A surgical emergency is considered a medical emergency for which immediate surgical intervention is the only way to solve the problem successfully.
We at AIG provide timely diagnosis and immediate care for surgical emergencies in a golden hour.
Surgical Airway A surgical airway is performed either when intubation via the mouth or nose is not considered a reasonable clinical option or when intubation has failed and critical oxygen saturation cannot be maintained via other means.
A surgical airway is contraindicated in children younger than 10 years of age in whom transtracheal jet ventilation is the preferred subglottic technique.
Bedside diagnosis and immediate intervention by the emergency provider may be lifesaving for significant injuries associated with severe chest trauma such as tension pneumothorax, hemothorax, and cardiac tamponade. We recognize and treat tension pneumothorax immediately with needle decompression without waiting for radiographs. By inserting a 14-G, 4.5-cm over-the-needle catheter in the second intercostal space at the midclavicular line. Hemothorax is treated with tube thoracostomy. A 32- to 40-F (10.7 to 13.4 mm) chest tube has historically been used but the larger size may not be necessary.
Indications for surgery include an immediate return of 1 L of blood or ongoing bleeding of 150 to 200 mL/h for 2 to 4 hours. Consider using a heparinized autotransfusion device if massive hemothorax is suspected but do not delay tube thoracostomy. A small open chest wound can progress to a tension pneumothorax through a one-way valve effect. Cover the wound with sterile petroleum gauze taped on three sides to allow air to exit but not enter. Perform tube thoracostomy but not through the wound. A patient with cardiac injury may present with chest pain, tachycardia unexplained by haemorrhage, and arrhythmias. Bedside echocardiography by the emergency provider should be performed as a first screen for cardiac tamponade and grossly impaired contractility. Treat tamponade the same as tamponade from penetrating cardiac injury.
Abdominal injuries EFAST( Extended focussed assessment with sonography in trauma) helps in diagnosing any possibility of bleeding in the abdomen requiring exploratory laparotomy apart from diagnosing pneumothorax, hemothorax and Cardiac tamponade.
Wound closure in the emergency department can reduce the risk of infection, provide for the improved cosmetic outcome, and maintain the skin’s protective functions. Methods for wound repair include primary closure (immediately after injury), secondary closure (allowing a wound to heal on its own, which may be useful for contaminated or infected would emergency providers are often called upon to evaluate acute wounds that are at risk for embedded foreign bodies. Assessment of older wounds may also be complicated by retained foreign material that was initially unrecognized and can impact the healing process and risk of subsequent infection. Careful evaluation of wounds, radiographic imaging when indicated, and local exploration allow identification of most foreign bodies.
Acute Limb ischemia It is a rapid new event or a progression of a flow deficit, requiring recognition and rapid therapy for limb salvage. The objective of therapy for acute arterial obstruction is restoration of blood flow to preserve limb and life and prevention of recurrent thrombosis or embolism. We stratify patients with acute limb ischemia by Rutherford criteria in conjunction with early surgical consultation guides initial care. The vascular surgeon will determine definitive treatment, which can include catheter-directed thrombolysis, percutaneous mechanical thromboembolectomy, revision of an occluded bypass graft, and revascularization with either percutaneous transluminal angioplasty or standard surgery. An abdominal aortic aneurysm (AAA) is commonly ≥3.0 cm in diameter and can be a significant cause of morbidity and mortality. Symptomatic aneurysms and those ≥5.0 cm in diameter frequently require prompt operative repair. Rapid referral to a vascular surgeon is mandatory. Emergency open repair remains the treatment of choice for most patients; however, endovascular repair is being used more frequently. Aortic dissection occurs when blood dissects between the intimal and adventitial layers of the aorta and classically presents with acute chest pain that is most severe at onset and radiates to the back.
The location of the pain may indicate the area of the aorta that is involved. Immediately consult with a vascular or thoracic surgeon for patients with confirmed or strongly suspected aortic dissection to determine if operative intervention is indicated.
More adult patients visit the ED for “stomach and abdominal pain, cramps, or spasms” than for any other chief complaint. History, physical examination, and laboratory studies can be helpful, but imaging is often required to make a specific diagnosis. Clinical suspicion for the serious disease is especially important for patients at high risk. Abdomen Pain with shock as presentation could be Abdominal sepsis, Aortic dissection, Leaking/ruptured abdominal aortic aneurysm, Hemorrhagic pancreatitis, Perforated diverticulum, Perforated appendix, Perforated ulcer, Ruptured esophagus, Splenic rupture, Mesenteric ischemia and Volvulus all requiring immediate Gastro Surgery intervention. Incarcerated hernias may lead to bowel obstruction and strangulation. Strangulation refers to vascular compromise of the incarcerated contents and is an acute surgical emergency. When not relieved, strangulation may lead to gangrene, perforation, peritonitis, and septic shock.
Incarcerated hernias that can’t be reduced with one or two attempts and strangulated hernias require emergent surgical consultation and intervention. Intestinal obstruction results from mechanical blockage or the loss of normal peristalsis. A dynamic or paralytic ileus is more common and usually self-limiting. Common causes of mechanical small bowel obstruction (SBO) are adhesions due to previous surgery, incarcerated hernias, or inflammatory diseases. Other causes to consider are inflammatory bowel diseases, congenital anomalies, and foreign bodies. The most frequent causes of large bowel obstructions are cancer, diverticulitis with stricture, sigmoid volvulus, and fecal impaction. Consider intussusception in children. Sigmoid volvulus is more common in the elderly taking anticholinergic medications while cecal volvulus is more common in gravid patients. Intestinal pseudo-obstruction (Ogilvie syndrome) may mimic large bowel obstruction.
