Sudan international university

Faculty of medicine
OSCE in emergency medicine

surgical
Emergencies
Prepared by:
Hider Mohamed Abdallah Ahmed (Medical student-SIU)

Sources:
Bright Future -OSCE- Emergency medicine

Bright Future – OSCE- General surgery

2019
Station 2: surgical Emergencies

Hello doctor
In order to achieve this station you should follow below general considerations :
1/ Call for help

2/ Be quickly as much as possible

3/ Don’t concentrate with anything except your patient

4/ Don’t leave the patient until he/she became stable.

5/ Regular fallow up after management until the patient become complete recovery.

6/ In OSCE the emergency usually come as the scenario ,you should read the scenario
carefully then answer according to examiner questions.

1/Acute appendicitis :
It is an inflammation of the appendix caused by obstruction of the appendicular lumen,
producing a close loop with resultant inflammation that can lead to necrosis and perforation.

=acute appendicitis it is the most common causes of acute abdomen

=Clinical presentations of acute appendicitis:

 Patient complain:
 Right iliac fossa pain:
- start suddenly
- constant and intense pain
-the pain usually start periumbilical as intermittent and crampy in nature then shifted
to RIF.
- associated with nausea and vomiting
 anorexia most constant symptom in acute appendicitis
 diarrhea and urinary symptoms  in case of pelvic appendix
 low grade fever if high grade suspect perforation
 if the patient come late may present with complications of appendicitis (see below).
 NB:
-these above symptoms is develops in less than 3days.
- the right iliac fossa pain is due to peritoneal irritation and periumbilical pain is referred
pain.
 On examination:
 right iliac fossa tenderness most specific sign
 Rebound tenderness pain upon releasing the palpating hand of examiner.
 Rovsing’s sign rebound pressure in left iliac fossa cause pain in right iliac fossa.
 Psoas sign: pain by extending hip and knee or flexing hip against
resistancecommonly in retro-cecal appendix.
 Obturator’s sign: pain on internal rotation of leg with hip and knee flexed
commonly in pelvic appendix .
 voluntary guarding or involuntary rigidity board like abdomen
NB: Mc Burney’s point it is a 1/3 from anterior superior iliac Spine to the
umbilicus(often the point of maximum tenderness).

OSCE Scenario: 

A 19yrs old man present with 2-days

history of abdominal pain .the pain started
in the central abdomen and has now
become constant and has shifted to the
right iliac fossa .the patient has vomited
twice today and is off his food .his motions
were loose today but there was no
associated rectal bleeding. On examination
The patient has a pulse 100beats/min and
BP 120/80mmHg.abdominal examination
reveal localized tenderness and guarding in
the right iliac fossa .urine analysis is clear.
A/ What is most likely diagnosis:
Acute appendicitis

B/ Why is acute appendicitis:

 there is constant abdominal pain in the RIF associated with vomiting
 the pain start centrally (around umbilicus) then shifted to RIF.
 There is no rectal bleeding (exclude colorectal condition-see below).
 On examination there is tenderness and guarding in the RIF.
 Urine analysis is clear(exclude ureteric stones and pyelonephritis –see below).
C/ Mention the differential diagnosis of acute appendicitis:
 Ureteric colic (stone) or pyelonephritis on the right side.
 Meckel’s diverticulitis in children
 Gynecological conditions:
- Ectopic pregnancy in child bearing age female
- Salpingitis , ovarian torsion or rupture
 Infections :
-mesenteric lymphadenitis
- Gastroenteritis vomiting precede the pain
 Carcinoma of the cecum  in more than 40yrs
 Perforated peptic ulcer (due to collection of fluid in paracolic gutter mimicking acute
appendicitis ) .

D/ How to investigate patient suspected with acute appendicitis to reach the diagnosis :
 Acute appendicitis mainly diagnose clinically and the following investigations for
exclusion:
 WBCs count >10000 especially neutrophils , if >18000 indicate complications
 Urine general to exclude pyelonephritis or renal calculus
 Pregnancy test (B-HCG) and U/S to exclude gynecological conditions
 Colonoscopy if older patient >40yrs
 CT and U/S of the abdomen to exclude other differential diagnosis
NB: sonographic features of acute appendicitis include:
-large , non-compressible appendix –see picture above.
-thick wall of the appendix
-tubular structure
-diameter>6 cm.

E/ Mention the outlines of management for acute appendicitis :

 Admission the patient
 NPO (No Per Oral for at least 4-6hours).
 Analgesics
 2large bore cannulas IV fluids
 Insert NG tube and urinary catheter
 Prophylactic antibiotics
 Surgery appendectomy :
-either open appendectomy (incisional)
-or laparoscopic appendectomy (lap appy).
 Discharge usually on post-operative first day
F/ Mention the complications of acute appendicitis :
 Complications of acute appendicitis :
 Perforation of the appendix indication for prompt appendectomy+ all pus are
drained with given antibiotics ,then wound left open after closer of fascia (to heal
by secondary intension).
 appendicular mass  indication for analgesics and antibiotic +follow up after
6weeks for interval appendectomy.
 appendicular abscess  indication for percutaneous drainage under U/S guide or
open surgery drainage and antibiotics + interval appendectomy after 3months .
 complications of surgery (appendectomy):
 bleeding
 injury to the cecum which may lead to low output fistula.
 early pain
 wound infection
 adhesive intestinal obstruction.

2/Acute cholecystitis:
It is an inflammation of the gall bladder due to calculus obstruction of cystic duct (95%) or
acalculus obstruction e.g. hypo-perfusion of gall bladder which occurs in ICU in hypotensive and
shocked patient (5%).

=Clinical presentations of acute cholecystitis:

 patient complain:
 Right hypochondria pain:
-start suddenly
-the pain is severe , constant and stabbing in nature
-the pain for several hours and continuous
-radiated to the tip of the shoulder due to irritation of phrenic nerve by inflamed ball
bladder.
-associated with fever ,nausea and vomiting .
-often precipitated by fatty food (due to release of CCK causing contraction against
obstructed gall gladder).
 if the patient come late may present with complications of acute cholecystitistoxic
,febrile with generalized abdominal pain.
  On examination:
 Rigidity and tenderness are present in right hypochondrium area.
 Murphy’s sign acute pain and inspiratory arrest elicited by palpation of the right
hypochondrium area.
 Boa’s signhyperesthesia between 9th and 11th the ribs posteriorly ,on the right side.
 If gall bladder is perforated signs of peritonitis present e.g. generalized tenderness
,rigidity .

OSCE Scenario: 

A 45yrs old female came to ER by right

upper abdominal pain of 3days duration.
The pain is stabbing , sudden onset
continuous radiated to the tip of the
shoulder. By history there was several
attack of vomiting .on examination : temp
39C , abdominal examination reveal Rt
hypochondeium tenderness .she has long
history of fat dyspepsia.

A/ What is most likely diagnosis:

Acute cholecystitis

B/ Why is acute cholecystitis:

 There is Rt hypochodrium pain sudden in onset ,constant and stabbing in nature
,radiated to tip of the shoulder and associated vomiting and fever.
 On examination there is Rt hypochondrium tenderness .
 Patient has long history of fat dyspepsia.

C/ Mention the differential diagnosis of acute cholecystitis:

 Acute pancreatitis
 Acute appendicitis
 Perforated peptic ulcer
 Right side pyelonephritis
 Other differential diagnosis of acute abdomen
D/ How to investigate this patient suspected with acute cholecystitis to reach the diagnosis :
 CBC (Complete Blood Count)  show leukocytosis
 Urine general to exclude pyelonephritis or renal stone
 Serum amylase to exclude acute pancreatitis
 Ultrasonography will confirm the diagnosis . showing distended gall bladder
containing stone or not , increased thickness >3mm and pericolecystic fluid collection
appear as acoustic shadow-see picture above.
 HIDA scan showing no visible gall bladder and consider the most effective diagnostic
tool.

