Surgical emergencies.docx

**Resuscitation in pregnancy** -The survival of the mother and fetus in cases of **cardiac arrest** depends on the management in the first critical minutes. -All obstetricians should be able to **diagnose cardiac arrest** and start basic cardiopulmonary resuscitation (CPR). -All obstetricians sho...

**Resuscitation in pregnancy** -The survival of the mother and fetus in cases of **cardiac arrest** depends on the management in the first critical minutes. -All obstetricians should be able to **diagnose cardiac arrest** and start basic cardiopulmonary resuscitation (CPR). -All obstetricians should be able to **recognize impending cardiorespiratory arrest** and take appropriate measures to prevent deterioration into an arrest. **ABC of resuscitation (basic life support)** **A. Airway:** is the airway clear? **B. Breathing:** is chest moving or air movement at lips? **C. Circulation:** can you feel a carotid or femoral pulse? **D. Displacement** of the gravid uterus to decrease the effect of aortocaval compression on venous return. **E. Emergency caesarean section** within 5-10 minutes of arrest if initial resuscitation is unsuccessful. **Changes in maternal physiology that may adversely affect resuscitation:** 1. Maternal oxygen demands in the latter half of pregnancy are 20% higher than in the non- pregnant state. 2. Cardiac output is 40% higher than non- pregnant state. 3. The gravid uterus makes ventilation more difficult. 4. 10% of maternal cardiac output goes to uterus and fetus. 5. Ineffective resuscitation may result in a hypoxic fetus. **Airway** -Clear airway of debris/ dentures/ vomit. -Tilt head back and thrust lower jaw forward, moving base of tongue from posterior pharyngeal wall creating clear passage from lips to larynx. **Breathing** -If patient is breathing, place in coma position -If patient is not breathing: -Ventilation should be at a rate of 2 breaths to 30 chest compressions. **Circulation** -To be effective, cardiac massage must be carried out on a firm surface (you may place patient on the floor). -Cardiac massage is **more difficult in the pregnant patient** because of displacement of the diaphragm and rib cage by the gravid uterus. -Compression should be carried out mid sternum to avoid possible damage to the liver. -Chest compression should be carried out at a rate of 100/ minute. **Displacement of gravid uterus** -With the patient lying on her back, aortocaval compression by the gravid uterus will decrease venous return, making effective resuscitation difficult. -To decrease aortocaval compression without compromising effective cardiac massage, one of the following methods can be applied: **Emergency caesarean section** -If resuscitation has not produced a spontaneous cardiac output within 5 minutes, an emergency CS should be carried out in situ. -Full resuscitation should continue during the CS. -This has the advantages of: **Abdominal pain in pregnancy** **Pregnancy- related causes:** **Physiological:** **1.Labor:** painful regular uterine contractions should be accompanied by cervical effacement or dilatation, and descent of the presenting part. **2.Musculoskeletal pain**, due to ligament stretching. **3.Constipation:** this is a common condition. **Pathological:** **Ectopic pregnancy:** **Miscarriage:** **Placental abruption**: **Polyhydramnios**: **Chorioamnionitis:** **Symphysis pubis dysfunction (SPD):** **Pre- eclampsia:** **Acute fatty liver of pregnancy (AFLP):** ** Complications of uterine fibroids:** **Uterine rupture or scar dehiscence:** **Uterine torsion:** **Causes unrelated to pregnancy:** **Ovarian cyst:** **Gastrointestinal tract:** **Appendicitis:** **Acute cholecystitis:** **Gastroenteritis:** **Intestinal obstruction.** **Acute pancreatitis.** **Peptic ulcer disease** **Inflammatory bowel disease** **(ulcerative colitis and Crohn's disease):** **Diverticulitis:** **Urinary tract:** **Cystitis:** **Acute pyelonephritis:** **Urolithiasis:** **Other causes:** 1.Sickle cell crises. 2.Pleurisy. 3.Splenic infarction. 4.Malaria. 5.Acute intermittent porphyria. 6.Vascular complications. **Trauma in pregnancy** **Causes** 1. Road traffic accidents (RTAs). 2. Falls. 3. Domestic accidental and non- accidental injury. 4. Assault. 5. Penetrating trauma. **Anatomical and physiological effects of pregnancy:** 1. Up to 30% of blood volume may be lost before pulse and blood pressure change. 2. Uterine perfusion may be compromised while maternal pulse and blood pressure are still maintained. 3. Reduced venous return in supine position, due to inferior vena cava (IVC) compression by the enlarged uterus. 4. Blood loss into uterus/ abdomen may be concealed. 5. Uterine size and position in late pregnancy render it more prone to trauma. 6. Fetus may be more immediately affected than mother. 