Renal and ureteric stones: Urologic consultation on an emergent basis is needed in patients with a complete obstruction complicated by fever and/or urosepsis and in patients with a solitary or transplanted kidney. Discuss disposition with a urologist in patients with a stone larger than 5 mm, renal insufficiency, severe underlying disease, extravasation or complete obstruction, sloughed renal papillae, UTI, or failed outpatient management. Testicular torsion results from the abnormal fixation of the testis within the tunica vaginalis, allowing the testis to twist. When the diagnosis of testicular torsion is obvious, immediate urologic consultation is indicated for exploration because imaging tests can be too time-consuming. Testicular salvage rates are excellent with surgical detorsion within 6 hours of symptom onset but decline rapidly thereafter. The emergency physician can attempt manual detorsion. Most testes twist in a lateral to medial direction, so detorsion is performed medial to lateral direction, similar to the opening of a book. The endpoint for successful detorsion is pain relief; urologic referral is still indicated. Urology should be consulted early in the patient’s course even if confirmatory testing is planned.
Paraphimosis is the inability to reduce the proximal edematous foreskin distally over the glans. Paraphimosis is a true urologic emergency because the resulting glans edema and venous engorgement can progress to arterial compromise and gangrene. Phimosis is the inability to retract the foreskin proximally. Physiologic phimosis is common in boys but less than 10% of foreskins remain nonretractile at age 3 with nearly all resolving by adolescence. Pathologic phimosis occurs as a result of infection, poor hygiene, or previous injury with scarring.
Ectopic pregnancy is the leading cause of maternal death in the first trimester. Major risk factors include the history of pelvic inflammatory disease, surgical procedures on the fallopian tubes including tubal ligation, previous EP, diethylstilbestrol exposure, intrauterine device use, and assisted reproduction techniques. The most common extrauterine location is the fallopian tube. This diagnosis must be considered in every woman of childbearing age presenting with abdominal pain and/or vaginal bleeding. Definitive treatment, as determined by the obstetric-gynecologic consultant, may involve laparoscopy, dilation and curettage, or medical management with methotrexate. Other surgical Emergencies are Ovarian torsion and Retained abortion products.
Retinal detachment typically presents as a sudden flash of light, floaters, or a dark veil or curtain-like defect in the patient’s visual field, affecting the symptomatic eye. A presumptive diagnosis can be made by bedside ultrasonography. Urgent ophthalmologic consultation is necessary for indirect ophthalmoscopic evaluation, and potentially laser surgery.
Patients with Intracerebral haemorrhage should be admitted to a monitored critical care area for treatment with antiepileptic medications if seizures occur, management of hyperglycemia, blood pressure management, and reversal of coagulopathy with vitamin K, fresh frozen plasma, and/or prothrombin concentrates. Patients with evidence of increased intracranial pressure (ICP) should be treated with head elevation to 30°, analgesia, and sedation. If more aggressive ICP reduction is indicated, such as with osmotic diuretics or intubation with neuromuscular blockade with mild hyperventilation, invasive monitoring of ICP by neurosurgery may be necessary. Appropriate use of neurology, neurosurgery, and neurocritical care specialists early in the evaluation of patients with a stroke can be helpful. Emergent neurology consultation may be helpful in stroke cases as the indications for intravenous thrombolysis and endovascular therapy are evolving rapidly. Early neurosurgical consultation is appropriate for patients with SAH and intracerebral haemorrhage when evidence of increased ICP, location of bleeding, or other conditions suggest that surgical intervention may be indicated.
Epistaxis is classified as anterior or posterior. Posterior epistaxis is suggested if an anterior source is not visualized, if bleeding occurs from both nares, or if blood is seen draining into the posterior pharynx after anterior sources have been controlled. Apply direct external pressure to the cartilage just distal to the nasal bones for 15 minutes while leaning forward in the “sniffing” position. Reexamine the patient. Repeat once if necessary. If bleeding continues, and an anterior source of bleeding is visualized, proceed to chemical cautery. If no source is identified, proceed to nasal packing. If packing or local cautery fail ENT consultation is required. To protect against potentially serious complications, all patients with posterior packs require ENT consultation for possible hospital admission. Posterior packs are removed 2 to 3 days after placement. Other surgical emergencies are foreign body removal from the ear, peritonsillar abscesses and nasal bone fracture with hematoma.
Orthopedic injuries have implications beyond localized pain and swelling at the site of injury. The clinician must methodically evaluate the patient to prevent missing an occult or concomitant injury. Prompt recognition and appropriate treatment are needed to prevent prolonged pain, temporary or permanent disability, or even death.
Many ortho-pedic injuries can be treated in the ED and discharged to home with outpatient follow-up. Some injuries require inpatient management due to comorbid health conditions or issues related to pain control or ambulatory dysfunction, such as hip fractures. Other injuries, such as open fractures, compartment syndrome, irreducible dislocations, circulatory compromise, and injuries needing surgical intervention, require direct communication and urgent consultation in the ED with the on-call orthopedic surgeon. Splinting and immobilization: Reduces pain, facilitates healing, and helps to prevent re-injury of the affected extremity.
Compartment Syndrome is identified on high clinical suspicion. Elevated pressures within a confined muscle compartment can lead to functional and circulatory impairment of that limb.
The most common compartments affected are in the lower leg and forearm. This syndrome develops as a result of external compressive forces on a limb or from any mechanism that increases the compartmental size and pressure. Once the diagnosis is confirmed, surgical fasciotomy is necessary. Admit all patients to the operating room or appropriate inpatient service for observation and serial examinations.