E/ Mention the outlines of management of acute cholecystitis :

 Unlike acute appendicitis , the treatment of acute cholecystitis is usually conservative as
following :

Initial medical conservative management :

 Admission the patient

 NPO (No Per Oral)  to rest the gall bladder
 Nasogastric suction and IV fluid stopped when the inflammation subsides and
fate free diet is advised .
 Insertion urinary catheter to monitor urine output
 Analgesics morphine or pethidine are avoided as it causes spasm of the
sphincter of Oddi thus increase the tension and spasm.
 IV antibiotics preferable to use 2nd generation of cephalosporin

NB: most of the patient response to medical management for 2-3days.

Definitive treatment :

 The definitive treatment of acute cholecystits is cholecystectomy either open

surgery (kocher incision) or laparoscopic (lap chole) for the following condition:
 When the inflammation is subsides usually by the third day after conservative
management , and diagnosis is confirmed by ultrasonography in doubtful
cases .cholecystectomy is performed usually after 6weeksinterval
 If no improvement occurs after conservative management clinically evidence
by increase toxicity or from the admission patient suspected gall bladder
perforation or empyema gall bladder need emergency cholecystectomy .

NB: in case of acalculus acute cholecystitis  cholecystotomy if need (drain of

gall bladder).
F/ Mention the complications of acute cholecytitis:
 Complications of acute cholecystitis :
 Mucocele of gall bladder
 Empyema of gall bladder(abscess formation) need drainage + emergency
cholecystectomy
 Perforation lead to biliary peritonitis
 Cholecystenteric fistula formation (between gallbladder and duodenum ).
 Gall stone ileus
 Emphysematous (dilatation) gall bladder .
 Chronic cholecystitis which may again lead to acute cholecystitis.
 Complications of surgery (cholecystectomy):
 Bleeding usually due to cystic artery injury.
 Nearby structural injury (common bile duct and duodenum).
 Hematoma formation
 Leakage of bile
 Wound infection
 Sclerosing cholangitis
 Biliary stricture
 Post cholecystectomy syndrome (patient come with same symptom after operation).

3/ Perforated Peptic Ulcer(PPU):

It is a complication of peptic ulcer disease in which there is rupture the wall of preexisting
ulcer.

=Clinical presentations of PPU:

 patient complain:
 Sudden severe epigastric pain in history of aspirin ,PPI drugs, steroid ,heartburn or
rheumatoid arthritis:
-the pain start in epigastric area due to perforation as sharp and stabbing in nature
associated with vomiting.
- then the pain may be elicited in RIF due to collation of perforated fluid ( mainly
HCL) along colic gutters in right lower quadrant which lead to chemical irritation .
- the pain continuous for few hours then disappear due to HCL dilution by secretions
of peritoneal cavity.
- generalized abdominal pain due to chemical peritonitis by perforated fluid may
develop.
 
Posterior perforated duodenal ulcer which may present just like acute pancreatitis (i.e.
epigastric pain radiated to the back + high serum amylase).
 if bacterial overgrowth occurs bacterial peritonitis with septicemia develops and the
patient look very ill with high grade fever.
 On examination:
 Abdomen not move with respiration
 Abdominal tenderness
 Board like rigid abdomen
 Decrease or absent of bowel sound
 Tympanic sound over the liver ( due to air collection).
 PR there is pelvic tenderness
 Hypotension and tachycardia .

OSCE Scenario: 

A 53-year-old woman known case of

rheumatoid arthritis, has a history of upper
GIT endoscopy few years ago ,she presents
with complaints of sudden onset epigastric
pain. While being evaluated, she is
veryill,febril,pulse102,Bp85/50mhg,abdome
n not move with respiration, has tender
abdomen and absent bowel sounds. no
investigation was done

A/ What is most likely diagnosis:

Perforated peptic ulcer

B/ Why is PPU:
 Patient know case of rheumatoid arthritis so definitively use steroid.
 Patient have history of upper GIT endoscopy definitively due to peptic ulcer disease.
 Complain of epigastric pain which start suddenly
 Patient look ill with tachycardia ,hypotension and fever
 On examination there is abdominal tenderness and abdomen not move with respiration
,additional to that the bowel sound is absent.
C/ Mention the differential diagnosis of PPU:
 Acute pancreatitis
 Severe gastritis
 Acute cholecystitis
 Perforated acute appendicitis
 Perforated viscus
 Myocardial infarction
 Colonic diverticulitis especially if perforated

D/ How to investigate patient suspected with PPU to reach the diagnosis :

 Erect x-ray showing air under the right diaphragm which confirm the perforation (see
x-ray above).
= differential diagnosis of air under diaphragm include:
-perforated viscus(e.g. perforated bowel).
-post-operative ( recent laparoscopy).
-pneumo- perineum
-external trauma (e.g. stab wound).
 Left lateral decubitus x-ray:
-can be performed because air can be seen over the liver and not confused with the gastric
bubble.
 CBC (Complete Blood Count) showing leukocytosis
 Serum amylase high serum amylase secondary to absorption into blood stream from
the peritoneum but not reach the level of acute pancreatitis.

E/ Mention the outlines of management of PPU:

 Initial treatment :
 Admission the patient
 NPO (No Per Mouth)
 NG tube and urinary catheter
 2 large bore cannulas and IV fluid
 Analgesics
 IV Proton Pump Inhibitors (PPI)
 IV antibiotics
 Prepare 5-7 units of blood for surgery
  Definitive treatment :
The definitive treatment of PPU is abdominal washout then surgical correction (open or
laparoscopic) as the following:
 Surgical options for perforated duodenal ulcer:
-graham patch (piece of omentum incorporated into the suture closure of
perforation).
-truncal vagotomy and pyloroplasty incorporating ulcer.
-graham patch and highly selective vagotomy best option
 Surgical options for perforated gastric ulcer:
-antrectomy incorporating perforated ulcer
-graham patch and wedge resection in unstable or poor operative candidate.
NB: in case of gastric ulcer you should send biopsy for histopathology to exclude
malignancy.

F/ Mention the complications of PPU:

 Complications of PPU:
 Chemical peritonitis due to perforated fluid which may become bacterial
peritonitis and subsequent septicemia and septic shocks.
 Bleeding especially in case of perforated posterior duodenal ulcer
 Complications of surgery:
 Bleeding
 Nearby structural injury
 Gallstones due to truncal vagotomy
 Pernicious anemia due to anti-acid surgery (truncal vagotomy or highly selective
vagotomy).

4/Acute pancreatitis:
It is an inflammation of the pancreas due to auto-digestion of pancreas caused by raised activated
pancreatic enzymes and it is intestinal liberation.

=Clinical presentations of acute pancreatitis:

 Patient complain:
 Sever constant epigastric pain:
-the pain start suddenly and radiated to the back (in between the scapula).
-relieved by leaning forward
-associated with nausea and vomiting
  On examination:
-patient look very ill and febrile
-epigastric tenderness
- then become diffuse abdominal tenderness
-decrease bowel sound (dynamic ileus).
- tachypnea with shallow breathing
-tachycardia and hypotensive
-dehydration and shock
NB: -if there is jaundice suspect gallstone as cause
-if there is Gullen’s signs (per umbilical hemorrhages) or Grey turner’s sign(flanks
hemorrhages)  suspect trauma +necrotizing of the pancreas.

OSCE Scenario: 

A 52yrs old male ,smoker and A B

use to drink alcohol was
brought to the causality
complaining of severe upper
abdominal pain of sudden onset
radiating to the back that
become generalized for few
hours later .he vomit large
amount twice. On examination
was very ill with pulse rate
100beats/min and blood
pressure 100/60mmHg .RR was
28/min .abdominal examination
revealed generalized tenderness
with mild distention and
decrease bowel sound.

