Oxford Handbook of Clinical Surgery (4 edn)
Annotate
Cite
Index to emergency topics
Acute abdominal emergencies: overview 426
Acute abdominal pain 302
Acute anorectal pain 414
Acute appendicitis 298
Acute breast pain 248
Acute groin swelling 350
Acute haematemesis 294
Acute limb ischaemia 570
Acute pancreatitis 332
Acute rectal bleeding 416
Acute severe colitis 418
Acute testicular pain 388
Acute upper GI perforation 296
Acute urinary retention (AUR) 386
Acute variceal haemorrhage 330
Burns: assessment 604
Burns: management 606
Cardiac complications 106
Gynaecological causes of lower abdominal pain 306
Haematuria 384
Intra-abdominal abscess 308
Post-operative anastomotic leakage 420
Post-operative haemorrhage 102
Pulmonary embolism 120
Respiratory complications 108
Ruptured abdominal aortic aneurysm 654
Stroke 62
Wound emergencies 104
Haemoglobin | men: | 13–18g/dL | |
women: | 11.5–16g/dL | ||
Mean cell volume, MCV | 76–96fL | ||
Platelets | 150–400 × 109/L | ||
White cells (total) | 4–11 × 109/L | ||
Neutrophils | 40–75% | ||
Lymphocytes | 20–45% | ||
Eosinophils | 1–6% | ||
Blood gases | kPa | mmHg | |
pH 7.35–7.45 | |||
PaO2 | >10.6 | 75–100 | |
PaCO2 | 4.7–6 | 35–45 | |
Base excess ±2 mmol/L | |||
U&E etc If outside this range, consult: | |||
Sodium | 135–145mmol/ | ||
Potassium | 3.5–5mmol/L | ||
Creatinine | 70–150µmol/L | ||
Urea | 2.5–6.7mmol/L | ||
Calcium | 2.12–2.65mmol/L | ||
Albumin | 35–50g/L | ||
Proteins | 60–80g/L | ||
LFTs | |||
Bilirubin | 3–17µmol/L | ||
Alanine aminotransferase, ALT | 3–35U/L | ||
Aspartate transaminase, AST | 3–35U/L | ||
Alkaline phosphatase | 30–35U/L (adults) | ||
‘Cardiac enzymes’ | |||
Creatine kinase | 25–195U/L | ||
Lactate dehydrogenase, LDH | 70–250U/L | ||
Lipids and other biochemical values | |||
Cholesterol | <6mmol/L desired | ||
Triglycerides | 0.5–1.9mmol/L | ||
Amylase | 0–180somorgyi U/dL | ||
C-reactive protein, CRP | <10mg/L | ||
Glucose, fasting | 3.5–5.5mmol/L | ||
Prostate specific antigen, PSA | 0–4ng/mL | ||
T4 (total thyroxine) | 70–140mmol/L | ||
TSH | 0.5– ~5mu/L | ||
Haemoglobin | men: | 13–18g/dL | |
women: | 11.5–16g/dL | ||
Mean cell volume, MCV | 76–96fL | ||
Platelets | 150–400 × 109/L | ||
White cells (total) | 4–11 × 109/L | ||
Neutrophils | 40–75% | ||
Lymphocytes | 20–45% | ||
Eosinophils | 1–6% | ||
Blood gases | kPa | mmHg | |
pH 7.35–7.45 | |||
PaO2 | >10.6 | 75–100 | |
PaCO2 | 4.7–6 | 35–45 | |
Base excess ±2 mmol/L | |||
U&E etc If outside this range, consult: | |||
Sodium | 135–145mmol/ | ||
Potassium | 3.5–5mmol/L | ||
Creatinine | 70–150µmol/L | ||
Urea | 2.5–6.7mmol/L | ||
Calcium | 2.12–2.65mmol/L | ||
Albumin | 35–50g/L | ||
Proteins | 60–80g/L | ||
LFTs | |||
Bilirubin | 3–17µmol/L | ||
Alanine aminotransferase, ALT | 3–35U/L | ||
Aspartate transaminase, AST | 3–35U/L | ||
Alkaline phosphatase | 30–35U/L (adults) | ||
‘Cardiac enzymes’ | |||
Creatine kinase | 25–195U/L | ||
Lactate dehydrogenase, LDH | 70–250U/L | ||
Lipids and other biochemical values | |||
Cholesterol | <6mmol/L desired | ||
Triglycerides | 0.5–1.9mmol/L | ||
Amylase | 0–180somorgyi U/dL | ||
C-reactive protein, CRP | <10mg/L | ||
Glucose, fasting | 3.5–5.5mmol/L | ||
Prostate specific antigen, PSA | 0–4ng/mL | ||
T4 (total thyroxine) | 70–140mmol/L | ||
TSH | 0.5– ~5mu/L | ||
Common perioperative care
Bowel prep
KleenPrep® 4 sachets over 8h the day preop or CitragMag® 2 sachets over 4h the night preop.