7. Delayed gastric emptying increases risk of vomiting and aspiration. **Approach to management:** -The pregnant woman should always be nursed and transported with a 15-- 30° left tilt, using a wedge or rolled- up clothing or in left lateral position. -For major trauma, start immediate resuscitation. -The woman is then transferred to an appropriate secondary or tertiary center. -Fetal assessment only follows stabilization of maternal condition. **Primary survey:** -Reveals immediately life- threatening problems. -It includes airway control, breathing/ ventilation, circulation and neurological assessment. -Note increased risk of aspiration in pregnant women. -Avoid moving neck/ tilting head if there is a possibility of neck injury. -Establish cervical spine control/ apply cervical collar/ sandbags. -Give O2 once airway control is achieved. -Pulse oximetry valuable in monitoring, ensuring ≥ 95% O2 saturation. -IV lines using large-bore cannulae (two 14-16 G) and aggressive infusions (warm infusions when large volumes used). -Rapid preparation of cross-matched blood. -Central venous access may be crucial when peripheral veins are inaccessible. -Once neck injury is excluded, left lateral position or 15-- 30° left tilt will relieve IVC pressure and improve venous return. -Neurological assessment: with orientation and responsiveness, pupillary reaction, motor response, and Glasgow coma scale. -Problems that need immediate attention are dealt with as they are identified. -Fetal viability and well-being are assessed after maternal primary survey/resuscitation. US assessment may be done when the patient is stabilized. Electronic FHR monitoring may be used if appropriate. -Depending on maternal and fetal status, delivery may be indicated. **Secondary survey:** -Secondary survey identifies and deals with problems that are not immediately life- threatening. -It is performed when the maternal condition is stable and involves more detailed assessment and investigations. -Maternal health remains the overriding priority and X- rays, CT, and MRI scans are safe in pregnancy and when needed should not be delayed or withheld because of pregnancy. -When a chest tube is indicated, it should be placed 1-- 2 intercostal spaces higher than would otherwise have been indicated to allow for the elevation of the diaphragm that occurs in pregnancy. -Obstetric evaluation is part of the secondary survey. **Definitive care phase:** *According to the type and severity of injury.* **General measures** -Urinary catheter allows examination of urine for hematuria as a sign of pelvic trauma and urine output as an indicator of renal perfusion. Urine output of 30 mL/ hour or more indicates good renal perfusion. -Kleihauer test is useful in determining feto- maternal haemorrhage (FMH) and dose of Rh globulin for Rh- negative women. To avoid undue delay, 250 U IM up to 20 weeks' gestation and 500 U after 20 weeks can be given while awaiting test result. -Check tetanus immunization status if indicated by nature of injuries. **Additional treatment options** -Emergency (perimortem) LSCS may be necessary to facilitate maternal resuscitation if mother has cardiopulmonary arrest and CPR is unsuccessful for 4 minutes, despite left lateral tilt → basic skin preparation is sufficient, anesthesia is not immediately needed and hemostasis is not an issue. Maternal resuscitation should continue through the LSCS. -Other indications for LSCS in pregnant trauma patients are: -Thromboprophylaxis with LMWH should be considered but only after risk of hemorrhage is controlled. **Persistent shock in trauma patients:** **Life- threatening problems in the chest** **Other systemic problems** **Pregnancy- specific traumas** Placental abruption Uterine rupture Eclampsia and its complications Amniotic fluid embolism (AFE). **Seat belts** -Maternal serious injury or death is more likely if the unrestrained woman is ejected from the moving vehicle. -Seat belts are protective at all stages of pregnancy. -The three- point lap and shoulder restraint is best. -It should be worn correctly, with the shoulder belt passing between the breasts and over the top of the fundus and the lap belt passing below the uterus. **Blunt trauma** -The commonest type of trauma in pregnancy (mainly due to RTAs). -Obstetric complications include preterm labor, FMH, placental abruption, and uterine rupture. -Recurrent presentation with minor blunt trauma should raise the suspicion of domestic violence. -Major peritoneal hemorrhage is more likely in advanced pregnancy because of the large blood supply to the uterus. -Hemorrhage may develop slowly and repeated assessment is necessary to detect any deterioration in physical condition. **Penetrating injury** -Uncommon and may be due to stab or gunshot. -In early pregnancy, the uterus is pelvic and the pattern of injury is similar to that in non- pregnant women. -In late pregnancy, the uterus is large and central in the abdomen. The viscera are displaced superiorly and laterally. Fetal injury is more likely and visceral injury less likely. -The high associated perinatal mortality rates may be due directly to the injury or the complications of resultant premature delivery. -When bowel is affected by penetrating injury, multiple wounds are more likely, due to the compression of more bowel in a smaller area. -Laparotomy should