A/ What is most likely diagnosis:

Acute pancreatitis

B/ Why is acute pancreatitis:

 Patient have history of smoking and drunken alcohol (see predisposing factors below).
 Sudden severe upper abdominal pain radiated to the back associated with vomiting.
 Patient look very ill with tachycardia ,hypotension and tachypnea.
 Abdominal tenderness and decrease bowel sound on auscultation.
C/ What are the causes of acute pancreatitis:
 Gallstones and alcohol most common cause 80%
 Iatrogenic (e.g. ERCP)
 Abdominal trauma
 Metabolic causes(e.g. hypercalcemia and hyperlipidemia).
 Scorpion and snake bites
 Inflammatory viral condition (e.g. mump, coxackie ,CMV).
 Drugs (e.g. highly active antiretroviral therapy and Na-valproate).

D/ Mention the differential diagnosis of acute pancreatitis:

 Perforated peptic ulcer
 Severe gastritis
 Acute cholangitis
 Inferior myocardial infarction
 Acute mesenteric ischemia or infarction
 Kinking or ruptured abdominal aortic aneurysm

E/ How to investigate this patient suspected with acute pancreatitis to reach the diagnosis :
 Diagnostic investigation :
 High serum amylase it become >1000 (normally between 100-200) but not specific.
=differential diagnosis of high serum amylase:
-acute pancreatitis
-Perforated peptic ulcer
-mesenteric ischemia
-renal failure
-DKA
-testicular torsion
-ovarian tumor/ectopic

 High serum lipase  specific for acute pancreatitis

 Erect CXR  to rule out perforated peptic ulcer
 Abdominal ultrasound to rule out gallbladder diseases and abdominal aortic
aneurysm .additional to that U/S reveal pancreas inflammation and edema.
 Abdominal x-ray acute cutoff sign ( due to retroperitoneal hemorrhage which lead
to paralysis of large bowel)- see picture A above or show sentinel loop (isolated
distended loop of bowel is seen near to the site of inflamed organ )-see picture B
above.
  CT scan  if the patient not responding to medical treatment within 72hours to see
state of pancreas if there is edema , necrosis or hemorrhage.

 General investigations:
 Serum calcium  hypercalcaemia cause acute pancreatitis and acute pancreatitis
cause hypocalcaemia.
 CBC high WBCs and decrease hematocrit
 Random blood glucose acute pancreatitis can lead to diabetes
 Renal function test  because there is vomiting
 Liver function test  for enzymes
 Arterial blood gases

F/ How to assess severity of acute pancreatitis :

 By Ranson’s criteria:
Contain investigation done at admission and after 48hours as following:
Investigation at admission:

 TWBs >15000
 Age >55yrs
 RBG>200mg/dL
 AST (Aspartate aminotransferase >250
 LDH( Lactate dehydrogenase) >350

After 48hrs investigations:

 Serum calcium <2mmol/L

 Based deficit Hco3 >4mg/dL (normal is +2
 6liter fluid sequestration (fluid need)
 8kpa arterial blood gases or po2< 60mmHg
 70% drop in hematocrit
 BUN > 5mg or 1.8mmol/L

Notice

-if patient have 3 positive severe acute pancreatitis

-if patient have 2-3 positive mortality rate is 50%

- if patient have  mortality rate is 100%

  Or by Glasgow prognostic criteria:
Included in PANCREAS word which include:
P = partial pressure of oxygen <60mmHg
A =age >55yrs
N= neutrophils count (WBCs >15000)
C = serum calcium <2 mmol/L
R = raised urea >5mg/dL
E = enzymes (AST ,LDH) is high
A= albumin < 32mg/dL
S = sugar >200mg/dL

Notice

-more than 2  likely of severe pancreatitis

-less than 3 severe pancreatitis unlikely

G/ Mention the outlines of management of acute pancreatitis :

 Initial medical management :
 Patient admission (preferable to ICU)
 Adequate hydration by IV fluid
 Analgesics (pethidine is better)
 IV antibiotics (meropenem or imipenem is better).
 PPH drugs to guard against ulcer
 NG tube in case of intractable vomiting
 Urinary catheter to monitor urine output
 Correct hypocalcaemia and hyperglycemia
 Consecutive management:
 ERCP after 24-72hrs for diagnostic and therapeutic if GBD suspected
 CT scan if patient not response to medical management (as mentioned it above).
 Role of surgery depend on complications as following
- abscess formation or pancreatic pseudo-cyst  U/S guide FNA
- necrosis  operative debridement (necrostomy )
-fistula formation surgical repaired

H/ Mention the complications of acute pancreatitis:

 Local complications:
 Pancreatic necrosis
 Pancreatic abscess
 Pancreatic pseudo-cyst
 Pancreatic ascites
Pancreatic peritonitis
 Fistula
 Systemic complications:
 Acute Respiratory Distress Syndrome ( which lead to respiratory failure type1).
 Septicemia
 Multi –organ failure
 Hyperglycemia and hypocalcaemia
 Pancreatic intra -ductal calcification which lead to chronic pancreatitis.

5/ Acute diverticulitis:
-diverticulum is an out- pouching of the all wall (true diverticulum) or part of it (false
diverticulum) of the bowel loop. .

-diverticulosis it is the present of diverticulum especially in the colon and it is one of the most
common cause of lower GIT bleeding.

= so It is an inflammation of a diverticulum –sometime called left side appendicitis .

=Clinical presentations of acute diverticulitis:

 Patient complain:
 Right iliac fossa pain cramping or steady
 Change in bowel habits e.g. diarrhea
 Fever with chills
 Nausea and vomiting
 Anorexia
 Dysuria
 On examination:
 Left iliac fossa tenderness
 Guarding and rigidity of the abdomen
 Right iliac fossa mass
 Patient look ill ,tachycardia and hypotensive
 PR is contraindication to prevent the risk of perforation

NB: patient usually had history of diverticulosis ,manifested clinically by lower GIT
bleeding.
OSCE Scenario: 

A 47yrs male presented by lower abdominal

pain and feeling tired .patient had history of
rectal bleeding of large amount ,bright red
and with clot. On examination pulse is
95beats/min , temp 39C and BP is
100/60mmHg. Abdominal examination
revealed tenderness below the umbilicus
toward the right iliac fossa.

A/ What is most likely diagnosis:

Acute diverticulitis

B/ Why is acute diverticulitis:

 Patient complain of lower abdominal pain
 On examination pain toward the right iliac fossa
 Patient had history of rectal bleeding ,bright red in color with clot which is definitively
colonic diverticulosis.

C/ What are the predisposing factors of diverticular disease generally :

 Chronic constipation from any causehypertrophy of the wall increase the pressure in
the lumen herniation of the mucosa through the weak points (diverticulosis)
diverticulosis inflamed acute diverticulitis complications of acute diverticulitis-see
below.

D/ Mention the differential diagnosis of acute diverticulitis:

 Left renal stones
 Left pyelonephritis
 Abdominal aortic aneurysm
 Superior mesenteric ischemia
 Colorectal carcinoma
 Gynecological conditions e.g. ectopic pregnancy ,ovarian torsion.
E/ How to investigate this patient to reach the diagnosis :
 Abdominal x-ray showing:
-partially obstructed colon
-air-fluid level
-free air under diaphragm if perforation occurs
 CT scan of the abdomen showing:
-swollen and edematous bowel wall of the colon(colon wall thickness) ; particularly
helpful in diagnosing an abscess  best in diagnosis .
 CT colonoscopy showing:
-globular outpouching given signet ring appearance best diagnosis in acute
diverticulitis.
 Barium enema (double contrast) showing:
-saw teeth appearance (helpful in diagnosis diverticulosis and contraindicated in acute
diverticulitis –see picture above.
 General investigationhigh WBCs
 Elective colonography after subside of inflammation and tumor marker (Carcino-
emberyonic antigen) to rule out colorectal carcenoma.

NB: sigmoidoscopy , colonoscopy and barium enema are contraindication in acute

diverticulitis because it increase the risk of perforation.

F/ Mention the outlines of management for this condition :

 Initial management :
The goal is conservative until inflammation is subside as following:
 Admission the patient
 NPO (No Per Oral)
 IV fluid for rehydration
 NG tube for suction
 IV broad spectrum antibiotics
 Specific management:
It is a surgical management usually for complicated cases as following:
 percolic abscess Percutaneous drainage for
 Complicated by peritonitis  laparotomy , resection of perforated colon by hartman’s
procedure and lavage.
 Elective resection of diverticulosis for recurrent cases of acute diverticulitis or
immunosuppressed patients.
G/ What are the complications of acute diverticulitis:
 Intestinal obstruction
 Free perforation and peritonitis
 Abscess formation and septicemia
 Formation of colon stricture
 Colovesical fistula (to bladder).

6/ Intestinal Obstruction:
It is a restriction of normal passage of intestinal content due to mechanical or functional
obstruction .

=Clinical presentations of intestinal obstruction:

 Patient complain:
 Abdominal pain :
-it is intermittent colicky pain
- small bowel obstruction  the pain around umbilicus (central)
-large bowel obstruction  the pain localized to the site of obstruction
-if progress to strangulation pain become constant
- functional bowel obstruction (paralytic ileus)  there is no pain
 Vomiting :
-high small bowel obstruction early and yellow in color
-lower small bowel obstruction  late and greenish in color
-large bowel obstruction  black and feculant (odor of feces)
 Abdominal distention:
-small bowel obstructioncentral abdominal distention
-large bowel obstruction flanks or localized to special site.
 Constipation:
-small bowel obstruction late
-large bowel obstruction  early
-constipation either absolute (no feces or flatus) which is cardinal feature of complete
intestinal obstruction .or relative constipation (flatus pass but no feces).
  On examination:
 General examination patient look ill, toxic , tachycardia ,tachypnea ,hypotensive
and fever .
 Inspection  visible peristalsis movement and abdominal distention.
 Palpation  there is abdominal tenderness
 Percussion  hyper-resonance or tympanic
 Auscultation  exaggerated bowel sound in early mechanical obstruction and absent
bowel sound in late mechanical obstruction or in paralytic ileus.

OSCE Scenario: 

A 35yrs old present to A B

casualty with colicky
abdominal pain and
vomiting .He had history of
surgery for perforated
appendix with gird iron
incision six month ago .on
examination there is
abdominal distention
centrally And patient look
very ill.

A/ What is most likely diagnosis:

Small bowel obstruction (adhesive intestinal obstruction).

B/ Why is small bowel obstruction:

 There is colicky abdominal pain
 Vomiting
 Central abdominal distention
 There is no constipation (because in small bowel obstruction come late).
 Patient had history of surgery (adhesion is cause –see below).
C/ Mention the causes of intestinal obstruction generally:
 Mechanical causes:
 Intraluminal causes:
-fecal impaction
-foreign bodies
-gallstones
-bezoars
 Intramural causes:
-inflammatory stricture (due to inflammatory bowel diseases )
-malignancy
-congenital atresia
 Extra-mural causes:
-adhesion (usually post-surgery).
-hernias
-masses
- volvulus
-intussusception
 Functional causes (paralytic ileus):
 Early post-operative (few days).
 Septicemia
 Hypokalemia
 Hyponatremia
 Hypomagnesaemia
 Peritonitis
 Pancreatitis
 Retroperitoneal hematoma or fibrosis
 Head injury and anemia

Notice
-generally the most common cause of intestinal obstruction is adhesion.

-in neonates  volvulus neonatorum and congenital atresia

-in infants intussusception and hirechsprung disease .

-in child strangulated umbilical hernia

-in young adult and middle age group  strangulated hernia and adhesion

-in elderly  fecal impaction and carcinoma of the colon

D/ How to investigate patient suspected with intestinal obstruction to reach the diagnosis :
 General investigation:
-CBC(Complete Blood Count) high WBCs
-RFT(Renal Function Test) dehydration can cause renal failure
-serum electrolytes intestinal obstruction cause electrolytes disturbances /or may be a
cause of paralytic ileus.
-RBS(Random Blood Glucose) hypoglycemia
 Definitive investigation:
 Erect abdominal x-ray:
-Multiple air –fluid level more than three (because normal person may have 3 air-
fluid level in stomach , duodenum or cecum)-see picture A above.
-if there is air under the diaphragm with dilated loop only without air –fluid level
perforation occurs.
 Supine abdominal x-ray :
Show dilated loop of bowel-see picture B above dilated loop as following:
-large bowel  haustration
-jejunum valvulae
-ileum feature less (tube).
 CT scan to determine the cause if unclear .

NB: in sigmoid volvulus x-ray showing coffee bean sign also called banana shape or U
shape and ultrasound showing taget sign in intussusception.

F/ Mention the outlines of management of intestinal obstruction generally:

 Initial management :
 Admission the patient
 NPO(No Per Oral)
 IV fluid for rehydration
 correction of electrolytes
 NG tube for suction
 Urinary catheter to monitor urine output.
 Analgesics
 IV broad spectrum antibiotics
 Definitive treatment:
 In case of adhesion conservative and observation must be done , if the patient not
response to treatment or become complicated  adhensiolysis.
 In case of sigmoid volvulus untwisting by rigid sigmoidoscopy +rectal tube (to
prevent recurrence ) , if the non-surgical methods failure of presence of complications
surgical option are don which include:
 -hartman procedure
-mikulicz procedure
-or primary resection and anastomosis.
 In case of hernia:
-release the constricting agent by division then hernioplasty.
 In case of intraluminal obstruction gall stones:
-laparotomy and removal/crushing of stone.
 In case of bezoars or food bolus or fecal impaction:
-laparotomy and removal
 In case of acute intussusception:
-laparotomy with reduction
 Functional obstruction (paralytic ileus) correction of the causes.

F/ What are the poor prognostic signs in intestinal obstruction:

 Change in pain character from colicky to continuous  indicate strangulation
 Absent in bowel sound indicate bowel exhaustion

G/ Mention the complications of intestinal obstruction:

 Strangulation and ischemia perforation peritonitis septicemia multi-organ failure
syndrome e.g. renal failure.
 Dehydration and electrolytes disturbanceshypovolemic shock
 Additional to that complications of surgery if done.

7/ Abdominal trauma:
It is a trauma at the any site of the abdomen extended from diaphragm (4th intercostal space) to
pelvic floor (fold of buttock posteriorly).due to either penetrating causes e.g. gunshot ,knife or
blunted causes e.g. Road Traffic Accident, falling.

=the common organ that injured is spleen (about 25% of all abdominal organs)

=Clinical presentations of abdominal trauma:

 Patient complain :
-usually in this condition patient come complain of abdominal trauma and tell the doctor
about type of trauma or come as emergency RTA.
-the patient may come with severe external bleeding or Evisceration in case of
penetrating trauma.
-patient may suffer from abdominal pain confined to the site of trauma in the abdomen
associated with nausea and vomiting .
  On examination:
 Penetrating trauma it is visible and clear on examination ,may associated Evisceration
 signs of blunt trauma :
-bruises ,abrasion over the abdomen (seat belt mark).
-abdominal tenderness
-rigidity to touch
-abdominal distension
-sluggish bowel sound.
-PR high rising prostate indicate urethral injury
 signs of splenic injury:
-tenderness and rigidity in the left hypochondrium spreading to the abdomen.
-balance sign shifting dullness right side and fixed dullness on the left side (left is
clot blood and right is free fluid).
-keher’s sign referred pain on the left shoulder due to irritation of the diaphragm
because of bleeding and it is associated with splenic injury + pressing on the left
hypochondrium.
-cullen sign’s : bluish discoloration around the umbilicus .

