Clinical Post-Operative

CCriSP

 

Scenario 1

x-ray.jpg

You the Orthopaedic SHO on call. You have been asked to see a patient who was admitted earlier in the day with a left isolated, closed mid shaft tibial fracture. They have been complaining of severe pain. Would you review this patient?


Answer: A leading question like this, your response should always be you would review this patient. This is an isolated problem and you should already be thinking of compartment syndrome as your top differential. If there is an indication to repeat you ABCDE assessment then do so but if not, proceed to a taking a history and examination




On inspection, the left leg is in an above knee backslab. Is there any examination you would want to perform and are there any measures you would take in your initial management of this patient?


Answer: This is testing your knowledge of assessment of compartment syndrome

  • History – Ask the patient if the pain has worsened since admission? Are they experiencing any parasthesia? Any numbness? C

  • Examination – Examine the neurovascular status of the remaining exposed limb. Passive stretch of the compartment in question – if the pain is disproptionate to the injury then this is highly suggestive of compartment syndrome

  • Chart review – What are there observations (particularly blood pressure)? What is the lactate of the patient? Have they been given appropriate analgesia as per the WHO pain ladder

  • Initial management – Is the limb elevated above the heart level? Is the backslab on too tight, would it be safe to split any circumferential dressings?




After attempting initial management strategies, the patients pain has gotten worse and you are suspecting compartment syndrome. What are your options?


Answer: Importantly, you must alert your senior. With a high suspicion of this Orthopaedic emergency, prompt operative treatment may be required. If there is diagnostic doubt, you should mention there is the option to measure the compartment pressure. However, it is a clinical diagnosis and this patient should be taken to theatre.




You alert your senior who has agreed this patient requires an urgent fasciotomy. They are off site and are making their way into the hospital. What can you do in the interim?


Answer: As the Orthopaedic SHO, you will not be expected to perform the fasciotomy but you will be expected to prepare the patient for theatre

  • Mark and consent the patient. If you are not comfortable with the theory of a fasciotomy (you should know the basics) then say you would get the documentation ready for the registrar
  • Ensure the patient is nil by mouth
  • Discuss the diagnosis and management plan with the patient
  • Inform the multidisciplinary team (anaesthetist/ theatre staff/ ward nurses)





 

Scenario 2

lungs.jpg

You the Orthopaedic SHO on call. You have been asked to see a patient who was admitted earlier in the day with a left isolated, closed mid shaft tibial fracture. They have been complaining of severe pain. Would you review this patient?


Answer: A leading question like this, your response should always be you would review this patient. This is an isolated problem and you should already be thinking of compartment syndrome as your top differential. If there is an indication to repeat you ABCDE assessment then do so but if not, proceed to a taking a history and examination




On inspection, the left leg is in an above knee backslab. Is there any examination you would want to perform and are there any measures you would take in your initial management of this patient?


Answer: This is testing your knowledge of assessment of compartment syndrome

  • History – Ask the patient if the pain has worsened since admission? Are they experiencing any parasthesia? Any numbness? C

  • Examination – Examine the neurovascular status of the remaining exposed limb. Passive stretch of the compartment in question – if the pain is disproptionate to the injury then this is highly suggestive of compartment syndrome

  • Chart review – What are there observations (particularly blood pressure)? What is the lactate of the patient? Have they been given appropriate analgesia as per the WHO pain ladder

  • Initial management – Is the limb elevated above the heart level? Is the backslab on too tight, would it be safe to split any circumferential dressings?




After attempting initial management strategies, the patients pain has gotten worse and you are suspecting compartment syndrome. What are your options?


Answer: Importantly, you must alert your senior. With a high suspicion of this Orthopaedic emergency, prompt operative treatment may be required. If there is diagnostic doubt, you should mention there is the option to measure the compartment pressure. However, it is a clinical diagnosis and this patient should be taken to theatre.




You alert your senior who has agreed this patient requires an urgent fasciotomy. They are off site and are making their way into the hospital. What can you do in the interim?


Answer: As the Orthopaedic SHO, you will not be expected to perform the fasciotomy but you will be expected to prepare the patient for theatre

  • Mark and consent the patient. If you are not comfortable with the theory of a fasciotomy (you should know the basics) then say you would get the documentation ready for the registrar
  • Ensure the patient is nil by mouth
  • Discuss the diagnosis and management plan with the patient
  • Inform the multidisciplinary team (anaesthetist/ theatre staff/ ward nurses)





 

Scenario 3

feet.jpg

You the Orthopaedic SHO on call. You have been asked to see a patient who was admitted earlier in the day with a left isolated, closed mid shaft tibial fracture. They have been complaining of severe pain. Would you review this patient?


Answer: A leading question like this, your response should always be you would review this patient. This is an isolated problem and you should already be thinking of compartment syndrome as your top differential. If there is an indication to repeat you ABCDE assessment then do so but if not, proceed to a taking a history and examination




On inspection, the left leg is in an above knee backslab. Is there any examination you would want to perform and are there any measures you would take in your initial management of this patient?