be undertaken by joint obstetric and surgical team but if uterus is not involved, delivery may not be necessary. **Burns** -Obstetric complications of major burns include premature labor and fetal death. -Early delivery may be considered to optimize maternal management. -Corticosteroids should be considered if gestation is \24 weeks' gestation use wedge for left lateral tilt. -Insert two large bore (16 G minimum) IV cannulae. -Commence monitoring (automated BP/ pulse), pulse oximeter, cardiac rhythm monitor. -Insert urinary catheter. **Investigations** FBC, KFTs, LFTs, electrolytes and coagulation screen on all Blood grouping. Serum lactate CRP and blood cultures (suspected septic shock) Fibrinogen and fibrinogen degradation products (possible DIC) Blood gases 12- lead ECG Request portable CXR Abdominal US. **Making a diagnosis** -Rapid review of antenatal risk factors and obtain history of events immediately prior to collapse. -Examine woman to assess cardiac/respiratory condition and for specific signs (abdominal tenderness, neurology). **Diagnosis- specific management** **Perimortem caesarean delivery** -Request CS set immediately in all cases of antenatal **cardiopulmonary arrest** (\>24 weeks' gestation). -If advanced life support with effective tilt is unsuccessful after 4 minutes, commence CS to assist in maternal resuscitation. -Vertical or horizontal abdominal incision are acceptable, whichever the operator feels will be quickest. -Vertical uterine incision saves time by avoiding need to reflect bladder. **Hemorrhagic shock due to antepartum hemorrhage** -IV fluids, and blood transfusion. -Continuous monitoring and ongoing evaluation of fetal and maternal condition. -Reaching a diagnosis: history and examination--- do not perform digital examination unless placenta previa has been excluded by US scan. If examination has to be performed and a diagnosis of PP is confirmed, this should be performed in theatre with set- up for delivery by CS. -Investigations: FBC, cross- match blood according to need, coagulation screen where abruption is suspected, and Kleihauer test in Rh- negative women. -An US scan will help with placental localization. -Immediate delivery is indicated in most cases of massive continuous hemorrhage. **Hemorrhagic shock due to postpartum hemorrhage** -Management involves maternal resuscitation to correct hemodynamic instability, and identification and treatment of the underlying cause. -An initial assessment of the degree of blood loss and hemodynamic instability is vital, and efforts should be made to ensure that blood loss is not underestimated. -Resuscitation involves the ABC approach. -Fluids and blood products: -**Pharmacological management:** -If bleeding is persisting, transfer to theatre and the most senior obstetrician available should be present. -**Surgical management:** Examination under anesthesia (EUA) should take place to assess the genital tract for tears (vagina and cervix). The uterine cavity should also be explored to exclude retained tissue. Direct uterine massage as an extension of bimanual compression which enables direct myometrial compression. Uterine packing/ tamponade: an effective method to control hemorrhage, using a Sengstaken or Bakri balloon. The balloon is instilled with up to 500 mL of warm saline to act as an intrauterine tamponade, which may arrest bleeding. If bleeding persists, then laparotomy would be the next step → Compression sutures: the B- lynch technique envelopes and compresses the uterus to arrest bleeding. If manual compression is of value, then compression sutures should be performed. Pelvic devascularization: ligation of blood vessels that supply the uterus. This would commence with ligation of the uterine arteries followed by tubal branches of both ovarian arteries. Internal iliac ligation would be the next step, although this would have to be performed by a senior surgeon. Uterine artery catheterization: this requires input from interventional radiologists. The need for specialized equipment and the availability of radiologists able to perform this preclude its widespread use. Hysterectomy: this should be the last resort, as a life-saving procedure, only performed when all other conservative measures have failed. **Amniotic fluid embolism** -Consider diagnosis in any woman collapsing intrapartum or immediately after delivery. \- Initial presentation is of massive right- sided heart failure. -Severe left- sided heart failure and DIC may follow in women who survive the initial presentation. **Management principles** Ventilation with 100% O2. Maintenance of cardiac output with crystalloid and inotropes. Admission to intensive care unit for invasive monitoring. Aggressive treatment of coagulopathy (platelets, fresh frozen plasma, and cryoprecipitate). Urgent delivery if antenatal and successful resuscitation. Anticipate possible massive PPH and manage promptly. **Septic shock** -Consider the possibility in any woman with previous diagnosis of infection, prolonged rupture of membranes, immunocompromise, or post CS. -Consider the possibility