OSCE Scenario: 

A 25yrs old male involved A B

in RTA .when he was seen
in the casualty he was
complaining of pain in the
lower part of his left chest
and left upper part of the
abdomen .on examination
he was conscious .pulse was
120beats/min. BP is
80/50mmHg. Both side of
the chest were moving
equally .abdominal
examination showed bruises
in the region of the left
hyopchondrium ,with
abdominal distention and
sluggish bowel sound .

A/ What is most likely diagnosis:

splenic injury complicated by hypovolemic shock
B/ Why is splenic injury:
 patient involving in RTA which is cause of abdominal trauma
 patient complain of pain in in the lower part of his left chest and left upper part of the
abdomen.
 abdominal examination showed bruises in the region of the left hyopchondrium.
 Both side of the chest were moving equally (exclude massive hemothorax and tension
pneumothorax).
 Tachycardia and hypotension which indicate internal bleeding.

C/ Mention the causes of abdominal trauma generally:

 Penetrating abdominal trauma:
-gunshot
-stab wound
 Blunt abdominal trauma:
-RTA (Road Traffic Accident)
-falling from up
-fighting

NB: -mechanism of splenic injury include: compression, crushing ,shearing and avulsion.

D/ How to investigate this patient with abdominal trauma to reach the diagnosis :
 Initial general investigations:
 CBC (Complete Blood Count)  reveal high WBCs and low Hb due to bleeding.
 Urine analysis to assess for present of hematuria which indicate urethral injury.
 Blood grouping and cross matching + coagulation profile.
 Renal Function Test hypervolemia due to hemorrhage may lead to acute renal
failure.
 Serum amylase high serum indicate pancreatic injury
 Definitive specific investigations :
 Focus abdominal sonography for trauma (FAST) showing:
-detect if there is free fluid in the peritoneal cavity
-to detect if there is present of free fluid in the intra-peritoneal cavity
-to evaluate solid organs is intact or not.
 Abdominal CT scan with contrast  diagnostic test showing:
-detecting intra-peritoneal bleeding
-can identify organ injured and determine the grade of injury in solid organ-see
picture B above.
 e.g. grading of splenic injury in CT scan is:

Grade 1 – Minor subcapsular tear or hematoma

Grade 2 – Parenchymal injury not extending to the hilum
Grade 3 – Major parenchymal injury involving vessels and hilum
Grade 4 – Shattered spleen
 Laparoscopy :
-useful in determining peritoneal penetration and identify diaphragmatic injury.
-can be useful in treating certain injuries.

 Diagnostic Peritoneal Lavage (DPL) showing:

-it is invasive procedure which insert needle in the peritoneal cavity and suction for
content if the content contain bile , blood or feces indicate positive DPL.
-if there is no suctioned content put saline and suction again then suctioning send to
lab for investigation (if RBCs count >100000/UL , WBCs count >500/UL and
amylase >175U/ml  indicate positive TPL.

NB:-DPL is useful in rural areas and U/S not available.

- if DPL is positive patient should send for U/S and CT.
 Chest or abdominal x-ray showing:
-If there is and air under the diaphragm which indicate perforation viscus.
-or give clue about organ injured –see picture A above.

 Laparotomy (exploration) for the following conditions:

-any patient hemodynami ally unstable
-any patient with gunshot wound
-any patient with stab wound and Evisceration
-positive DPL patient
-peritonitis
-air under the diaphragm on AXR.
-positive CT + FAST
NB : the most common organs diagnostic late in abdominal trauma is diaphragm and
duodenum.
F/ Mention the outlines of management of abdominal trauma:
If the patient with abdominal trauma you should fallow Advance Trauma Life Support (ATLS)
guideline which include:

 Primary survey/Resuscitation :
 Airway (assess and securing the airway).
 Breathing (assess O2 saturation and put oxygen or ventilation if need).
 Circulation (insert two IV bore cannula + assess BP and pulse .and give fluid and
blood according to guide line of fluid management+ analgesic and antibiotics then
insert urinary catheter for monitoring).
 Disability ( assess mental status ,usually by Glasgow Coma Scale).
 Exposure and environment (exposure for inspection and keep a warm environment
because hypothermic patient can become coagulopathic).
 Secondary survey :
Complete physical examination including all orifices as:
 ears
 nose
 mouth
 vagina
 rectum
 definitive treatment:
the definitive treatment of abdominal trauma either non-operative or operative treatment
as the following:
 indications of non-operative management/conservative :
-hemodynamically stable patient
-no increased in pain
-less than 4 units transfused blood
-less than 500 ml of blood on CT scan.
 Indications of operative management –see indications of exploration above ,then
do the following:
-stomach injury  laparotomy and repaired
-pancreatic injury conservative
-liver injury if unstable for repaired
-splenic injury  laparotomy and splenectomy or splenic repaired

G/ Mention the complications of abdominal trauma:

 Injury to the solid organs and major vessels  lead to severe bleeding ended by
hemorrhagic shock and death.
  Rupture of hallow organs  lead to peritonitis ended by septicemia and septic shock and
multi-organ failure.
 Complications of splenic injury:
-internal bleeding  hypovolemic shock .
-splenic cyst following peri-splenic hematoma.

 Complications of splenctomy:
-general surgical complication as bleeding
Leukemoid reaction increased WBCs ,platelets and RBCs.
-acute gastric dilatation
-portal vein thrombosis
-pancreatic fistula
-sub-phrenic hematoma
-post-splenectomy infection

8/ Tension Pneumothorax:
It is accumulation excessive amount of air in the pleural space and the pleural air pressure
exceed atmospheric pressure.

=Clinical presentations of tension pneumothorax:

 Patient complain:
 Respiratory distress
 Pleuritic chest pain(stabbing pain)
 Anxiety
 On examination:
 Tachypnea
 Cyanosis
 neck venous distention due to kinking of great vessels.
 Asymmetrical chest wall movement9 affected side is moving less).
 Trachea shifted away from the affected side.
 Hyper-resonance percussion on the affected site.
 Decrease TVF and air entering
 Unilateral diminished or absent of breath sound
 Hypoxemia due alveolar collapse
 Hypotension and tachycardia due to decrease venous return and cardiac output.
OSCE Scenario: 

A 45yrs old male arrived to emergency

department two hours after being involved
in RTA (Road Traffic Accident) .he
complained of respiratory compromise and
sharp right side chest pain increased with
each breath .his pulse rate is 120beats/min
and blood pressure is 95/50mmHg.chest
examination revealed trachea deviated to
the left , hyper-resonance on percussion on
right and decrease air entering .the neck
veins of the patient look distended.

A/ What is most likely diagnosis:

Tension pneumothorax(right side)

B/ Why is tension pneumothorax:

 Patient complain of respiratory compromise and sharp Rt side chest pain on after chest
trauma.
 There is hypotension and tachycardia which indicate decrease venous pressure and
cardiac output.
 On examination there is trachea deviated to the opposite side ,hyper-resonance on
percussion , decrease air entering on the affected side and distended neck veins.

