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Preface
Many textbooks are available dealing with the details of emergency surgical conditions. Not many are available dealing exclusively with the emergency conditions, especially those related to surgery. Not that every patient coming to the casualty at odd hours with an acute symptom has a life-threatening emergency, but it becomes necessary to comfort the patient at the first instant, followed by a quick diagnosis of the clinical condition. It is also imperative that the impending emergency should be identified by the clinician, so that a catastrophe is avoided. The classical example of such confusing situation is the acute pancreatitis. This can present with a variety of symptoms which will not give a lead towards diagnosis, but the whole clinical picture establishes after some time, and takes the patient through a very tough morbid situation, and may also end in death. This concise book has been designed in such a way that the common emergency conditions are detailed to the extent so that surgical students or the casualty doctors or young surgeons may not miss the diagnosis. It cannot replace the many well-established textbooks, but it gives sufficient information for a clinician to manage the emergency. Color photographs are useful add-ons to these chapters, which will make the reader remember the information for a long time. Every new doctor who is resident in the casualty and the intensive care unit will face with a variety of clinical problems, and I hope the handbook will come handy. I also hope that I have hit the required details at the right level for the young surgeons. S
I sincerely thank Professor SM Balaji, Professor J Cornelius, Dr Gayathri, Dr M Kanagavel, Dr Kirthana Rao, Professor N Mohan, Dr R Narasimhan, Professor MG Rajamanickam, Professor R Rajaraman, Professor N Sekar, Dr K Sridhar, Professor V Srinivasan, Dr V Thulasiraman, Dr Usha Dorairajan, Professor PS Venkatesh Rao and Dr S Vijayaraghavan, who contributed their clinical photographs, from their personal collections. My special thanks to my friends Dr Mani Veeraraghavan for the endoscopy photographs and Dr V Ganesan for the ultrasound photographs. Most of the CT and MRI pictures were procured from Bharat Scans, Chennai, Tamil Nadu, India, and I sincerely thank Dr R Emmanuel for providing them. My special thanks to my daughters Dr Bhavna for going through the script and making corrections, and Dr Kirthana for drawing the diagrams. My very special thanks goes to my wife Kalpana for the tolerance during the preparation of this manual.
Contents
SECTION ONE: INTRODUCTION 1. Introduction 3 SECTION TWO: ASSESSMENT 2. Assessment of Surgical Emergencies 7 Make the Patient Lie Down Comfortably 7 Elicit a Quick History 8 • Make a Thorough Clinical Examination 8 • Come to a Quick Working Clinical Diagnosis 10 • Ask for Essential Meaningful Investigations 10 • Admit the Patient where Thought to be Required 11 • Put the Patient in Intensive Care Whenever Required 11 • Collect Investigation Reports at the Earliest 11 • Start Emergency Treatment 11 • Ask for Expert Opinions 12 SECTION THREE: CRITICAL CARE 3. Critically Ill Patient and Critical Care 15 Cardiac Support 15 Respiratory Support 15 Inotropic Support 16 4. Shock 17 Hypovolemic Shock 17 • Treatment of Hypovolemic Shock 18 Septic Shock 18 • Symptoms and Signs 18 • Pathogenesis 18 • Treatment 19 Anaphylactic