Lower airway sounds
Percussion Hyper-resonance and
Dullness
Neck Veins
Trachea
Tension Needle decompression
pneumothorax Before x-ray or consultation
Cardiac Consult cardiothoracic / FAST
tamponade / CVP / Needle
pericardiocentesis under ECG
monitoring / Thoracotomy
Flail chest O2 + analgesia / Intubation
and positive pressure
ventilation may be needed
Massive Chest tube
hemothorax Thoracotomy if indicated
Open 3 way occlusive dressing /
pneumothorax Chest tube

You may need the help of General

surgeon
Circulation

Assessment Management

Symptoms and signs of Control bleeding

shock: Blood on floor (Compression) and 4 more
Tachycardia, cold, sweaty, Chest  Chest Tube
anxious, thirsty, low urine Abdomen GS consultation / laparotomy
output Pelvis  pelvic wrap with sheet ‫مالية سرير‬
Hypotension is a LATE
Extremities  traction
sign Intracranial Hemorrhage is NOT a cause of hypovolemic
shock
Insert 2 large caliber 16G or 14G peripheral IV line
Blood sampling for: Typing, Cross-matching & routine labs
Ringer's lactate (warm 2 liters)/early Blood transfusion

17
 You may need the help of
Disability
neurosurgeon

GCS Prevent 2ry brain insults (hypoxia and hypotension)

Examination SO2 > 95%, Systolic BP > 90 mmHg
of pupil
Exposure and environment

Remove all clothes Logrolling Warmth DRE

Mini radiological assessment and adjuncts

 AP chest, AP pelvis and any other indicated X rays (e.g Cervical spine) Pulse oximeter, Foley's
catheter, FAST/DPL, ECG, ABGs and Gastric tube.

SECONDARY SURVEY
 Mini history
AMPLE
Allergies, Medications, Past medical history/Pregnancy, Last meal time and Events of injury
 Complete head to toe examination
 Complete neurological examination (dermatomes and myotomes)

Now it is your chance to transfer the patient or to consult other specialties like
vascular surgery, urology or plastic surgery.

Role of investigation in diagnosis of a traumatized patient

 You may very well operate without investigation
 If investigation is urgent and not to delay operation
 Resuscitate first
 Be ready to resuscitate during investigation

3 way occlusive dressing in open

pneumothorax

18
ABCDEs interpretation of Chest X-ray:

 Airways
 Breathing
 Circulation and cardiac shadwo
 Diaphragm
 Edges And Soft tissues

Supine anteroposeterior radiograph of normal Opaque left haemothorax with evidence of

chest with ABCDEs interpretation contralateral shift of the mediastinum.

ABCDEs interpretation of Pelvis X-ray:

 Alignment
 Bones
 Cartilage
 Soft tissues

Radiograph of supine pelvis showing ABCDEs interpretation

19