Surgical Problems in Primary Care Ronald H. Labuguen, MD Clinical - - PowerPoint PPT Presentation

Surgical Problems in Primary Care

Ronald H. Labuguen, MD

Clinical Professor UCSF Department of Family and Community Medicine

• UCSF Family Medicine Board Review Course

March 7, 2017

Faculty Disclosure

• I have nothing to disclose

The closest I’ll get to being a surgeon

Road Map for Our Journey

• Gastrointestinal Problems/Acute Abdominal Pain
• Preop/periop/postop care, wounds, and infections
• Other surgical specialties:

– Trauma surgery – Vascular surgery – Thoracic surgery – Otolaryngology/head and neck surgery – Urology – Neurosurgery

Top 30 High Yield Items

GASTROINTESTINAL PROBLEMS ACUTE ABDOMINAL PAIN

Right Upper Quadrant Pain

• 42 year old woman with right upper quadrant

pain

• Worse with eating
• Nausea, no vomiting
• No fever
• Exam:

– Tender to palpation in the RUQ – Murphy’s sign: reproducible pain & halts breathing on inspiration on palpation at right costal margin at the midclavicular line

RUQ Ultrasound = Test of Choice

Heilman J. File:Gallstones.PNG [Wikimedia Commons Web site]. March 18, 2011. Available at: http://commons.wikimedia.org/wiki/File:Gallstones.PNG.

Cholangiocarcinoma

Cholangiocarcinoma

• Treatment: complete surgical resection
• Generally poor prognosis

– Only 10% present at an early enough stage to consider curative resection – 5-year survival rate up to 40% for patients with completely resected tumors

Cholangiocarcinoma: Klatskin tumor

• Hellerhoff. File:Klatskintumor-ERC.jpg [Wikimedia Commons Web site]. July 15, 2011.

Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-ERC.jpg .

Klatskin tumor: Palliative stent placement

• Hellerhoff. File:Klatskintumor-Stents.jpg [Wikimedia Commons Web site]. July 15,
• 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-Stents.jpg.

RIGHT LOWER QUADRANT PAIN

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

• History

– Periumbilical for 3 days, then right lower quadrant for 2 days

• Physical exam

– Tenderness to palpation at McBurney’s point

McBurney’s Point (#1)

Fruitsmaak S. File:McBurney’s_point.jpg [Wikimedia Commons Web site]. September 24, 2006. Available at: http://commons.wikimedia.org/wiki/File:McBurney%27s_point.jpg.

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

• 5 day history

– Periumbilical for 3 days, then right lower quadrant for 2 days

• Physical exam

– Tenderness to palpation at McBurney’s point – (-) psoas, (+) obturator signs

• Labs

– Normal

Physical Diagnosis

• McBurney’s point tenderness LR+ 3.4
• Peritonitis:

–Rigidity LR+ 3.6 –Abdominal wall tenderness LR+ 0.1

LR+ 10.0 = +45% probability LR+ 0.1 = -45% probability

McGee S, Evidence-Based Physical Diagnosis, 4th ed. Philadelphia: Elsevier, 2018, pp. 449-453

Labs

• no WBC cutoff has sufficient sensitivity or

specificity to rule out appendicitis

• 25% of appys have normal WBC

Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007 Jul 25; 298(4): 438-51 Cartwright SL, Knudson MP. ฀ Evaluation of Acute Abdominal Pain in Adults. Am Fam Physician 2008, Apr 1;77(7):971-8

Alvarado (MANTRELS) Score

• Migration (1 pt)
• Anorexia (1)
• Nausea and vomiting (1)
• Tenderness RLQ (2)
• Rebound tenderness (1)
• Elevation of temperature (1)
• Leukocytosis WBC > 10 (2)
• Shift to the left > 75%

neutrophils (1)

• Score ≥ 7  LR+ 3.1

≤ 4  LR+ 0.1

• Better to help rule out

appendicitis than to diagnose it

McGee S, Evidence-Based Physical Diagnosis, 4th ed. Philadelphia: Elsevier, 2018,

• pp. 449-453

Appendicitis on CT

Heilman J. File:Appy4.jpg [Wikimedia Commons Web site]. April 24, 2010. Available at: http://commons.wikimedia.org/wiki/File:Appy4.jpg.

Imaging: ACR appropriateness criteria

• Classical presentation

– CT abd/pelv w/ contrast (8 – usually appropriate) – CT abd/pelv w/o contrast (7 – usually appropriate) – RLQ US (6 – may be appropriate)

• Atypical presentation

– CT abd/pelv w/ contrast (8 – usually appropriate) – X-ray abd, RLQ US, pelvic US, CT abd/pelv w/o contrast (6 – may be appropriate)

American College of Radiology. ACR Appropriateness Criteria: Right Lower Quadrant Pain - Suspected Appendicitis. Available at https://acsearch.acr.org/docs/69357/Narrative/. Accessed 24 February 2017.