Answer: This is testing your knowledge of assessment of compartment syndrome

  • History – Ask the patient if the pain has worsened since admission? Are they experiencing any parasthesia? Any numbness? C

  • Examination – Examine the neurovascular status of the remaining exposed limb. Passive stretch of the compartment in question – if the pain is disproptionate to the injury then this is highly suggestive of compartment syndrome

  • Chart review – What are there observations (particularly blood pressure)? What is the lactate of the patient? Have they been given appropriate analgesia as per the WHO pain ladder

  • Initial management – Is the limb elevated above the heart level? Is the backslab on too tight, would it be safe to split any circumferential dressings?




After attempting initial management strategies, the patients pain has gotten worse and you are suspecting compartment syndrome. What are your options?


Answer: Importantly, you must alert your senior. With a high suspicion of this Orthopaedic emergency, prompt operative treatment may be required. If there is diagnostic doubt, you should mention there is the option to measure the compartment pressure. However, it is a clinical diagnosis and this patient should be taken to theatre.




You alert your senior who has agreed this patient requires an urgent fasciotomy. They are off site and are making their way into the hospital. What can you do in the interim?


Answer: As the Orthopaedic SHO, you will not be expected to perform the fasciotomy but you will be expected to prepare the patient for theatre

  • Mark and consent the patient. If you are not comfortable with the theory of a fasciotomy (you should know the basics) then say you would get the documentation ready for the registrar
  • Ensure the patient is nil by mouth
  • Discuss the diagnosis and management plan with the patient
  • Inform the multidisciplinary team (anaesthetist/ theatre staff/ ward nurses)





 

Scenario 4

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You are the General Surgical SHO on call. You are asked to review a patient who has increasing abdominal pain.


Answer: Ironically, the most useful approach for managing this patient is dealt with in a course that only Core Surgical Trainees can attend; yet it regularly appears in your interview process. That does not mean you should not be prepared for it.

  • Immediate management of ABCDE. The examiners will prompt you in how much details to go and provide you with the paramaters needed to guide your management




This patient has a heart rate of 120, a blood pressure of 90/60, a respiratory rate of 32, oxygen saturations of 94% and a temperature of 39.2. How would you manage this patient?


Answer: If given the observations in a list format like this then state the overall principles you would apply to your immediate management by front loading your answer –

I would manage this patient as per the CCriSP protocol and implement management for acute sepsis. Using my ABCDE approach, I will ensure their airway is patent (pause). I would provide this patient with oxygen through a non-rebreathe mask and auscultate the chest. I would insert 2 large bore cannulae (pause) to provide this patient with a fluid challenge of 1 litre of Normal Saline given over 15 minutes before which I would take a full blood count, check the patients renal function and electrolytes, the CRP and the clotting for this patients (pause). I would also send off a group and save for this patient in case they need to return to theatre and I would also take blood cultures. I will also run an urgent gas to check the lactate of my patient and I would also consider inserting a catheter so the fluid balance of this patient can be monitored (pause). I will then auscultate the heart and check the gross peripheral vascular system of this patient through a capillary refill check and palpating a peripheral pulse (pause). I would also like to get an ECG. I will go on to check if there is any dysfuntion of the central nervous system by using an AVPU measure of the patient cognitive state and a more formal GCS if there are any concerns (pause.) Throughout my immediate management I will reassess the patient after applying my interventions to see if there is a response to the initial resuscitation.

This is an example of how to thoroughly answer a question like this. I have inserted pauses as some examiners may want to give further prompts or want you to proceed to another question. Always take hints given by the examiners, they are trying to help you!




The patient has transiently responded to your measures and this has given you time to arrange any further investigations and to establish more details of what may be going on.


Answer: The blood results are likely to be given as you ask for them. If not, they are holding them back for when you may need to use them to help guide your decision making process. With a question like this they want you to go beyond ABCDE and approach this in a more realistic manner.

  • Review the patients observations over the past 24 hours
  • Take a history and a systematic examination (notably the recently operated on abdomen)
  • Check available results (trends in blood results)
  • The operation note and post operative documentation
  • Discuss with the nursing staff on how the patient has been throughout the day

In your head, you will already have a list of differentials, so try and guide your investigations based on this

  • Initial bedside investigations
    • Urine dip (as a possible cause for the sepsis)
    • Repeat observations
    • Fluid balance for this patient
  • Radiological investigations
    • An urgent bedside chest x ray (to look for air under the diaphragm)




Is there anything else you would do now the patient is relatively stable?


Answer: Alert your senior. As a core surgical trainee, you should be able to perform immediate management and reassess the patient. You will alert your senior, this is inevitable. This is also the time you would consider a CT abdomen and pelvis with contrast if the patient is stable enough and there is diagnostic uncertainty and for surgical planning.




This patient had a primary anastomosis following a Hartmann’s operation. What is your top differential diagnosis?


Answer: You should have a list of differentials for your septic/ unwell postoperative patient. Here they only want your top differential, which is likely to be an anastomotic leak.

Anastomotic leaks are a common and complex surgical complication. Initial assessment and management and recognition make a Core Surgical Trainee however below is a detailed insight into the pathology:

https://www.acpgbi.org.uk/content/uploads/2016/03/management-of-colorectal-anastomtic-leakage.pdf