of appendicitis. **Management principles** Administer crystalloid and inotropes. Culture for source of infection prior to commencing broad- spectrum IV antibiotics in appropriate doses. If antenatal and resuscitation successful, deliver only if signs of fetal compromise. **Magnesium toxicity** -Magnesium sulfate toxicity is very rare with standard doses but consider the possibility of drug error or in women with impaired renal function. **Management principles** Stop magnesium infusion and withhold until levels available. Give 10 mL of 10% calcium gluconate IV over 2 minutes. Send blood for magnesium levels. If antenatal, consider delivery (CS or assisted vaginal delivery) as pre- eclampsia is now further complicated. **Acute abdominal pain in gynecology** **Definition:** Pain that is sudden in onset (\38°C), cervical excitation/ dyspareunia, vaginal discharge, and raised WCC/ CRP. Laparoscopy is the gold standard for diagnosis, but is usually not required as PID first- line management is medically with antibiotics. If non- responsive to IV treatment, consider tubovarian abscess and indication for drainage. **Treatment** Ovarian cyst: If patient requires parenteral analgesia and/ or there are signs of acute abdomen then laparoscopy and ovarian cystectomy may be advisable. Hemorrhagic ovarian cysts: haemorrhage into a cyst is usually managed conservatively provided it is not causing a lot of pain and the patient is hemodynamically stable. If pain is not controlled, and there are signs of peritonism or hemodynamic disturbance, laparoscopic lavage is performed and a cystectomy or hemostatic maneuver employed. Ovarian cyst torsion: torsion can be managed conservatively by laparoscopically untwisting the torted ovary and cyst if undertaken within 36 hours of the torsion, thus avoiding adnexectomy if the ovary is viable (not gangrenous). PID: oral antibiotics (ofloxacin 400 mg twice a day plus oral metronidazole 400 mg twice a day for 14 days) or IV antibiotics followed by oral therapy 24 hours after clinical improvement. Surgical (laparoscopic) drainage is often required for tubo-ovarian abscess. **Intraoperative emergencies** **Hemorrhage** -An unexpected blood loss of \>500 mL at any gynecological operation is considered significant. -In this situation the following measures may be considered: **Perforated uterus** -This may occur during D&C, hysteroscopy, insertion of a coil, or at suction termination of pregnancy. -It may be noticed at the time by the feeling of 'lack of resistance' when probing the uterine cavity or may present postoperatively with signs of acute abdomen. -Its incidence is 0.1-- 0.5% and risk of associated bowel trauma is \>0.1%. -Treatment 1\. Inform the anesthetist and ensure a large- bore IV cannula is inserted. 2\. Leave instrument in the uterus that you believe has caused perforation and, if this is a suction cannula, then turn off the suction. 3\. Proceed to a laparoscopy, assuming the patient is hemodynamically stable. 4\. Inspect uterus for perforations/ bleeding points and if possible, inspect as much intestine at the laparoscopy as you can. 5\. Commonly small perforations that are not bleeding can be managed conservatively with antibiotics (cefuroxime and metronidazole) and admitted overnight for observation. 6\. Should there be bleeding from the uterus then a laparoscopic suture or laparotomy may be needed to repair the perforation and to arrest bleeding. 7\. termination of pregnancy can then be completed under laparoscopic control and under US guidance to ensure there are no retained products of conception. **Damage to urinary tract/ blood vessels/ bowel** **Urinary tract trauma** -Damage to the urinary tract should ideally be recognized at the time of surgery. -Postoperative vaginal leakage of urine, urine in drainage bottles, or the presence of loin pain should always raise the possibility of damage to the urinary tract. \- For intraoperatively diagnosed trauma to the bladder dome, a two- layer closure should be performed followed by methylene blue dye to check for leakage. -If the ureter is damaged and noted during surgery then, depending on the site of damage to the ureter, the suitable repair method is carried out by a consultant urologist. -If the urinary tract trauma is diagnosed in the postoperative period, then: **Trauma to blood vessels** -These can occur during laparotomy or laparoscopic procedures. **Trauma to large vessels (aorta, vena cava, iliac vein/ artery):** -This is usually during laparoscopy. \- If suspected (blood returning up the needle/ trocar) the following management should be started: **Trauma to pelvic side wall vessels/ venous oozing:** -Commonly occurs during performing laparoscopy and dividing adhesions. **Inferior epigastric injury** -This should be avoided by careful inspection of the course of the epigastric vessels when inserting laparoscopic ports, but should the epigastric vessel be damaged then the following can be instituted: **Trauma to bowel** -If perforation occurred during laparoscopy with the **Veress needle or the trocar insertion**: