This document discusses the management of surgical emergencies. It begins by outlining the signs of shock and how to assess patients presenting with shock. It then discusses the immediate management of shock, including fluid resuscitation and appropriate investigations. Specific investigations discussed include full blood count, electrolytes, blood glucose, and coagulation profile. The document also discusses appropriate intravenous fluid selection and oxygen delivery. Principles of management are discussed for conditions like upper gastrointestinal bleeding and lower gastrointestinal bleeding.

1. Surgical Emergencies
the
G1Group
B y
Q u a h C h e e S i a n
P a r t h i b a n S .

2. S H O C K
I M M E D I A T E
M A N A G E M E N T S
S I G N S
I N V E S T I G A T I O N S
I N F O G R A P H I C S
Introductio
n..

3. S U R G I C A L E M E R G E N C I E S
Sign of Shock

4. • ↑ HR (>100)
• ↓ pO2 (< 90%)
• ↑ RR (> 20)
• SBP < 90 mmHg
Signs of Shock
SURGICAL EMERGENCIES
CP presentation

5. S U R G I C A L E M E R G E N C I E S
Immediate Management

6. CP presentation

7. S U R G I C A L E M E R G E N C I E S
Investigati
ons

8. What specific laboratory
studies will help you?
CP presentation
These are the appropiate initial screening tests.
i. FBC
ii. BUSE/Cr
iii. Blood glucose
iv. Coagulation profile
v. Blood grouping/ X matching
vi. Investigate source of bleed

9. IV Fluids

12. Colloid or Crystalloids?
• Theoretical advantage of colloids 
remains in IV space, smaller volume
required
• Risks: Anaphylaxis, Coagulopathy
• Evidence: No significance difference in
outcome between 4% albumin & NS

13. NS or RL?
• NS has strong anion gradient
• Cause Hyperchloremic Metabolic acidosis 
Worsen Coagulopathy
• HyperKalemia after 6 hours

14. Cannula Size

15. O2 Delivering

16. Oxygen
• Target SpO2: 95-99% (Normal pt)
• 88-92% (COPD pt)
1.Nasal prong: 2-5L/min (28-35%)
2.Simple face mask: 5-15L/min (35-50%)
3.Venturi mask: (24-60% based on valve)
4.Non-Rebreathing mask (up to 85% in 15L/min)

17. CP presentation
Thank
s

18. Upper Gastrointestinal Bleeding
SITI NUR AQILAH MOHD AZRY
YEE ZHEN AUN

19. Variceal
Non-variceal:
I. Bleeding PUD
II. CA gastric, esophagus
III. Drugs?
IV. Mallory Weiss tear
V. Others: AVM, Dielafoy syndrome
AETIOLOGYUPPER GASTROINTESTINAL BLEEDING
19
PEPTIC ULCER DISEASE
ESOPHAGEAL VARICES
CARCINOMA
STOMACH,
ESOPHAGUS

20. Management
step-wise management of patients with upper gastrointestinal
bleeding

21. GENERAL MANAGEMENT
UPPER GASTROINTESTINAL BLEEDING
21
In addition…
• Stop any aspirin, NSAID, anticoagulant, B-blockers
• Tranexamic acid
• IV Pantoprazole 80 mg bolus, 8 mg/hour continuous infusion for 72 hours
• Suspected oesophageal varices: vasoconstrictors till bleed dealt with endoscopy, gastric lavage
lavage with large (32 F) NG tube for better visualization
• IV Terlipressin 2 mg 6th hourly or
• S/C sandostatin 50-100 micrograms BD

22. SPECIFIC MANAGEMENT
UPPER GASTROINTESTINAL BLEEDING
22
In acute UGIB:
• emergency endoscopy (within 24 hours)
For bleeding PUD;
• if Forest grade I, IIa and IIb proceed with endoscopic therapy, CLO
test
3 modalities (choose 2):
• Adrenaline (1:10000) 15-30 ml
OGDS ELECTROCOAGULATI
ON
 HEMOCLIP

23. DEFINITIVE MANAGEMENT
UPPER GASTROINTESTINAL BLEEDING
23
If endoscopic therapy fail…
Laparotomy and under-running of bleed gastric
or duodenal ulcer with silk suture
DEFINITIVE MANAGEMENT
Duodenal ulcer: truncal vagotomy +
(pyloroplasty or post. gastrojujenostomy or
antrectomy)
Gastric ulcer: truncal vagotomy + pyloroplasty,
highly selective vagotomy, partial gastrectomy

24. FOR ESOPHAGEAL VARICES
UPPER GASTROINTESTINAL BLEEDING
24
ENDOSCOPIC BAND LIGATION ENDOSCOPIC INJECTION SCLEROTHERAPY
PREFERED IN
EMERGENCY

25. If EBL and EIS not feasible or fail…
UPPER GASTROINTESTINAL BLEEDING
25
SANGSTAKEN BLAKEMOORE TUBE
Open surgery: if bleeding cannot be manage by endoscopy
• Emergency open surgery: devascularization
• Shunt surgery: porto-caval shunt, spleno-renal shunt
• TIPS
Others:
• Therapy to prevent or reduce hepatic encephalopathy
Oral neomycin 1 g QID
Oral lactulose 100g/day in divided doses, high enema
IV vitamin K 10 mg

26. 26
By
Aminurulamirah and Atiqah Zayed
LOWER
GASTROINTESTINAL
BLEEDING BLEEDING DISTAL
TO LIGAMENT OF
TREITZ

27. 27
AETIOLOGY
•IBD
•Colitis (amoebic colitis, typhoid)
Inflammatory
•Benign : Intestinal Polyps
•Malignant : Colorectal CANeoplastic
•Iatrogenic : post-endoscopy
Traumatic
•Vascular: angiodysplasi, hemorrhoids, ischaemic colitis.
•Anal fissure
•Diverticulum :bleeding diverticulosis/meckels
•Drugs: Anticoagulant
•Radiation : Colitis
Misc

28. 28
Lower Gastrointestinal Bleed Classification
TYPESOFLGIB
WHO WE ARE
BEST SERVICE OF US
GOOD VISION
VERY USEFUL TIMELINE
EXCELLENT DIAGRAM
CONTACT US
Minor
Hemorrhage
Major Hemorrhage Occult Bleed
Hemorrhoids Bleeding diverticulosis Polyps
IBD Angiodysplasia Colorectal CA
Colorectal Polyps Dieulafoy lesion of
intestines
Intussusception Ischaemic cholitis
Meckel’s Diverticulum

29. 29
Schematic
Presentationof
approachinLGIB
A schematic representation of proper workflow
approach towards lower GI bleed.

30. CP Presentation 30
•Most of LGIB are chronic cases.
•Acute LGIB : 20% of GI bleed cases
Management of Acute LGIB
Resuscitation and
initial assessment
Localization of the
bleeding site
Therapeutic
intervention to stop
bleeding at the site

31. CP Presentation 31
Immediate Mx
i. 02, NG tube, IV fluids, CBD, CVP
ii. Correct metabolic acidosis
iii.Blood transfusioan (p.RBC,platelets, FFP)
iv.Administer hemostatic adjunct
v. IVG : all baseline IVG
ABC Protocol

32. 32
Usually LGIB source difficult to identify
Localization
of the cause
• 99mTC radionuclide/ scintigraphy
• Digital Subtraction Angiogram
• Arteriogram of I.M.A
• Emergency colonoscopy
• Unstable patient subjected to urgent laparotomy

33. If actively bleed vessel is identified:
Therapeutic
interventionstostop
bleedingatthesite
Vasopressin injected = vasospasm
Injection of 1:20000 adrenaline into 4 quadrants of
bleeding (bleeding diverticulum)
Laparotomy
Embolization with metal microcoil or PVA. (life-saving but
need interventional radiologist)

34. 34
Management for Non-urgent Cases
Baseline
blood IVG
Stools for
occult blood
Endoscopy
Imaging
Double contract
barium enema, CT,
angiography

35. 35
references
I. Website: gi.org/wp-content/uploads/2016/03/ACGGuideline-Acute-Lower-GI-Bleeding-
03012016.pdf
II. Website: emedicine.medscape.com/article/188478-treatment#d14
III. Manipal Manualof Surgery
IV. Clinical Companion in Surgery

36. Causes & management
Lili syafinaz & Teo pei shin

37. MICROSCOPIC
●Can be detected on
dipstick or FEME
●Red Blood Cell (RBC):
>3 /hpf
Non-visible haematuria / dipstick-positive
HAEMATURI
A
CLASSIFICATIONS
MACROSCOPICVisible haematuria or gross haematuria

38. 38
aetiologyCAUSES OF HAEMATURIA
CONGENIT
AL
OLICYSTIC KIDNEY DISEASE
 Infective: Urinary infection
 Non-infective: Interstitial cystitis,
glomerulonephritis,
pyelonephritis
 Direct: Blunt/ penetrating
trauma
 Iatrogenic: Instrumentation/
catheterisation
ACQUIRED
 Benign: Benign prostatic hyperplasia
 Malignant: Renal cell carcinoma, transitional cell
carcinoma of renal pelvis, ureter and bladder,
carcinoma of prostate
INFLAMMATORY
TRAUMATIC
NEOPLASTIC
MISCELLANEOUS
BLEEDING DISORDER
 Urinary calculi
 Strenous exercise, Haemoglobinuria
 Autoimmune (SLE)
 Anticoagulant (Warfarin), blood thinner (Aspirin)

39. 39
HAEMATURIA

40. 40
• History
Pain
Blood at which stage of micturation
Ability to pass urine
Clots?
Symptoms of UTI
Bleeding disorder/ on anti-coagulant
History of trauma
Other causes of discoloured urine: beetroot, Nitrofurantoin
ManagementIn Emergency Department:
• Resuscitate:
Volume replacement
Correct coagulopathy
Hemostasis