C/ What are the causes of pneumothorax generally:

 Traumatic pneumothorax:
 Penetrating chest trauma secondary to bullet or knife penetration
 Blunt trauma chest trauma broken ribs puncture lung with air escape into pleura
 Iatrogenic common cause of traumatic pneumothorax which include:
-needle aspiration lung biopsy
-thoracocentesis
-central venous catheter placement
 Spontaneous pneumothorax (simple):
 Primary spontaneous pneumothorax occurs with no underlying lung diseases
 Secondary spontaneous pneumothorax commonly associated with COPD and
asthma.
D/ Mention the differential diagnosis of tension pneumothorax:
 Mechanical airway obstruction
 Acute severe asthma (status asthmaticus).
 Acute pulmonary embolism
 Acute left ventricular failure
 Massive plural effusion
 Massive hemothorax

E/ How to investigate patient suspected with tension pneumothorax to reach the diagnosis:
 Tension pneumothorax is a clinical diagnosis no time for investigation
 Conformation of diagnosis only after insertion of needle in the 2nd intercostal apace(see
below) and can hear sound of air come out (positive hiss sign).

F/ Mention the outlines of management of tension pneumothorax:

 Immediate decompression by needle thoracostomy 14-16 large bore in the second
intercostal space midclavicular line.
 Followed by chest tube in the fifth intercostal space anterior axillary line (triangle of
safety).
 Then send the patient for x-ray for the following purposes:
-show rim of air on the affected side which is diagnostic  see picture above
-check position of chest tube
-check re-expansion of lung
-show if there is other pathology.
 Immediate treatment in case of open pneumothorax(sucking chest wound) is 3 side
adhesive tape(occlusive plaster over chest wall defect).
 Emergency thoracotomy if there is patient collapse with penetrating trauma.
 Closed monitoring of the patient and put on continuous oxygen.

G/ Mention the complications of tension pneumothorax:

 Cardiac arrest due to kinking of the great blood vessels which is major cause of death in
tension pneumothorax.
 Respiratory failure type 2(hypercapnia and hypoxia) in case of open pneumothorax.
9/ Massive Hemothorax:
It is accumulation excessive amount of blood in the pleural space, usually following chest
trauma (pleural space hold up to 3 liters of blood).

=Clinical presentations of massive hemothorax:

 Patient complain :
 Shortness of breath (dyspnea) but no respiratory distress as in T.pneumothorax.
 Pleuritic chest pain
 Anxiety
 On examination:
 Same as the Pneumothorax(see above) but in the massive hemothorax there is
dullness on percussion.

OSCE Scenario: 

35 years old male brought to the casualty

after being involved in road traffic accident.
The patient is conscious, complain of pain in
the lower part of the Rt side of the chest,
difficulty in breathing. O/E : He is pale,
looks ill .Pulse is 110 regular, small volume.
BP 80/40 RR 32 breath/ minute. Respiratory
system/ diminished air entry in the lower Rt
side of the chest. Stony dullness at the same
site.

A/ What is most likely diagnosis:

Massive hemothorax

B/ Why is massive hemothorax:

 Patient complain of chest pain and difficulty in breathing after chest trauma.
 On examination patient look pale ,tachycardia and hypotensive which indicate blood loos
 Diminished air entering in the Rt lower lobe.
 Stony dullness at the affected side which indicate blood accumulation.
C/ What are the source of bleeding in massive hemothorax:
 90% from internal mammary or intercostal arteries
 10% from pulmonary vessels which lead to hemo-pneumothorax-see picture above.

D/ Mention the differential diagnosis of massive hemothorax:

 Massive pleural effusion
 Tension pneumothorax
 Mechanical airway obstruction
 Acute severe asthma (status asthmaticus).
 Acute pulmonary embolism
 Acute left ventricular failure

E/ How to investigate patient suspected with massive hemothorax to reach the diagnosis:
 Chest x-ray –see above
 CT scan
 Chest tube output (see below)conformation of hemothorax

F/ Mention the outlines of management of massive hemothorax:

 Initial management :
 Admission the patient
 Put patient on oxygen
 Insert two large IV cannula and give IV fluid
 Insert urinary catheter
 Definitive treatment:
 Tube thoracotomy (chest tube) to removal of blood outside
 Volume replacement of blood
 Open thoracotomy if there is:
-more than 1500 ml of blood on initial placement of chest tube.
-persistent more than 200ml of bleeding via chest tube per hour over 4hours.

G/ Mention the complications of massive hemothorax:

 Severe blood loss which lead to hypervolemia and shock
 Iron deficiency anemia
 Respiratory failure
10/ Cardiac Tamponade:
It is a collection of fluid(blood) in pericardium space under pressure , lead to impaired cardiac
filling and hemodynamic compromise. Associated with penetrating trauma more than blunt.

=Clinical presentations of cardiac tamponade:

 Patient complain:
 Dyspnea
 Chest pain
 On examination :
 Sinus tachycardia
 Hypotension
 Engorged neck veins (JVP).
 Pulsus paradoxus (decrease in systolic blood pressure with exaggerated inspiration).

NB: Beck’s triad for clinical diagnosis ofcardiac tamponade include:

-muffled heart sound

-hypotension

-distended neck veins

OSCE Scenario: 

A 34yrs old male come to emergency room

with shortness of breath and chest pain after
penetrating trauma with knife in the left
upper side of the chest. On examination
patient had pulse 120beats/min ,
BP80/50mmHg.chest examination is normal
but there is distended neck veins.
cardiovascular examination revealed
muffled heart sound There is no abnormal
detect regarding other system.

A/ What is most likely diagnosis:

Cardiac tamponade
B/ Why is cardiac tamponade:
 Patient complain of SOB and chest pain after penetrating trauma in left upper side of the
chest most probable in the pericardium.
 On examination there is tachycardia , hypotension and distended neck veins.
 Muffled heart sound in CVS examination.
 Chest examination is normal which exclude respiratory causes of SOB.

C/ Mention the differential diagnosis of cardiac tamponade:

 Tension pneumothorax
 Acute left ventricular failure
 Massive pleural effusion
 Mechanical airway obstruction
 Acute severe asthma (status asthmaticus).
 Acute pulmonary embolism

D/ How to investigate patient suspected with cardiac tamponade to reach the diagnosis:
 Chest x-ray showing:
-enlarged cardiac shadow with clear lung field-see picture above.
 Electrocardiography (ECG) showing:
-sinus tachycardia
-low voltage
-electrical alternans
 Echocardiography showing:
-chambers collapse
-abnormal venous flow

F/ Mention the outlines of management of cardiac tamponade:

 Pericardiocentesis from xyphoid process by 45degree toward left shoulder under cardiac
monitoring using percutaneous catheter ( to removal of pericardial fluid).
 Definitive treatment is pericardium repaired in cardiothoracic center.
 Emergency thoracotomy if there is collapsing pulse with penetrating trauma.

F/ Mention the complications of cardiac tamponade:

 Cardiopulmonary compromise and arrest
11/ Critical limb ischemia:
It`s persistently recurring ischemic rest pain for 2weeks or ulceration or gangrene of the foot or
toes with ankle s. pressure <50mmHg or toe s. pressure< 30mmHg (ABPI will be less than 0.3).

=Clinical presentations of critical limb ischemia:

 Patient complain:
 Very severe leg pain at rest worse at night improved with dependent position.
 With or without ulceration in foot or toes (ischemic ulcer).
 On examination:
 Deficit or absent pulse (better check by handheld Doppler device).
 Color change to black and temperature change).
 Ulceration confined to foot or toe may present .
 Gangrene may present
 Ankle systolic blood pressure<50mmHg.
 Toes systolic blood pressure<30mmHg.
 Ankle –brachial pressure index(ABPI) <03.
 Hair loss ,hypertrophic nails and atrophic muscles in patient had history of
intermittent claudication .

OSCE Scenario: 

A 32yrs old female come to emergency

department crying from severe left leg pain
continuous for 2 days event at rest .patient
know case of cardiac disease .on
examination pulse is 110beats/min, BP
100/90mmHg.leg examination revealed
darkness of the foot on inspection ,pulse is
not detected and ankle -brachial pressure
index is 0.2. ankle systolic pressure
40mmHg and toe systolic pressure is
25mmHg.

