Surgical emergency

The acute abdomen, head injury and urological emergencies in surgical ER.

• Acute abdominal painResuscitate, give pain relief, pregnancy test in every woman who could be pregnant, and look for the killers first: ruptured aneurysm, ectopic, perforation, ischaemic bowel and obstruction.
• AppendicitisPain that moves to the right iliac fossa, fever and tenderness. Pregnancy test in every woman, score it, scan when unsure, antibiotics once likely, and get the surgeon.
• Gallstone disease: colic, cholecystitis, cholangitisFever plus deranged LFTs in a patient with gallstones is cholangitis until proven otherwise. Treat it early and get the duct drained.
• Acute pancreatitisConfirm it with lipase or amylase, give moderate IV fluids guided by the patient, good pain relief, feed early, find the cause, and score the severity. No routine antibiotics.
• Perforated viscus and peritonitisSudden pain and a rigid belly. Resuscitate, give antibiotics, image if stable, and get to theatre. Typhoid perforation is still common in Pakistan.
• Bowel obstructionResuscitate, nil by mouth, NG tube on free drainage, correct the electrolytes, CT to find the cause, and look hard for signs of strangulation that need theatre today.
• Hernias in the emergency departmentA tense, tender lump that won't go back is strangulated until proven otherwise. Always feel below the inguinal ligament.
• Acute diverticulitisLeft lower pain, fever and raised CRP in an older patient. Not every case needs antibiotics; every patient needs the colon checked afterwards.
• Inflammatory bowel disease flaresAcute severe ulcerative colitis needs IV steroids, clot prevention and the surgeons involved from day one. Exclude infection, including amoebic colitis and TB.
• Renal colic (kidney stones)NSAID first for the pain, urine dip, scan to confirm, and remember the two dangers: an infected blocked kidney and a leaking aortic aneurysm pretending to be colic.
• Testicular torsionSudden testicular pain in a boy is torsion until proven otherwise. Call surgery or urology now: the testis can die within 6 hours.
• Head injuryAirway with the neck protected, GCS and pupils repeatedly, decide on CT using the criteria, reverse blood thinners, and call neurosurgery for any bleed.
• Minor head injuryGCS 15 and well? Use the NICE criteria to decide on CT, and send home only with a responsible adult and clear warning signs.