Thromboprophylaxis
Low risk, e.g. day or fully ambulatory cases: TEDS only.
Medium risk, e.g. major surgery without risk factors or past history of DVT: TEDS + Clexane® 30mg SC od or Fragmin® 2500U SC od.
High risk, e.g. pelvic surgery, malignancy, obesity, past history of DVT: TEDS + Clexane® 30mg SC bd or Fragmin® 5000U SC od.
Diabetic perioperative regimens
Minor surgery (e.g. day surgery)
Oral controlled: give normal regimen.
Insulin controlled: omit preop insulin on day of surgery; monitor blood sugar (BS) every 4h; restart normal insulin once oral diet established.
Major surgery
Oral controlled: omit long-acting hypoglycaemics preoperatively; monitor BS every 4h. If BS > 15mmol/L start IV insulin regimen.
Insulin controlled: commence on IV insulin sliding scale preoperatively once NBM and continue until normal diet re-established. Check BS 4-hourly. Restart normal insulin regimen (initially at half dose) once oral diet established.
Typical IV sliding scale (Actrapid® with 5% dextrose):
BS < 4mmol/L: infusion 0.5U/h;
BS 4–15mmol/L, infusion 2.0U/h;
BS 15–20mmol/L, infusion 4.0U/h;
BS > 20mmol/L, infusion 4.0U/h plus consult diabetology team. Con-sider treatment as for ketoacidosis.
Fluid balance
Fluid depletion = ((PCV1 – PCV2)/PCV1) × 0.7 × weight in kg
where PCV1 = normal haematocrit and PCV2 = current haematocrit.
| Fluid volume | Na+ | K+ | |
|---|---|---|---|
100mL/kg for 1st 10kg of weight + 150mL/kg for next 10kg of weight + 20mL/kg for every kg of weight thereafter | 2mmol/kg/24h | 1mmol/kg/24h |
| Fluid volume | Na+ | K+ | |
|---|---|---|---|
100mL/kg for 1st 10kg of weight + 150mL/kg for next 10kg of weight + 20mL/kg for every kg of weight thereafter | 2mmol/kg/24h | 1mmol/kg/24h |
Managing oliguria
Check catheter not blocked.
Check fluid balance status—try bolus crystalloid with frequent reviews.
Check drug chart for possible drug toxicity.
Managing postoperative hypotension
Check fluid balance status first. If in doubt assume it is hypovolaemia.
Check epidural status. Check drug chart for possible drug toxicity.
Cardiac arrest: 2010 Adult Advanced Life-Support Algorithm1
Each step assumes the previous one has been unsuccessful
Do not interrupt CPR for >10s, except to defibrillate.
Shockable rhythm:
Amiodarone 300mg IV should be given with first dose of adrenaline (peripherally if no central access). A further 150mg may be given, followed by an infusion of 1mg/min for 6h, then 0.5mg/min for 6h.
Alteratives to amiodarone are:
Lidocaine 100mg IV; can repeat once; then give 2–4mg/min IVI.
Procainamide 30mg/min IV to a total dose of 17mg/kg.
Seek expert advice from a cardiologist.
Asystole/PEA2:Give adrenaline 1mg immediately IV access is achieved. Atropine 3mg IV is no longer recommended. If P waves the patient may respond to pacing.
Treat acidosis with good ventilation. Sodium bicarbonate may worsen intracellular acidosis and precipitate arrhythmias, so use only in severe acidosis after prolonged resuscitation (eg 50mL of 8.4% solution by IVI).
Algorithm reproduced with the permission of the Resuscitation Council (UK), ©2010. NB: adrena-line/epinephrine in large doses (eg 5mg) has theoretical haemodynamic advantages, but studies have failed to show benefit (Ballew K 1997 BMJ i 1462). See Baskett P 1992 Br J Anaesthesia 69 182
PEA = Pulseless Electrical Activity = electromechanical dissociation (EMD)