Bottom Line: Diagnosis of Appendicitis

• H&P and labs low sensitivity and specificity by

themselves

• CT and MRI have better sensitivity/specificity

compared to H&P and labs; ultrasound slightly less sensitive than CT/MRI (studies varied widely)

• No single lab or clinical test has superior

sensitivity or specificity. Specific cutoffs could not be defined.

• Few studies evaluating clinical decision aids

Dahabreh IJ, Adam GP, Halladay CW, et al. Diagnosis of Right Lower Quadrant Pain and Suspected Acute Appendicitis AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. Report No. 15(16)- EHC025-EF (Review) PMID: 27054223

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

What is the most appropriate treatment for this patient?

• A. Appendectomy
• B. IV broad spectrum antibiotics
• C. PO antibiotics
• D. Watchful waiting

Appendectomy IV broad spectrum antibi... PO antibiotics Watchful waiting

71% 9% 9% 12%

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

• Appendectomy is historically the treatment
• f choice

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

• Conservative treatment with antibiotics and

watchful waiting?

Historically, reports of cases treated successfully with antibiotics – Coldrey E. Treatment of acute appendicitis. Br Med J 1956;2(5007):1458-1461

• 471 pts treated
• Mortality 0.2%
• Recurrent appendicitis 14.4%

Case: 34 yo man with Right Lower Quadrant Pain in Urgent Care

• Conservative treatment with antibiotics and

watchful waiting?

– Antibiotics not definitively “non-inferior” to surgery

Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute

• appendicitis. Cochrane Database Syst Rev. 2011 Nov

9;(11):CD008359.

Uncomplicated Appendicitis: Antibiotics vs. Surgery

• APPAC

– Did not demonstrate “noninferiority” of antibiotics:

27% in Antibiotics group had surgery within 1 year of presentation (cutoff for “noninferiority” ≤24% )

– Surgery group had higher rate of complications 20.5% vs. 7.0% in Antibiotics group

Salminen P, Paajanen H, Rautio T et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340-2348.

Uncomplicated Appendicitis: Antibiotics vs. Surgery Meta-analyses

• Higher rate of complications in surgery group
• Antibiotics group: 8.2% had surgery at 1 mo

22.6% had recurrence at 1 yr

• No difference in hospital length of stay or incidence
• f complicated appendicitis

Sallinen, V., Akl, E. A., You, J. J., Agarwal, A., Shoucair, S., Vandvik, P. O., Agoritsas, T., Heels-Ansdell, D., Guyatt, G. H. and Tikkinen, K. A. O. (2016), Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg, 103: 656–667. doi:10.1002/bjs.10147 Rollins KE, Varadhan KK, Neal KR, et al. Antibiotics Versus Appendicectomy for the Treatment of Uncomplicated Acute Appendicitis: An Updated Meta-Analysis of Randomised Controlled Trials. World J Surg. 2016 Oct;40(10):2305-18. doi: 10.1007/s00268-016-3561-7. (Review) PMID: 27199000

Non-operative treatment of uncomplicated appendicitis in children

• Preliminary reports of ongoing studies

indicate:

– Success rates 89.2% at 30 days 75.7% at 1 year – Lower incidence of complicated appendicitis (2.7%

• vs. 12.3%)

– Fewer disability days – Lower costs

Minneci PC, et al. JAMA Surg. 2016;151:408-415

Antibiotic treatment post appendectomy in children

• Extended-spectrum antibiotics not superior to

narrow-spectrum antibiotics re: 30 day readmission rates of children

Kronman MP, Oron AP, Ross RK, et al. Extended- Versus Narrower- Spectrum Antibiotics for Appendicitis. Pediatrics. 2016;138(1):e20154547

Appendicitis: Red Flags

• Signs of rupture

– Change in condition:

• Fever
• Increased pain
• Abdominal rigidity

– Could see improvement in pain (think of a walled-

• ff ruptured abscess) until peritonitis more fully

develops

Appendicitis: Red Flags

• Higher proportion of

patients with ruptured appendicitis at the extremes of age (early childhood, elderly)

– May be due to lower incidence, because absolute rate of rupture is constant across ages

• Psychopoesie. File:Grandma&me_at_my_cousin’s_wedding.jpg [Wikimedia Commons Web site].

October 31, 2011. Available at: http://commons.wikimedia.org/wiki/File:Grandma%26me_at_my_cousin%27s_wedding.jpg .

Chan Ho Park

Meckel’s Diverticulum

Meckel’s Diverticulum: Rule of 2’s

• 2% prevalence
• 2 years of age at presentation
• 2 feet from the ileocecal junction
• 2 inches in length
• 2 types of common ectopic tissue

– Gastric – Pancreatic

• 2% symptomatic
• 2 times more symptomatic in boys

LEFT LOWER QUADRANT PAIN

Diverticulitis

• Typical story:

– Acute constant abdominal pain in LLQ – Fever – Can also see nausea, vomiting, constipation, diarrhea, “sympathetic cystitis” (dysuria and frequency caused by bladder irritation from inflamed colon)

• Typical physical exam findings:

– LLQ tenderness, guarding, rebound

Which one of the following is NOT associated with complications of diverticulitis?

• A. NSAIDs
• B. Opioids
• C. Corticosteroids
• D. Recurrences of diverticulitis

NSAIDs Opioids Corticosteroids Recurrences of diverticulitis

27% 27% 30% 15%

Diverticulitis

• Risk factors: Smoking, obesity
• Negative risk factor: Increased physical activity
• Associated with complications:

–Yes: NSAIDs, opioids, corticosteroids –No: Recurrences

• Recurrences are uncommon (13.3%) & not

clustered

Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid Diverticulitis: A Systematic Review. JAMA. 2014;311(3):287-297.

Diverticulitis

• Diagnostics:

– CBC (leukocytosis) – Urinalysis – CT of abdomen and pelvis with contrast (US, MRI acceptable alternatives)

Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon

• Rectum. 2014 Mar;57(3):284-94.

Diverticulitis

Heilman J. File:Diverticulitis.png [Wikimedia Commons Web site]. June 2, 2011. Available at: http://en.wikipedia.org/wiki/File:Diverticulitis.png.

Treatment of diverticulitis with antibiotics has been shown to reduce which of the following?

• A. Complications
• B. Need for surgery
• C. Recurrence
• D. Median length of inpatient stay
• E. None of the above

Complications Need for surgery Recurrence Median length of inpati... None of the above

16% 30% 41% 10% 3%

Uncomplicated Diverticulitis: Treatment

• Stable, tolerating oral fluids: outpatient

Cochrane review – best available data do not support abx No effect on complications, need for surgery, recurrence, median length of inpatient stay 1st episode – observation decreased hospital LOS, no effect on complications or recovery time

• Older or ill pts, not tolerating fluids: admit

IV fluids, bowel rest/NPO, ? Antibiotics

Daniels L, Unlu C, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017 Jan;104(1):52-61. Chabok A, Pahlman L, Hjern F et al. Randomized clinical trial of antibiotics for acute uncomplicated diverticulitis. Br J Surg 2012;99(4):532-539. Shabanzadeh DM, Wille-Jorgensen P. Antibiotics for uncomplicated

• diverticulitis. Cochrane Database Syst Rev. 2012 Nov 14;11:CD009092.

Diverticulitis: Treatment

• Complicated (sepsis, perforation, abscess, fistula,
• bstruction)
• stabilize, IV fluids, antibiotics, surgical consultation,

percutaneous drainage, intraperitoneal lavage

• Broad-spectrum antibiotics to cover anaerobes,

gram negative rods

Diverticulitis: Treatment

• Indications for surgery

– Sepsis, acute peritonitis – No improvement with medical therapy, percutaneous drainage, or both – Trend toward minimally invasive surgical techniques (laparascopic preferred in American Society of Colon and Rectal Surgeons guideline) – Consider after complicated episode

Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic Review. JAMA Surg. 2014;149(3):292-303. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

AGA Recommendations: Diverticulitis

For

• Selective use of abx
• Colonoscopy after

resolution to r/o CA

• Fiber
• ASA, seeds, nuts,

popcorn OK

• Vigorous physical

activity Against

• Elective colon resection

after 1st uncomplicated episode

• NSAIDs
• Mesalamine
• Rifaximin
• Probiotics

Stollman N, Smalley W, Ikuo Hirano I, and AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology 2015;149:1944–1949.

Which of the following is the most common cause of lower GI bleeding?

• A. Hemorrhoids
• B. Diverticulosis
• C. Inflammatory bowel disease
• D. Colon polyps
• E. Ischemic bowel

Hemorrhoids Diverticulosis Inflammatory bowel disease Colon polyps Ischemic bowel

72% 23% 0% 2% 3%

Causes of lower GI bleeding

Diagnosis Frequency (%) Diverticulosis 30 Hemorrhoids 14 Ischemic 12 Inflammatory Bowel Disease 9 Post-polypectomy 8 Colon cancer/polyps 6 Rectal ulcer 6 Vascular ectasia 3 Radiation colitis/proctitis 3 Other 6

Source: UCLA-CURE Hemostasis Research Group database. Ghassemi KA, Jensen

• DM. Lower GI Bleeding: Epidemiology and Management. Curr Gastroenterol Rep

(2013) 15:333.

Diverticulosis

• Typical story: abrupt onset of painless

voluminous bleeding (arterial)

• Diagnostics: nuclear bleeding scan,

angiography, colonoscopy

• Treatment: colonoscopy; may require surgery

Diverticulosis

• Hellerhoff. File:Sigmadvivertikulose CT axial.jpg [Wikimedia Commons Web site]. December 23,
• 2010. Available at: http://commons.wikimedia.org/wiki/Sigmadivertikulose_CT_axial.jpg.