Shock 19 • Incidence and Etiology 19 • Pathogenesis 19 • Symptoms and Signs 19 • Treatment 20 Cardiogenic Shock 20 Neurogenic Shock 20 • Pathogenesis 20 • Treatment 20 5. Acute Respiratory Distress Syndrome 21 • Incidence and Etiology 21 • Pathogenesis 21 • Clinical Presentation 21 • Relevant Investigations 21 • Treatment 22 SECTION FOUR: TRAUMA 6. Polytrauma 25 Introduction 25 Preparation 25 • Prehospital Communication 25 xiiGENERAL SURGICAL EMERGENCIES Trauma Reception Team 26 • Receiving the Patient 27 • Primary Survey and Resuscitation 27 • Airway and Cervical Spine Control 27 • Breathing 28 • Circulation and Hemorrhage Control 29 • Recognition and Assessment of Hypovolemia 29 • Fluid Resuscitation 30 • Disability 30 • Exposure 30 Secondary Survey 30 Clinical Evaluation 31 • Eliciting History 31 • Physical Examination 31 • Scalp 31 • Neurological State 31 • Base of Skull 31 • Neck 32 • Eyes 32 • Face 32 • Thorax 32 • Abdomen 33 • Extremities 33 Definitive Care 33 7. Head Injuries 34 Brain Injury 34 Fractures of Skull 36 • Symptoms and Signs 36 CSF Fistulae 39 Scalp Injuries 39 8. Facial Injuries 41 Fractures of Midfacial Skeleton 41 Fractures of Mandible 42 • Clinical Presentation 43 • Relevant Investigations 45 • Treatment 45 9. Spine and Spinal Cord Injuries 46 Injuries to Bony and Ligamentous Spine 46 • Incidence and Etiology 46 • Symptoms 46 • Signs 47 • Relevant Investigations 47 • Treatment 48 Injuries of the Spinal Cord 48 • Incidence and Etiology 48 • Symptoms and Signs 48 • Relevant Investigations 49 • Treatment 49 10. Thoracic Injuries 50 Rib Fractures 50 • Incidence and Etiology 50 • Symptoms 50 • Signs 51 • Relevant Investigations 51 • Treatment 51 Flail Chest 53 • Incidence and Etiology 53 • Symptom 54 • Sign 54 • Relevant Investigations 54 • Treatment 54 Sternal Fracture 54 • Incidence and Etiology 54 • Symptom 54 • Sign 55 • Relevant Investigations 55 • Treatment 55 Pneumothorax 55 • Incidence and Etiology 55 xiii CONTENTS • Symptoms 56 • Signs 56 • Relevant Investigations 56 • Treatment 58 Surgical Emphysema 58 • Incidence and Etiology 58 • Pathogenesis 59 • Symptoms and Signs 59 • Relevant Investigations 59 • Treatment 59 Hemothorax 59 • Incidence and Etiology 59 • Symptoms 60 • Signs 60 • Relevant Investigations 60 • Treatment 61 Pulmonary Contusion/laceration 61 • Incidence and Etiology 61 • Symptoms and Signs 61 • Relevant Investigations 61 • Treatment 62 Injuries of Thoracic Aorta 62 • Incidence and Etiology 62 • Symptom 63 • Signs 63 • Relevant Investigations 63 • Treatment 64 Injuries of Myocardium 64 • Incidence and Etiology 64 • Symptoms 64 • Signs 64 • Relevant Investigations 65 • Treatment 65 Esophageal Injuries 65 • Incidence and Etiology 65 • Symptoms 65 • Signs 65 • Relevant Investigations 65 • Treatment 66 Diaphragmatic Injuries 66 • Incidence and Etiology 66 • Symptoms and Signs 67 • Relevant Investigations 67 • Treatment 67 11. Abdominal Injuries 68 Closed Injuries 68 Open Injuries 69 • Symptoms and Signs 69 Injuries of Liver 69 • Incidence and Etiology 69 • Symptoms and Signs 70 • Relevant Investigations 70 • Treatment 70 Injuries of Spleen 72 • Incidence and Etiology 72 • Symptoms 72 • Signs 72 • Relevant Investigations 73 • Treatment 74 Injuries of Mesentery 74 • Incidence and Etiology 74 • Symptoms 74 • Sign 75 • Relevant Investigations 75 • Treatment 75 Injuries of Duodenum 75 • Incidence and Etiology 75 • Symptoms and Signs 75 • Relevant