A/ What is most likely diagnosis:

Critical limb ischemia

B/ Why is critical limb ischemia:

 Severe continuous resting leg pain till crying.
  On inspection there is darkness which indicate ischemia
 Ankle systolic pressure <50mmHg.
 Toe systolic pressure <30mmHg.
 Ankle-brachial pressure index <0.3.
 Patient known case of cardiac diseases most probable is embolic cause.

C/ Mention the causes of limb ischemia generally:

 Arterial embolism
 Arterial thrombosis
 Arteritis e.g. burger or reynaud’s diseases.
 Trauma
 Radiation therapy

D/ Mention the differential diagnosis of critical limb ischemia:

 Arterial intermittent claudication (due to atherosclerosis).
 Neurological claudication(due to stenosis of spinal canal)
 Venous claudication (due to occlusion of deep system).

E/ How to investigate patient suspected with critical limb ischemia:

 Duplex ultra sound visualize blood flow
 CT angiography best diagnostic
 MRA(MR angiography)
 Conventional angiography if surgery is indicate.

F/ Mention the outlines of management of critical limb ischemia:

 The options on management in critical limb ischemia is surgically as following :
 Endovascular surgery percutaneous angioplasty + stent (cushin balloon catheter).
 Bypass grafting surgery an open surgery saphenous vein graft or synthetic dacron’s
graft.
 Amputation of limb if there is:
-failed surgical options
-deadly (infection)
-dead limb (dry gangrene )

G/ What are the complications of critical limb ischemia:

 Loos of limb(amputation)
 Complications of surgery
12/ Lower Gastrointestinal bleeding:
Lower GIT bleeding is defined as bleeding per rectum coming from a site below ligament of
trietze (=ligament of trietze in duodenum separate upper and lower GIT).

=Clinical presentations of lower GIT bleeding:

 Passage of fresh, bright red blood per rectum

 Malena (black stool color).
 Hematochezia (massive upper GIT bleeding)
 Symptoms of anemia(occult blood loss).

OSCE Scenario: 

A 60yrs old known case of diabetes and apple core sign of colorectal carcinoma
hypertension .presented to ER complaining
of rectal bleeding of large amount ,bright
red with clot and weight loss .on
examination he was pale a , pulse
110beats/min , BP110/60mmHg.abdominal
examination was unremarkable but there is
mass in PR. Othere system on examination
was reveal no abnormal detect.

A/ What is most likely diagnosis:

Colorectal carcinoma

B/ Why is colorectal carcinoma:

 Age is 60yrs old
 Rectal bleeding fresh ,bright and in massive amount
 Other complain is weight loss(sign of malignancy).
 On PR examination there is felt of mass.

C/ Mention the differential diagnosis/causes of lower GIT bleeding generally:

 Anal conditions:
 Hemorrhoid (commonest cause of lower GIT bleeding).
 Anal fissure
  Colorectal conditions:
 Inflammatory (e.g. ulcerative colitis or infective colitis)
 Diverticular disease
 Ischemic colitis
 Angiodysplasia
 polyps
 Colorectal carcinoma
 Rare causes :
 Massive upper GIT bleeding
 Aortoenteric fistula
 General causes:
 Thrombocytopenia
 Leukemia
 Generally common causes of massive bleeding per rectum are:
 Angiodysplasia
 Colorectal cancer
 Diverticulitis
D/ What are the important questions to be answered at presentation of lower GIT bleeding :
 Is the bleeding painful or painless?
 Colour(bright red or altered blood)?
 Relation to defecation (before or after)?
 Mixed with stool or not?
 Any associated abdominal pain?
 Any previous episode?

E/ How to investigate patient with lower GIT bleeding to reach the diagnosis:
 Aim is to know site of bleeding as following:
 Check upper GIT bleeding by NG tube or endoscopy for exclusion.
 Proctoscopy .reveal internal hemorrhoid .
 Sigmoidoscopy .if this negative then proceed to:
 Colonoscopy .if this negative or the bleeding is too brisk to detect the origin then two
option are there:
 Mesenteric angiography .effective only if the bleeding is greater than 1-2ml/min
 Or technetium-99 scan .it is very useful technique for localizing site of bleeding.
 Barium enema to diagnose colonic diverticulosis and colorectal cancer- see picture
above
 Stool analysis for bilharziasis or amebiasis
 Abdominal CT scan
 Laparotomy (only if all the above not available and bleeding is massive continous) .
F/ Mention the outlines of management of massive lower GIT bleeding:
Massive continuous lower GIT bleeding is an emergency should treated as following:

 Initial management :
 Admission the patient
 Assess the airway and breathing then put oxygen 100% if need.
 Insert two IV lines and start fluid and blood if need as following:
-IV fluid 2 liters of saline initially then reassess
-if fluid need >2liters ,he candidate for blood transfusion
-if blood need > 3liters , he candidate for 2liters platelets , 1liter plasma +calcium.
 Insert urinary catheter for monitoring urine out put
 Insert of NG tube
 Analgesic if there is abdominal pain.
 Definitive treatment :
 Endoscopic intervention: (such as adrenaline injection and coagulation of bleding
vascular lesion or for polypectomy ).
 Interventional radiology: (embolization of (embolization of bleeding vessels).
 Surgical procedures for underlying causes.

13/ Burns injuries:

Burn injury is a coagulative type of necrosis of varying depth and of skin and deeper tissues.

 Classification of burns injuries:

 According to injuring agent:
-thermal burn(90%): due to dry heat like flames ,fire , sunburn or comb injuries.
-chemical burn: due to any strong acid or alkaline(alkaline is more serious than acid
because body cannot buffer against it).
-electrical burn: may be caused by high voltage or low voltage current.
-radiation burn: due to x-ray or radium ; when the tissues has been radiated beyond
tolerance limit.
 According to severity of burn:
-minor burn (mild): burned area less than 15% of total body surface area.
-intermediate (moderate): burned area between (15-30) % of total body surface area.
-major burn (severe): burned area more than 30% of total body surface area.
 According to depth:
-first degree burns: burn confined to epidermis layer only
-second degree burns: burn confined to epidermis and varying level to dermis
-third degree burns: all layer of skin including the entire dermis.
-fourth degree burns: burn injury into the muscles and bones.
  Estimation total burn surface area by percent:
 By Rule of nine in adult or modified rule in children:

part of the body adult children

head & neck 9% 18%
anterior trunk 18% 18%
posterior trunk 18% 18%
each upper limb 9% 9%
each lower limb 18% 13.5%
perineum and genitalia 1% 1%

 Or by Rule of palm  using for estimating size of small burn:

-surface area of the patient’s palm is =1% of the total surface body area.

=Clinical presentations of burnes injures:

 Painful, dry, red area that do not form blister first degree burn first degree burns.
 Painful , hypersensitive ,swollen , mottled area with blister second degree burns.
 Painless , insensate , swollen , dry , mottled white and charred area third degree burns.
 Muscles and bones appears, nerves and blood vessel injury fourth degree burns.
 Hoarse voice , brassy cough , oro-mucosal edema ,respiratory ,stridor or wheeze, low O2
saturation inhalational injury especially if the burn occurs in small closed space.
 Patient may present neurogenic shock , hypovolemic shock or septicemia .

NB: you should ask the patient about the type of burn injuring agent.

OSCE Scenario: 

A 42yrs old female caught in kitchen fire,

she sustained burn her anterior upper
trunk , both upper limbs and anterior
upper right thigh. She was brought to
emergency room within hour of accident.
On examination weight is 50kg.

A/ Estimate total burn surface area :

-anterior upper trunk=9%

-both upper limb =18%

-anterior aspect of the right thigh=4.5%

-so total surface burn area= 31.5% of the total body area.

B/ How to classify this burn above according to severity:

 Major burn  total burn surface area more than 30%.

C/ What are the initial life-saving steps of burns injuries management as general:
 Check the airway patency and cervical stabilization
 Assess the breathing and give oxygen100% or tracheostomy or cPAP or endotracheal
tube if need.
 Insert 2large bore cannula
 Give IV fluid ( crystalloid such as ringer lactate by two formula –see below)
 IV analgesics morphine or pethidine.
 IV antibiotics(2nd generation cephalosporin) + steroid and bronchodilator if inhalational
injury suspected.
 Anti-tetanus as prophylactic
 IV proton pump inhibitors as prophylactic from curling peptic ulcer.
 Urinary catheter (30-40ml/kg/hour)
 Then re-evaluate
 wound management:
-Escharotomy and Fasciatomy for circumferential wound.
-wash and clean wound with antiseptic and antibiotics
-if wound is deep, debridement until healthy tissues appear and take swap for
investigation.
 Treatment of complications –see below.

NB: fluid resuscitation is calculated by two formula as following:

 Parkland formula body weight per kg x percent of burn x{2-4}-use crystalloid fluid
-the amount of fluid given over 24hrs  ½ of fluid over first 8hrs , ¼ of fluid over
the second 8hrs and the last ¼ hour over 8hrs.
e.g. in above case fluid requirement are: 50x 31.5 x4 =6300ml of ringer lactate/24hrs.
NB: the time measure from the onset of burns.
 Muris and Barclay formula give colloid fluid- not commonly used in calculation.

=Adequacy of fluid resuscitation is judged by:

-urine output(30-40ml/hrs)
-regulars checkup of vital signs
-CVP (Central Venous Pressure) in critical cases.
D/ What are the necessary investigations should be done in case of burns :
 WBCs(White Blood Cells) to assess if there if infection.
 Wound swab for the micro-organism.
 ABG(Arterial Blood Gases) to assess if there is acidosis.
 Serum electrolytes  because there is risk of electrolytes disturbances.
 RFT (Renal Function Test) because there is risk of acute kidney injury.
 Carboxyhemoglobin level and bronchoscopy in case of inhalational injury.
 urine test for myoglobeinuria in case of electrocutionif positive give IV fluid and
mannitol.
 ECG also in case of electrical burns because there is risk of arrhythmias

E/ Mention the complications of burns injuries:

 Acute complications of burns:
 Infection and septicemia
 compartment syndrome
 shock (septic , hypovolemic{burns shock} or neurogenic)
 renal failure
 respiratory failure
 peptic ulcer (curling ulcer)
 multi-organ failure may develops.
 Psychological disturbances.
 long term complications of burns:
 contracture
 scar formation
 joint stiffness
 deformities
 pigmentory change
 malignant transformation (marjolin ulcer).

E/ Mention the criteria of burns injuries admission:

 inhalational burn injury
 burn need resuscitation
 electrical and hydrochloric acid injury
 burns in special area(e.g. head& neck , hand &foot ,perineal area).
 Total burn surface area >15% in adult and >10% in children.
 If there is associated injury e.g. head trauma or chest trauma.
15/ Shock in surgery:
It is a state of inadequate perfusion and oxygenation of the body’s vital organs which eventually
lead to impaired removal of their waste products and lastly ended by metabolic acidosis and
coma.

 Types of shock:
 S=septic shock due to severe sepsis(E-coli , klebsiella and pseudomonas are most
common causes).
 H=hypovolemic shock either due to hemorrhage or burn or dehydration.
 O=obstructive shock tension pneumothorax or massive hemothorax.
 C=cardiogenic shock due to cardiac tamponade, massive MI.
 K=anaphylaktic –anaphylactic due to allergic reaction , neurogenic due to pain or
spinal injury.
 Distributive shock due to vasodilation either due to sepsis or anaphylaxis .

=Clinical presentations of shock:

 Agitation and restlessness

 Fever in case of sepsis.
 Tachycardia (bradycardia in neurogenic shock).
 hypotension and tachypnea
 Decrease capillary refilling time
 Cold extremities (warm extremities in septic shock).
 Pallor in case of hemorrhage .
 Loss of consciousness and coma as the last presentation.

NB: grades of hemorrhagic shock include:

grades of blood loss pulse rate blood urine output general

shock pressure condition
grade 1 <750ml <100 beats/m normal normal normal
grade 2 750-1500ml >100beats/m decreased decreased anxious
grade 3 1500-2000 >120beats/m decreased decreased irritable
grade 4 >2000ml >140beats/m decreased decreased confused
OSCE Scenario: 

A 20yrs old male

come to emergency
room after involved
in road traffic
accident and injured
in abdomen. On
examination there is
large wound on the
midline of the
abdomen and still
bleed .pulse rate is
120beats /m , blood
pressure is
80/50mmHg.

A/ What is most likely diagnosis:

Abdominal trauma complicated by hypovolemic (due to hemorrhage) shock.

B/ How to diagnose shock condition:

 Pulse rate increased
 Blood pressure  decreased
 Conscious state disturbed
 Oxygen saturation desaturation

C/ Mention the outlines of management of shock as general:

 General management of shock:
 ABCs management:
-A= assess the airway clearance
-B= assess breathing +oxygen saturation and put 100% oxygen
-C= assess the pulse rate and blood pressure
 Insert 2 IV large bore cannula
 Insert urinary catheter to monitor urine output.
 Take a sample for investigations (e.g. CBC, blood grouping and cross matching, RFT
, U&E and random blood glucose).
 Tack a short history to know the cause.
 In case of hemorrhagic shock Ov- blood until cross matching.
 Hypovolemic shock due to hemorrhage :
 First stops is stop bleeding by pressure if external .
 General management of shock –see above.
 Best replacement is blood , if not available start with normal saline.
 give 3liters for every 1liter loss of blood –see table above(e.g. loss of 750ml of blood
give 2250ml of normal saline).
 In case of available blood give liter by liter (e.g. loss of 500ml of blood give 500ml
blood transfusion only).
 If you start by fluid and patient receive 2liters of saline and not stable start blood
transfusion as possible.
 When give 3liters of blood ,should give 2liters of platelets + 1liters of plasma +
calcium.
 If bleeding not stopped , surgical intervention and close the source of bleeding.

NB: If the hypovolemic shock due to burn give ringer lactate only and if due to
dehydration give normal saline only.

 Septic shock:
 General management of shock
 Full sepsis screen (CBC , urine analysis , blood /urine / sputum culture).
 IV broad spectrum antibiotics
 If there is abscess derange it .
 Inotropes (dopamine and dobutamine ).
 Distributive shock:
 General management of shock
 Remove the cause
 IV fluid –ringer lactate
 IM adrenaline
 IV 10 mg of chlorphenamine
 IV 100 mg hydrocortisone .
 Cardiogenic shock:
 General management of shock
 Cardiac bed
 IV morphine for pain
 Management of MI if present(see part of medical emergencies –ACS).
 Management of arrhythmias (see part of medical emergencies –arrhythmias
management ).
 Correct electrolytes imbalance
 Cardiac and CVP monitoring
 Treatment the underlying causes
  Neurogenic shock:
 General management of shock
 IV morphine( for pain)
 Maintain spinal mobilization
 Vasopressor drugs e.g. noradrenaline (maintain blood pressure).
 Atropine if there is significant bradycardia.

D/ What are the complications of shock as general:

 The lack of oxygen affect on the all vital organs which result in features of hypo-
perfusion as following:
 Cerebral hypo-perfusion confusion and coma
 Cutaneous hypo-perfusion cold , calm and pale skin.
 Renal hypo-perfusion renal ischemia and acute renal failure .
 Coronary hypo-perfusion cardiac failure and arrest .
 Complications of fluid overload
 Complications of blood transfusion.
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