Diverticulosis

Case: 53 yo woman with hemorrhoids

Hemorrhoids

• WikipedianProlific. File:Hemorrhoid.png [Wikimedia Commons Web site]. September 12, 2006.

Available at: http://commons.wikimedia.org/wiki/File:Hemorrhoid.png.

Volvulus

• Midgut volvulus from malrotation of the gut
• Sigmoid volvulus

Midgut Volvulus: Malrotation of the Gut

• Typical story:

– 1st month of life: bilious vomiting, feeding intolerance, sudden onset of abdominal pain, upper abdominal distention – Older children: More vague (chronic, unexplained) abdominal pain, irritability, anorexia, nausea/vomiting, failure to thrive

Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children BMJ 2013;347:f6949

Midgut Volvulus: Malrotation of the Gut

Midgut Volvulus: Malrotation of the Gut

• Diagnostics

– Physical exam: normal, or subtle findings – Abdominal x-ray: “double bubble” sign (gastric and duodenal dilatation); lack gas in lower GI tract; pneumatosis coli (ominous sign) – UGI contrast w/ “bird’s beak”, spiral, corkscrew signs

• f duodenal obstruction
• Sensitivity 96%, false negative rate 3-6%

– Ultrasound scanning of the mesenteric vessels

• Sensitivity 86.5%, specificity 75%, positive predictive value

42%, negative predictive value 96%

Midgut Volvulus: Malrotation of the Gut

• Treatment: Ladd’s procedure

(1) untwist the intestine, (2) divide any adhesive bands, and (3) widen the mesentery to result in the bowel being in a “safe” non-rotated position

Sigmoid Volvulus

• Older patients
• Typical story – sx of bowel obstruction/ischemia:

– Abdominal pain, distention, inability to pass stool or flatus (obstipation), history of constipation – Vomiting may be late presenting feature

• Diagnostics: abdominal x-ray shows distended

sigmoid colon

• Treatment: sigmoidoscopy/rectal tube placement;

resection & primary anastomosis

Sigmoid Volvulus

• Hellerhoff. Files:Sigmavolvulus_Roentgen_Abdomen_pa.jpg,

Sigmavolvulus_Roentgen_Abdomen_LSL.jpg [Wikimedia Commons Web site]. 22 September 2014.

EPIGASTRIC PAIN

Case: 34 yo man with epigastric pain

Ranson’s criteria at admission: GA LAW

• Glucose > 200
• AST > 250
• LDH > 350
• Age > 55
• WBC > 16

Ranson’s criteria at 48 hours: Cal(vin) & HOB(BE)S

• Calcium < 8
• Hematocrit drop > 10 % pts
• pO2 < 60
• BUN incr > 5 after fluid hydration
• Base deficit > 4 (Base Excess < -4)
• Sequestration of fluid > 6 L

Grey Turner’s Sign

Fred H, van Dijk H. Images of Memorable Cases: Case 21 [Connexions Web site]. December 3,

• 2008. Available at: http://cnx.org/content/m14942/1.3/.

Cullen’s Sign

Fred H, van Dijk H. Images of Memorable Cases: Case 120 [Connexions Web site]. December 8,

• 2008. Available at: http://cnx.org/content/m14904/1.3/.

Pancreatitis

• Surgery indicated for infected necrosis

– 80% of deaths from acute pancreatitis caused by infection of dead pancreatic tissue

• Pancreatic pseudocysts

– Endoscopic drainage as effective as surgery, both more effective than percutaneous drainage

Johnson MD, Walsh RM, Henderson JM, et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol 2009 Jul;43(6):586-90.

Peptic Ulcer Disease

• Surgery rarely needed
• Vagotomy
• Gastrectomy

Surgical Treatment for GERD

Surgical Treatment for GERD

• Unresponsive to aggressive antisecretory

therapy (proton pump inhibitors)

• After surgery, some patients still require

antisecretory therapy

• Potential obstructive complications of Nissen:

– dysphagia – rectal flatulence – inability to belch or vomit

Right Inguinal Hernia

Hernia Inguinal

Inguinal Hernia

16th Century Hernia Surgery

21st Century Hernia Surgery

Hernia Surgery

• Indications for surgery

– Emergent

• Strangulated hernias

–Nonreducible bulge with pain, sometimes after heavy lifting – Urgent

• Incarcerated hernias

Hernia Surgery

• Indications for surgery

– Elective

• Inguinal hernias – watchful waiting

recommended

• Femoral hernias – higher risk of strangulation
• Ventral hernias
• Umbilical

–Normally resolve without intervention by age 5

Umbilical Hernia

Hernia Surgery: What about mesh?

• Fewer recurrences

–5-7% absolute risk reduction

• More long-term complications requiring

surgical intervention –3-5% absolute risk reduction

Scott N, Go PM, Graham P, McCormack K, Ross SJ, Grant AM. Open Mesh versus non- Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3.