Investigations 75 • Treatment 76 Injuries of Small Intestine 76 • Incidence and Etiology 76 xivGENERAL SURGICAL EMERGENCIES • Clinical Presentation 76 • Relevant Investigations 76 • Treatment 77 Injuries of Large Intestine 77 • Incidence and Etiology 77 • Symptoms 77 • Signs 77 • Relevant Investigations 77 • Treatment 77 Abdominal Compartment Syndrome 78 • Incidence and Etiology 78 • Pathogenesis 78 • Symptom 78 • Signs 78 • Relevant Investigations 78 • Treatment 78 12. Urological Injuries 79 Renal Injuries 79 • Incidence and Etiology 79 • Symptom 79 • Signs 79 • Relevant Investigations 80 • Treatment 80 Ureteric Injuries 80 • Incidence and Etiology 80 • Symptom and Sign 81 • Relevant Investigation 82 • Treatment 82 Urinary Bladder Injuries 82 • Incidence and Etiology 82 • Symptoms 83 • Signs 83 • Relevant Investigations 83 • Treatment 84 Urethral Injuries 84 • Incidence and Etiology 84 • Symptom 84 • Sign 84 • Relevant Investigation 84 • Treatment 85 13. Male Genital Injuries 86 Injuries of Penile Skin 86 • Incidence and Etiology 86 • Symptom 86 • Sign 86 • Relevant Investigation 86 • Treatment 86 Foreign Bodies in Penile Urethra 87 • Incidence and Etiology 87 • Symptoms and Signs 87 • Relevant Investigation 88 • Treatment 88 Scrotal Laceration 88 • Incidence and Etiology 88 • Symptom 89 • Signs 89 • Relevant Investigation 89 • Treatment 89 14. Female Genital Injuries 90 Coital Injuries 90 • Incidence and Etiology 90 • Symptom 90 • Signs 90 • Relevant Investigations 90 • Treatment 90 Injuries during Childbirth 91 • Incidence and Etiology 91 • Clinical Presentation 91 • Relevant Investigations 91 • Treatment 91 15. Hand Injuries 92 • Incidence and Etiology 92 xvCONTENTS • Clinical Presentation 92 • Relevant Investigations 96 • Treatment 96 SECTION FIVE: ORGANS AND SYSTEMS 16. Oral Cavity 99 Acute Odontogenic Infections 99 • Incidence and Etiology 99 • Pathogenesis 99 • Symptoms and Signs 100 • Relevant Investigations 100 • Treatment 100 17. Head and Neck 101 Acute Suppurative Sialadenitis 101 • Incidence and Etiology 101 • Clinical Presentation 101 • Relevant Investigation 103 • Treatment 103 Ludwig’s Angina 103 • Incidence and Etiology 103 • Pathogenesis 103 • Symptoms 103 • Signs 103 • Relevant Investigation 103 • Treatment 104 18. Thorax 105 Acute Mediastinitis 105 • Incidence and Etiology 105 • Clinical Presentation 105 • Relevant Investigations 105 • Treatment 106 Acute Pleuritis 106 • Incidence and Etiology 106 • Symptom 106 • Sign 106 • Relevant Investigations 107 • Treatment 107 Pleural Effusion 107 • Incidence and Etiology 107 • Symptom 107 • Signs 107 • Relevant Investigations 108 • Treatment 109 Acute Empyema Thoracis 109 • Incidence and Etiology 109 • Symptom 110 • Signs 110 • Relevant Investigations 110 • Treatment 110 Spontaneous Pneumothorax 110 • Incidence and Etiology 110 • Symptom 110 • Sign 111 • Relevant Investigations 111 • Treatment 111 Foreign Bodies in the Respiratory Tract 112 • Incidence and Etiology 112 • Pathogenesis 112 • Symptoms 112 • Signs 112 • Relevant Investigations 112 • Treatment 113 Suppurative or Aspiration Pneumonia 113 • Incidence and Etiology 113 • Pathogenesis 113 • Symptoms 114 • Sign 114 • Relevant Investigation 114 • Treatment 114 Hospital Acquired Pneumonia 115 • Incidence and Etiology 115 xviGENERAL SURGICAL EMERGENCIES • Symptoms 115 • Signs 115 • Relevant Investigations 115 • Treatment 115 Acute Lung Abscess 115 • Incidence and Etiology 115 • Symptoms 116 • Sign 116 • Relevant Investigations 116 • Treatment 116 Pulmonary Embolism 116 • Incidence and Etiology 116 • Symptoms and Signs 116 • Relevant Investigations 117 • Treatment 117 19. Breast 118 Breast Hematoma 118 • Incidence and Etiology 118 • Symptoms 118 • Sign 118 • Relevant Investigations 118 • Treatment 118 Acute Breast Abscess 119 • Incidence and Etiology 119 • Symptoms 119 • Signs 119 • Relevant Investigations 119 • Treatment 119 20. Spine 120 Degenerative Diseases of Disk and Facet Joints 120 • Incidence and Etiology 120 • Symptoms and Signs 120 • Relevant Investigations 121 • Treatment 121 Spondylolisthesis 122 • Incidence and Etiology 122 • Symptom 122 • Signs 122 • Relevant Investigations 123 • Treatment 123 21. Gastroenterology 124 Acute Abdomen 124 • Introduction 124 • Pain 125 • Vomiting 128 Acute Upper Abdominal Pain 130 • Abdomen 131 • Relevant Investigations 133 • Treatment Plan 134 Acute Lower Abdominal Pain 134 • Treatment Plan 138 Acute Liver Abscess 138 • Incidence and Etiology 138 • Pathogenesis 138 • Symptoms 138 • Signs 139 • Differential Diagnosis 139 • Relevant Investigations 139 • Treatment 140 Acute Cholecystitis 140 • Incidence and Etiology 140 • Pathogenesis 140 • Complications 140 • Symptoms 140 • Signs 141 • Differential Diagnosis 141 • Relevant Investigations 141 • Treatment 142 Acute Cholangitis 143 • Incidence and Etiology 143 xvii CONTENTS • Pathogenesis 143 • Symptoms 143 • Signs 144 • Relevant Investigations 144 • Treatment 146 Primary Sclerosing Cholangitis 146 • Incidence and Etiology 146 • Clinical Presentation 146 • Relevant Investigations 146 • Treatment 147 Splenic Abscess 148 • Incidence and Etiology 148 • Pathogenesis 148 • Symptoms 148 • Sign 148 • Relevant Investigation 148 • Treatment 149 Acute Hemorrhagic Pancreatitis 149 • Incidence and Etiology 149 • Pathogenesis 150 • Symptoms 150 • Signs 150 • Relevant Investigations 151 • Treatment 153 Acute Appendicitis 154 • Incidence and Etiology 154 • Pathogenesis 154 • Symptoms 154 • Signs 155 • Relevant Investigations 157 • Treatment 159 Acute Mesenteric Lymphadenitis 159 • Incidence and Etiology 159 • Pathogenesis 159 • Symptoms 159 • Signs 159 • Relevant Investigations 159 • Treatment 160 Acute Colonic Diverticulitis 160 • Incidence and Etiology 160 • Pathogenesis 160 • Symptoms 161 • Signs 161 • Relevant Investigations 161 • Treatment 162 Acute Meckel’s Diverticulitis 162 • Incidence and Etiology 162 • Symptom 163 • Sign 163 • Differential Diagnosis 163 • Relevant Investigations 163 • Treatment 164 Acute Solitary Cecal Diverticulitis 164 • Incidence and Etiology 164 • Symptom 164 • Sign 164 • Relevant Investigations 164 • Treatment 164 Acute Ulcerative Colitis 164 • Incidence and Etiology 164 • Symptoms 165 • Signs 165 • Relevant Investigations 165 • Treatment 165 Acute Intestinal Obstruction 166 • Symptoms 166 • Signs 167 • Relevant Investigations 167 • Treatment 168 Gallstone Ileus 168 • Incidence and Etiology 168 • Symptoms 169 xviiiGENERAL SURGICAL EMERGENCIES • Signs 169 • Relevant Investigations 169 • Treatment 169 Acute Intussusception 170 • Incidence and Etiology 170 • Symptoms 171 • Signs 172 • Relevant Investigations 172 • Treatment 173 Swallowed Foreign Bodies 173 • Incidence and Etiology 173 • Symptoms 173 • Signs 173 • Relevant Investigations 173 • Treatment 173 Perforated Bowel Pathologies 174 • Differential Diagnosis 175 • Relevant Investigations 175 • Treatment 177 Intestinal Strictures 177 • Incidence and Etiology 177 • Symptoms 177 • Signs 177 • Relevant Investigations 177 • Treatment 177 Bands and Adhesions 178 • Incidence and Etiology 178 • Symptoms and Signs 178 • Relevant Investigations 178 • Treatment 178 Enteroliths/Food Bolus 179 • Incidence and Etiology 179 • Symptoms and Signs 179 • Relevant Investigations 179 • Treatment 179 Volvulus 179 Sigmoid Volvulus 179 • Incidence and Etiology 179 • Pathogenesis 179 • Symptoms 179 • Signs 180 • Relevant Investigations 180 • Treatment 180 Cecal Volvulus 180 • Incidence and Etiology 180 • Clinical Presentation 181 • Relevant Investigations 181 • Treatment 181 Midgut Volvulus 181 • Incidence and Etiology 181 • Symptom 181 • Signs 181 • Relevant Investigation 181 • Treatment 181 Gastric Volvulus 182 • Incidence and Etiology 182 • Symptoms 182 • Sign 182 • Relevant Investigation 182 • Treatment 182 Intestinal Obstruction due to Herniae (Internal and External) 182 • Incidence and Etiology 182 • Symptoms 183 • Sign 183 • Relevant Investigation 183 • Treatment 183 Paralytic Ileus 183 • Incidence and Etiology 183 • Symptoms 184 xix CONTENTS • Sign 184 • Relevant Investigations 184 • Treatment 185 Torsion of Mesenteric Cyst 185 • Incidence and Etiology 185 • Pathogenesis 186 • Symptom 186 • Signs 186 • Relevant Investigation 186 • Treatment 186 Torsion of Omentum 186 • Incidence and Etiology 186 • Pathogenesis 186 • Symptoms 187 • Signs 187 • Relevant Investigation 187 • Treatment 187 Colics 187 • Incidence and Etiology 187 • Clinical Features 188 • Symptoms 188 • Signs 189 • Differential Diagnosis by Clinical History and Examination 190 • Relevant Investigations 190 • Radiology 190 • Treatment Plan 190 Gastrointestinal Hemorrhage 190 • Definitions 190 • Types of Gastrointestinal Hemorrhages 191 • Hematemesis and Melena 192 • Melena 192 • Hematochezia 192 • Eliciting History 193 • Hematochezia 193 • Past History 194 • Family History 194 • Clinical Examination 194 • Abdomen 195 • Differential Diagnosis by Clinical History and Examination 195 • Relevant Investigations 196 • Treatment 198 • Surgical Treatment 198 22. Anorectum 199 Acute Anal Fissure 199 • Incidence and Etiology 199 • Pathogenesis 199 • Symptoms 199 • Signs 200 • Relevant Investigation 201 • Treatment 201 Anorectal Abscess 201 • Incidence and Etiology 201 • Pathogenesis 202 • Symptoms 202 • Signs 202 • Relevant Investigation 203 • Treatment 203 Hemorrhoids 203 • Incidence and Etiology 203 • Symptoms 203 • Signs 204 • Relevant Investigation 205 • Treatment 205 Perianal Hematoma 206 • Incidence and Etiology 206 • Pathogenesis 206 • Symptoms 206 • Sign 206 xxGENERAL SURGICAL EMERGENCIES • Relevant Investigation 207 • Treatment 207 Prolapse of Rectum 207 • Incidence and Etiology 207 • Pathogenesis 207 • Symptoms 207 • Signs 207 • Relevant Investigation 208 • Treatment 208 23. Vascular System 209 Acute Limb Ischemia 209 • Incidence and Etiology 209 • Symptoms 210 • Signs 210 • Relevant Investigations 211 Acute Intestinal Ischemia 211 • Incidence and Etiology 211 • Clinical Presentation 211 • Relevant Investigations 212 • Treatment 212 Leaking or Dissecting Aortic Aneurysm 212 • Incidence and Etiology 212 • Clinical Presentation 212 • Relevant Investigation 213 • Treatment 213 24. Urology 214 Acute Retention of Urine 214 • Definition 214 • Incidence and Etiology 214 • Symptoms 214 • Signs 214 • Relevant Investigations 215 • Treatment 215 Hematuria 215 • Definition 215 • Incidence and Etiology 215 • Symptoms 216 • Signs 216 • Relevant Investigations 216 • Treatment 217 Renal Colic 217 • Relevant Investigations 218 • Treatment 218 Ureteric Colic 218 • Symptom 218 • Relevant Investigations 218 • Treatment 219 Acute Urethritis 220 • Incidence and Etiology 220 • Symptoms 220 • Sign 220 • Relevant Investigations 220 • Treatment 220 Acute Prostatitis 221 • Incidence and Etiology 221 • Symptom 221 • Sign 221 • Relevant Investigation 221 • Treatment 221 Acute Prostatic Abscess 221 • Incidence and Etiology 221 • Symptom 221 • Sign 222 • Relevant Investigations 222 • Treatment 222 25. Male Genitalia 223 Acute Scrotal Pain 223 • Definition 223 • Causes of Acute Scrotal Pain 223 • Symptoms 224 • Past History 224 • Signs 224 xxi CONTENTS • On Palpation 225 • Differential Diagnosis by Clinical History and Examination 225 • Relevant Investigations 225 • Treatment 226 Torsion of Testis 226 • Incidence and Etiology 226 • Pathogenesis 226 • Symptoms 226 • Signs 227 • Relevant Investigation 227 Torsion of Appendages of Testis 228 • Incidence and Etiology 228 • Pathogenesis 228 • Symptom 228 • Signs 228 • Relevant Investigation 228 • Treatment 228 Acute Epididymo-orchitis 229 • Incidence and Etiology 229 • Pathogenesis 229 • Symptom 229 • Signs 229 • Relevant Investigations 229 • Treatment 229 Traumatic Orchitis 230 • Incidence and Etiology 230 • Clinical Presentation 230 • Relevant Investigation 230 • Treatment 230 Hematocele 230 • Definition 230 • Incidence and Etiology 230 • Symptoms 230 • Signs 231 • Relevant Investigation 231 • Treatment 231 Pyocele 231 • Definition 231 • Incidence and Etiology 232 • Symptom 232 • Signs 232 • Relevant Investigations 232 • Treatment 232 Idiopathic Scrotal Edema 232 • Incidence and Etiology 232 • Pathogenesis 232 • Symptom 232 • Signs 233 • Relevant Investigations 233 • Treatment 233 Acute Scrotal Abscess 233 • Incidence and Etiology 233 • Symptoms 233 • Sign 233 • Relevant Investigations 233 • Treatment 234 Fournier’s Gangrene 234 • Incidence and Etiology 234 • Symptoms 235 • Signs 235 • Relevant Investigation 235 • Treatment 235 Acute Filarial Scrotum 236 • Incidence and Etiology 236 • Clinical Presentation 236 • Relevant Investigation 236 • Treatment 236 Fracture Penis 237 • Incidence and Etiology 237 • Symptoms and Signs 237 xxiiGENERAL SURGICAL EMERGENCIES • Relevant Investigations 238 • Treatment 238 Paraphimosis 238 • Incidence and Etiology 238 • Symptoms 238 • Sign 238 • Relevant Investigation 238 • Treatment 238 Priapism 239 • Incidence and Etiology 239 • Clinical Presentation 240 • Relevant Investigation 240 • Treatment 240 26. Hernias 241 Complicated Hernias 241 • Definition 241 • Anatomy of the Hernial Sac 242 • Complications 242 • Symptoms 243 • Signs 244 • Relevant Investigations 244 • Treatment 244 27. Gynecology 245 Acute Torsion of Ovarian Cyst 245 • Incidence and Etiology 245 • Pathogenesis 245 • Symptom 245 • Signs 245 • Relevant Investigations 245 • Treatment 246 Acute Salpingitis 246 • Incidence and Etiology 246 • Pathogenesis 246 • Symptoms 246 • Signs 247 • Relevant Investigations 247 • Treatment 247 Rupture of Lutein Cyst 247 • Incidence and Etiology 247 • Clinical Presentation 247 • Relevant Investigations 247 • Treatment 247 28. Pediatrics 248 Acute Intussusception 248 • Incidence and Etiology 248 • Pathogenesis 248 • Symptoms 248 • Signs 249 • Relevant Investigations 249 • Treatment 249 Congenital Pyloric Stenosis 250 • Incidence and Etiology 250 • Pathogenesis 250 • Symptoms 250 • Signs 250 • Relevant Investigations 250 • Treatment 250 Necrotizing Enterocolitis 250 • Incidence and Etiology 250 • Pathogenesis 251 • Symptoms 251 • Signs 251 • Relevant Investigations 251 • Treatment 251 Tracheoesophageal Fistula 251 • Incidence and Etiology 251 • Pathogenesis 251 • Symptoms 252 • Signs 252 • Relevant Investigations 252 • Treatment 252 xxiii CONTENTS 29. Lymphatic System 253 Acute Lymphangitis 253 • Incidence and Etiology 253 • Clinical Presentation 253 • Relevant Investigations 254 • Treatment 254 Acute Viral and Bacterial Lymphadenitis 254 • Incidence and Etiology 254 • Symptoms 254 • Signs 254 • Relevant Investigations 255 • Treatment 255 Acute Filarial Lymphangitis and Lymphadenitis 255 • Incidence and Etiology 255 • Symptoms 255 • Signs 255 • Relevant Investigation 255 • Treatment 256 30. Skin and Subcutaneous Tissues 257 Hematoma 257 • Incidence and Etiology 257 • Symptom 257 • Sign 257 • Relevant Investigations 257 • Treatment 257 Erysipelas 258 • Incidence and Etiology 258 • Symptoms 258 • Investigations 259 • Treatment 259 Furuncle 259 • Incidence and Etiology 259 • Symptom 259 • Signs 260 • Relevant Investigations 260 • Treatment 260 Cellulitis 260 • Incidence and Etiology 260 • Pathogenesis 260 • Symptoms 261 • Signs 261 • Relevant Investigations 261 • Treatment 261 Acute Pyogenic Abscess 261 • Incidence and Etiology 261 • Symptoms 262 • Sign 262 • Relevant Investigations 262 • Treatment 262 Carbuncle 262 • Incidence and Etiology 262 • Symptom 263 • Signs 263 • Relevant Investigations 263 • Treatment 263 Burns 263 • Definition 263 • Pathogenesis 264 • Clinical Features 264 • Metabolic Effects of Burns 267 Physical Examination 268 • Preliminaries Before Examination 268 Inspection 271 • General Examination 272 • Systemic Examination 272 • Relevant Investigations 272 • Treatment 273 Necrotizing Fasciitis 274 • Incidence and Etiology 274 • Pathogenesis 274 xxivGENERAL SURGICAL EMERGENCIES • Symptom 274 • Sign 274 • Relevant Investigations 274 • Treatment 274 SECTION SIX: SPECIAL PROCEDURES AND SITUATIONS 31. Emergency Surgical Procedures 277 Pericardial Aspiration 277 • Materials Required 277 • Procedure 277 • Complications 278 Intubation of Trachea 279 • Materials Required 279 • Procedure 279 • Complication of Endotracheal Intubation 280 Percutaneous Tracheostomy 280 • Advantages of Tracheostomy 280 • Indications 280 • Contraindications 281 • Materials Needed for Percutaneous Tracheostomy 281 • Procedure 281 • Complications 282 Cricothyroidotomy/Minitracheostomy 282 • Indications 282 • Contraindications 283 • Materials Required 283 • Procedure 284 • Complications 284 Insertion of Chest Drains 284 • Indications 284 • Type of Drain 285 • Site of Drain 285 • Materials Required 286 • Procedures 286 Passing a Nasogastric Tube 287 • Indications 287 • Contraindications 289 • Materials Required 289 • Procedure 289 Peritoneal Tap 289 • Materials Required 289 • Procedure 291 32. Preparing the Patient for Emergency Surgery 292 • General Measures 292 • Investigations Support 292 • Situations which Need Special Attention 293 33. Antibiotics 294 Antibiotics and Emergency Surgery 294 • Which Emergency Surgical Procedure should have Antibiotic Prophylaxis ? 294 34. Death 296 • Breaking the News 296 Index 299
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