41. 41
• Baseline investigations
Blood: FBC, BUSE, coagulation profile, Bloog grouping & crossmatch
Urine: Dipstick, C&S
Imaging: X-ray KUB
ManagementIn Emergency Department:
• Indications for admission:
Clot retention
Heavy hematuria
CVS instability
Uncontrolled pain
Sepsis
Acute renal failure
Coagulopathy
Severe comorbidities

42. 42
Subsequent management
In Ward
LABORATORY
• Urine FEME
IMAGING
USG KUB
Intravenous urogram
CT scan
MRI scan
Radioactive scan
OTHERS
• Cystoscopy— biospy and HPE
• Ureterorenoscopy— Brushing
and cytology

43. General Treatment of
Haematuria
Continuous Bladder
IrrigationExcept in a case of haematuria
following instrumentation…

44. 44
Management of renal stoneConsist of two main components
Medical expulsive therapy (MET)
•Drink lots of fluids (>1.2 L)
•Diuretic
•Antispasmotic, alpha blocker,
CCB— Relax ureteric smooth
muscles
Surgical
•Upper 1/3: Push and bang method
I. Cystoscopy—> pass a stent (Pigtail/
Double J stent)—> ESWL
II. Prevent damage to bones.
•Middle 1/3 & Lower 1/3:
I. By dormia basket or lithotripsy

45. 45
LithotripsyPigtail stentDormia basketDouble J stentESWL
Must know (Extra)

46. 46
Bladder
stone
Urethral stone
●Urethroscopy + lithotrypsy
●Surgery (urethrolithotomy)
Lithotrite instrument (hendrickson
lithotrite)
●ESWL
●Cystoscopy and lithotrite (instrument used to
crush stone)
●Cystoscopy and lithotripsy (electrohydraulic/
laser lithotrypsy)

47. Benign Prostatic Hyperplasia
Medical
•Alpha blocker (Prazosin, Terazosin, Doxazosin
5mg ON): relax smooth muscle of bladder neck and
prostate
•5-alpha reductase inhibitor (Finasteride 5 mg):
reduce epithelial layer in prostate glands
Surgery
•TURP (gold standard)

48. Bladder carcinoma
•Depends on staging
•Cancer not involving muscle  Transurethral resection of tumour+ post-op
intravesical chemotherapy (Thiotepa/ Adriamycin/ Mitomycin)
•T2-T4  Radical cystectomy
•Any nodes/ metastasis  systemic radiation
•Small lesion: Partial cystectomy + intravesical
chemotherapy.

49. Renal Cell Carcinoma
•Mainly surgery, respond poorly to
chemotherapy or radiotherapy.
•Surgery
I. Nephron sparing surgery (T1)
II. Radical nephrectomy
•Targeted therapy
I. VEGF inhibitor
II. Immunotherapy
III. Interleukin-2

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Hemopty
sisEtiology
Specific Management

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Etiology
Haemoptysis is the coughing of blood from a source below the
glottis. [1]
Common causes:
1. Tuberculosis (most common in southeast Asia)
2. ****Lung cancer - most common in age > 60 years.old ( bronchogenic ca)
3. Pneumonia,
4. Acute and chronic bronchitis
5. Bronchiectasis.
massive bleeding with
life-threatening
consequences
Small amount of blood-streaked sputum

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Approach to Hemoptysis
To differentiate haemetemesis /pseudo-hemoptysis /haemoptysis
Volume (in 24 hours)
● mild (15-30ml )
● frank (>15 <600 ml)
● massive (>600 ml)
History and examination

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Specific for Lung Cancer ...
Chest x ray - to locate site of bleeding
Investigations for diagnosis:
doubt ?
Flexible Bronchoscopy (4% to 22% discovered bronchogenic ca) 86% can detect
site of bleeding with/ without CT thorax
Bronchoscopy sampling procedures involved several techniques including
bronchial washing (BW), bronchial brushing (BB), broncho-alveolar lavage (BAL),
transbronchial biopsy (TBB) and endobronchial biopsy (EBB).
* visible tumours. : BW > EBB > BB
* not visible by bronchoscopy : BAL > BB > followed by TBB.

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Management
STAGE MANAGEMENT
 Clinical stage I or II non-small cell lung cancer (NSCLC) Curative Surgical Resection
 Stage IIIA NSCLC , T1-3 primary tumors Combined modality treatment approach
 Unresectable stage IIIB NSCLC due to T4 primary
tumours, N2-3
Platinum-based doublet chemotherapy
(gemcitabine, paclitaxel, or vinorelbine) + -
Radiotherapy
 Stage IIIB disease due to the presence of a malignant
pleural or pericardial effusion
Platinum-based doublet chemotherapy alone
Stage IV disease
 - good performance status
 - Poor performance
Platinum-based doublet chemotherapy or
single agent chemotherapy
Supportive care

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Thank you
Reference:
The causes of haemoptysis in Malaysian patients aged over 60 and the diagnostic yield of different
investigations - Published article by Catherine Mee-Ming WONG,Kim Hatt LIM,Chong-Kin LIAM