• Art. No.: CD002197. DOI: 10.1002/14651858.CD002197.

Kokotovic D, Bisgaard T, Helgstrand F. Long-term recurrence and complications associated with elective incisional hernia repair. JAMA 2016 Oct 18; 316:1575.

Case: 6 year old boy with severe abdominal pain in the Peds ED

Small Bowel Obstruction

Heilman J. File:SBO2009.JPG [Wikimedia Commons Web site]. November 8, 2009. Available at: http://commons.wikimedia.org/wiki/File:SBO2009.JPG.

Large Bowel Obstruction

Heilman J. File:LargeBowelObsUp2008.jpg [Wikimedia Commons Web site]. August 28, 2008. Available at: http://commons.wikimedia.org/wiki/File:LargeBowelObsUp2008.jpg. Heilman J. File:LargeBowelObsFlat2008.jpg [Wikimedia Commons Web site]. August 28, 2008. Available at: http://commons.wikimedia.org/wiki/File:LargeBowelObsFlat2008.jpg.

A 48-year-old male presents with a 4-week history

• f rectal pain associated with minimal rectal
• bleeding. On examination there is a small tear of

the anorectal mucosa at the 6 o’clock position. The most appropriate initial treatment would be topical:

• A. Botulinum toxin
• B. Clobetasol (Temovate)
• C. Capsaicin (Capzasin-HP, Zostrix)
• D. Nitroglycerin

Botulinum toxin Clobetasol (Temovate) Capsaicin (Capzasin-HP, Z... Nitroglycerin

2% 71% 3% 24%

Anal Fissure

Anal Fissure

• Nonsurgical measures that are proven effective in

relaxing the sphincter: – Topical nitroglycerin ointment – Diltiazem, nifedipine (topical preparations usually have to be compounded by a pharmacist) – Botulinum toxin injected into the internal sphincter – Corticosteroid creams may decrease the pain temporarily

• Surgery: internal sphincterotomy

Fargo MV, Latimer KM: Evaluation and management of common anorectal

• conditions. Am Fam Physician 2012;85(6):624-630.

Pilonidal Cyst

• GiggsHammouri. File:Pilonidal cyst.JPG [Wikimedia Commons Web site]. April 1, 2010.

Available at: http://commons.wikimedia.org/wiki/File:Pilonidal_cyst.JPG.

PREOP/PERIOP/POSTOP CARE WOUNDS INFECTIONS

Preoperative Workup

• Source #1: 2014 ACC/AHA Guidelines on

Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2007 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

• Circulation. 2014;130:e278-e333

Preoperative Workup

• Source #2: Feely MA, Collins CS, Daniels PR,

et al. Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations. Am Fam Physician. 2013 Mar 15;87(6):414- 418.

• Free App: Joshua Steinberg

Preoperative Workup

• No routine/indiscriminate testing
• Base testing on H&P, perioperative cardiac risk

assessment, clinical judgment

• Not required for cataract surgery

Preoperative Workup

• EKG:

–Signs/symptoms of cardiovascular disease –Consider in elevated-risk procedure, patients with cardiac risk factors –Not needed for low-risk procedures

Preoperative Workup

Noncardiac Surgery Risk of Cardiac Death or Nonfatal MI:

• Elevated (≥ 1%)
• Low (< 1%)

– Ambulatory, breast, endoscopic, superficial, cataract

Preoperative Workup

• Risk factors:

– Cerebrovascular disease – Congestive heart failure – Creatinine level >2.0 mg/dL – Diabetes mellitus requiring insulin – Ischemic cardiac disease – *Suprainguinal vascular surgery, intrathoracic surgery, or intra-abdominal surgery

RF’s % Risk major cardiac event (95% CI)

0 0.4 (0.05 to 1.5) 1 0.9 (0.3 to 2.1) 2 6.6 (3.9 to 10.3) ≥3 ≥11 (5.8 to 18.4)

Revised Cardiac Risk Index (RCRI)

Preoperative Workup

• Elevated cardiac risk and poor or

unknown functional capacity

• Only if a positive test would change

management

Stress Tests

Preoperative Workup

CXR:

• New or unstable

cardiopulmonary signs

• r symptoms
• Increased risk of postop

pulmonary complications if results would change management

UA:

• Urologic procedures
• Implantation of foreign

material (e.g., heart valve or joint replacement)

Preoperative Workup

BMP:

• At risk of electrolyte

abnormalities or renal impairment (based on history, medications)

Glucose, A1c:

• Signs/symptoms or very

high risk of undiagnosed diabetes, if abnormal result would change periop management

CBC:

• At risk for anemia
• Significant blood loss

anticipated

Coags:

• On anticoagulants
• History of abnormal

bleeding

• At risk for coagulopathy

(e.g., liver disease)

Perioperative Areas of Focus

• Anticoagulation management
• Venous thromboembolism (VTE) prevention
• Beta-blocker therapy
• Antibiotic prophylaxis
• Chronic disease

Anticoagulation

• Stop ASA 7-10 days (3 days?) pre-op (unless benefit

preventing ischemia outweighs bleeding risk), restart 8-10 days post-op

• Stop warfarin 4-5 days pre-op
• Stop heparin

– LMWH 12 hrs pre-op – UFH

• IV 4-6 hrs pre-op
• SQ 12 hrs pre-op

Devereaux PJ et al for the POISE-2 Investigators. Aspirin in Patients Undergoing Noncardiac Surgery. N Engl J Med 2014;370:1494-503.

Venous Thromboembolism

• Assess risk
• Check renal function
• Consider prophylaxis
• Bridge therapy (treat w/ LMWH after holding

warfarin) for patients with mechanical heart valve, h/o VTE

BRIDGE trial: Do patients w/ atrial

fibrillation on warfarin need bridge therapy with LMWH when warfarin is held pre-op?

• Placebo was noninferior to LMWH with

respect to preventing atrial thromboembolism

• More bleeding complications in LMWH group
• Excluded patients: stroke, mechanical valves
• Relatively low risk population (only 13% high-

risk by CHADS2)

Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-33

In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?

• A. Nonfatal MI
• B. Stroke
• C. Death
• D. Hypotension
• E. Bradycardia

Nonfatal MI Stroke Death Hypotension Bradycardia

75% 5% 0% 0% 20%

In patients undergoing noncardiac surgery, which of the following outcomes does perioperative beta blockade decrease?

• A. Nonfatal MI RR 0.69
• B. Stroke

RR 1.76

• C. Death

RR 1.30*

• D. Hypotension RR 1.47
• E. Bradycardia RR 2.61

INCREASED risk

*excluding DECREASE trial data

Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative Beta Blockade in Noncardiac Surgery: A Systematic Review for the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):2246-64

Beta Blockade

• Stay on them if already on them
• Modify or discontinue based on clinical

picture

• Assess risk (Revised Cardiac Risk Index)
• If administering perioperative beta blockers:

– Start well in advance of surgery (2-7 d preop) – Do not start on day of surgery

Perioperative Beta blockade? Not routinely in pts w/ uncomplicated HTN

• Increased incidence of CV death, nonfatal

ischemic stroke, nonfatal MI

• NNH 140 for pts > 70 yo

142 for men 97 for pts undergoing emergency surgery

Jorgensen ME, Hlatky MA, Kober L, et al. beta-Blocker-Associated Risks in Patients With Uncomplicated Hypertension Undergoing Noncardiac Surgery. JAMA Intern Med. 2015 Dec;175(12):1923-31.

Perioperative Diabetes Management

• Best if A1c < 7
• Tight glycemic control controversial

– 140-180 may be adequate

Statins

• Stay on them if already on them
• Consider initiating in selected high-risk

patients

Postoperative Care

• Monitor cardiovascular, pulmonary, fluid

status

• Pain management
• Complications

Postop fever

• Non-evidence based workup:

5 (or 6) W’s

– Wind – atelectasis – Water – UTI – Wound – wound infection – Walk (“Wegs”) – deep venous thrombosis – Wonder drug – drug fever – Winnebagos (or upside down “W”) – Mastitis

Postop fever

• Recommendations for Evaluation of Fever

Within 72 Hours of Surgery

O'Grady NP, Barie PS, Bartlett JG et al., American College of Critical Care Medicine, Infectious Diseases Society of America. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of

• America. Crit Care Med 2008 Apr;36(4):1330-49.

Postop fever

• Recommendations for Evaluation of Fever

Within 72 Hours of Surgery

– CXR, UA, UCx not mandatory if fever is only indication – UA, UCx in febrile patients w/ indwelling catheter > 72 hrs – High level of suspicion for VTE in at-risk patients – Open & culture incisions w/ signs of infection

Care of Surgical Wound

• Sterile dressing 24-48 hrs
• Minor surgical wounds can be allowed to get

wet in the first 48 hours without increasing risk of infection

• Extremity wounds may be covered with a clear

film dressing (reduced rate of blistering, exudates)

Case: 23 yo man with swelling, redness, pain, pus from thigh

I & D of Skin Abscesses

• Antibiotics after I & D?

– I & D alone is usually sufficient for uncomplicated abscesses – Indications: Large abscess > 10 cm, cellulitis, immunocompromised, multiple or recurrent abscesses, extremes of age, failure of I&D alone

Singer HJ, Thode Jr. HC. Systemic antibiotics after incision and drainage of simple abscesses: A meta-analysis. Emerg Med J 2014;31:576-578.

I & D of Skin Abscesses

• Slight benefit using trimethoprim-

sulfamethoxazole after I&D of uncomplicated abscesses

– Increases cure rate by 7% (NNT = 14) – Already high cure rates in control group 80-85%

Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016;374:823- 832

Time Out

OTHER SURGICAL SPECIALTIES: TRAUMA SURGERY

VASCULAR SURGERY THORACIC SURGERY OTOLARYNGOLOGY/HEAD AND NECK SURGERY UROLOGY NEUROSURGERY

TRAUMA SURGERY

Primary Survey: ABCDE

• Airway
• Breathing
• Circulation
• Disability
• Exposure/Environment

Secondary Survey

• Vital Signs
• Repeat Primary Survey
• Review patient’s history
• Physical exam: “Fingers or tubes

in every orifice”

Shock Classification

Signs of Basilar Skull Fracture

• Periorbital ecchymosis (raccoon eyes)
• Mastoid ecchymosis (Battle’s sign)
• Hemotympanum

Raccoon Eyes (Periorbital Ecchymoses)

Clearing C-spines: NEXUS Criteria

When a significant mechanism of injury is present, a cervical spine is stable if:

• No posterior midline cervical tenderness
• No evidence of intoxication
• Patient is alert and oriented to person, place,

time, and event

• No focal neurological deficit
• No painful distracting injuries (e.g., long bone

fracture)

Clearing C-spines: Canadian C-Spine Rule

• Only applies to GCS=15 and stable trauma
• Not applicable for:

– GCS<15 – Non-trauma – Hemodynamically unstable – Age <16 – Acute paralysis – Previous spinal disease or surgery

Clearing C-spines: Canadian C-Spine Rule

X-ray if ANY of the following High Risk factors:

• Age >65 years
• Dangerous mechanism

– fall from elevation ≥ 3 feet / 5 stairs – axial load to head, e.g. diving – MVC high speed (>100km/hr), rollover, ejection – motorized recreational vehicles – bicycle struck or collision

• Parasthesia in extremities

Clearing C-spines: Canadian C-Spine Rule

If ANY Low-Risk factor present, assess clinically with ROM testing (If all NO: x-ray)

• Simple rear-end MVC which DOES NOT include the

following

– pushed into oncoming traffic – hit by bus / large truck – rollover – hit by high speed vehicle

• Sitting position in ED
• Ambulatory at anytime
• Delayed onset of neck pain
• Absence of midline C-spine tenderness

Clearing C-spines: Canadian C-Spine Rule

• (If at least 1 low-risk factor present) Able to

actively rotate neck 45 degrees left and right?

– If able then NO x-ray needed – If unable, X-ray.

Clearing C-spines: Which is Better?

• Sensitivity: Canadian 99.4% vs. NEXUS 90.7%
• Specificity: Canadian 45.1% vs. NEXUS 36.8%

Stiell IG, Clement CM, McKnight RD et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003; 349:2510-2518

C-Spine Films: Lateral

Monfils L. File:C1-C2 Lat.JPG [Wikimedia Commons Web site]. March 13, 2011. Available at: http://commons.wikimedia.org/wiki/File:C1-C2_Lat.JPG.

C-Spine Films: Odontoid

Monfils L. File:C1-C2 AP.JPG [Wikimedia Commons Web site]. March 13, 2011. Available at: http://commons.wikimedia.org/wiki/File:C1-C2_AP.JPG.

C-Spine Films: Flexion & Extension

Lamiot F. File:Cervical XRayFlexionExtension.jpg [Wikimedia Commons Web site]. November 10,

• 2010. Available at: http://commons.wikimedia.org/wiki/File:Cervical_XRayFlexionExtension.jpg.

VASCULAR SURGERY

Peripheral Vascular Disease

Peripheral Vascular Disease

• Intermittent claudication (many may not

have classic symptoms)

• Late symptoms: rest pain, ulcers, gangrene
• Risk Factors = CAD, esp. smoking
• Diagnosis: ABI, PE – pulses, bruits, hair loss

(watering the plants), poor nail growth, dependent rubor, ulcers

Peripheral Vascular Disease

• Treatment: modify risk factors, exercise,

meds (ASA, clopidogrel, cilostazol)

• Ticagrelor no better than clopidogrel

Hiatt WR, Fowkes FG, Heizer G, et al. Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease. N Engl J Med. 2017 Jan 5;376(1):32- 40.

Peripheral Vascular Disease

• Surgery: not enough evidence to favor

bypass surgery over angioplasty

Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002000. DOI: 10.1002/14651858.CD002000.pub2.

Medical vs. Surgical Management: Asymptomatic Carotid Artery Stenosis

• No evidence clearly favoring:

–Carotid endarterectomy vs. carotid artery stenting –Surgery vs. medical management

• Low rates of ipsilateral stroke in patients

managed medically

– 1.68% all studies, 1.18% newer studies

Raman G, Moorthy D, Hadar N, et al. Management Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158:676-685.

THORACIC SURGERY

Aortic Aneurysm

Ruptured Aortic Aneurysm

Heilman J. File:CTRupturedTA.PNG [Wikimedia Commons Web site]. January 19, 2011. Available at: http://commons.wikimedia.org/wiki/File:CTRupturedTA.PNG.

USPSTF Recommendation for Ultrasound Screening for AAA

• One time screening in men aged 65-75 who

have ever smoked (B recommendation)

• No recommendation for or against screening

in men aged 65-75 who have never smoked (C recommendation)

• Recommends against routine screening in

women (D recommendation)

Coronary Artery Disease

Häggström M. File:Coronary arteries.png [Wikimedia Commons Web site]. January 19, 2011. Available at: http://commons.wikimedia.org/wiki/File:Coronary_arteries.png .

Indications for CABG

• Disease in left main, or all 3 coronary vessels

(L Cx, LAD, RAD)

• Diffuse disease not amenable to PCI
• Severe CHF, diabetes

Valvular Surgery: Stenotic vs. Regurgitant Lesions

• Stenotic:

– can be monitored until symptoms appear

• Regurgitant:

– may require surgery even if asymptomatic – carefully monitor LV function by echo

Aortic Stenosis: Bicuspid Aortic Valve

Lynch PJ. File:Heart_bicuspid_aortic_valve.svg[Wikimedia Commons Web site]. December 23,

• 2006. Available at: http://commons.wikimedia.org/wiki/File:Heart_bicuspid_aortic_valve.svg.

Aortic Stenosis

• Classical presentation: asymptomatic, then

angina, exertional syncope, dyspnea

• After symptoms develop

– Average survival 2-3 years – 75% die w/in 3 yrs w/out valve replacement

Aortic Stenosis: Workup

• Echocardiogram

–mild/moderate AS – q2-5 yrs –severe AS – annual (to check LV function)

• Critical stenosis: Valve area < 0.8 cm2 or

gradient > 50 mm Hg

• CXR, EKG
• CT (thoracic – ascending aortic aneurysm)
• NO stress testing

Transcatheter vs. Surgical Aortic Valve Replacement

• Clear mortality benefit in high-risk pts w/ severe

aortic stenosis (NNT = 20 to avoid 1 death at 1 year)

• Similar benefit in intermediate-risk patients at 2

years

Popma JJ, Adams DH, Reardon MJ et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014 May 20;63(19):1972-81. Adams DH, Popma JJ, Reardon MJ et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis. N Engl J Med 2014;370:1790-8. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2016 Apr 28;374(17):1609-20.

Mitral Stenosis

• Symptoms mimic CHF
• Atrial fibrillation, pregnancy bring out

symptoms

Mitral Stenosis: Treatment

• Mild disease: diuretics
• Atrial fibrillation: rate control
• Surgery: > mild symptoms, or pulmonary

hypertension

– Balloon valvotomy, open commisurotomy, MV reconstruction, MV replacement

Aortic Regurgitation

• Causes: endocarditis, rheumatic fever,

collagen vascular disease, aortic dissection, syphilis

• Typical presentation:

Initially asymptomatic, then subtle initial signs (decreased functional capacity or fatigue), then sx of L-sided heart failure

Aortic Regurgitation: Treatment

• AV replacement even in asymptomatic

patients

– before EF < 55 % or end systolic dimension reaches 55 mm

• Severe AR + normal LV function:

– afterload reduction w/ vasodilators, especially nifedipine, can delay surgery

Mitral Regurgitation

• Causes: infectious endocarditis, mitral valve

prolapse, rheumatic fever

• Surgery:

– if > mild sx – If asymptomatic but EF < 60%, or end-systolic dimension approaches 45 mm – Usually MV repair preferred over replacement

What about Mitral Valve Prolapse?

• Typical symptoms: chest pain, dyspnea,

anxiety, palpitations

• Treatment: reassurance – no need for surgery

OTOLARYNGOLOGY HEAD AND NECK SURGERY

Otitis Media with Effusion

Descouens D. File:Tympan-normal.jpg. [Wikimedia Commons Web site]. November 3, 2009. Available at: http://commons.wikimedia.org/wiki/File:Tympan-normal.jpg.

• welleschik. File:Trommelfell_Paukenerguss.jpg. [Wikimedia Commons Web site]. November 3,
• 2009. Available at: http://commons.wikimedia.org/wiki/File:Trommelfell_Paukenerguss.jpg.

Otitis Media with Effusion

• Candidates for surgery

– persistent hearing loss or other signs and symptoms – recurrent or persistent OME in at-risk children regardless

• f hearing status

– structural damage to the tympanic membrane or middle ear

• Shared decision-making re: surgery
• Tympanostomy tube insertion is the preferred initial

procedure (+/- adenoidectomy in children ≥ 4 yo)

Rosenfeld RM, Shin JJ, Schwartz SR et al. Clinical Practice Guideline: Otitis Media with Effusion Executive Summary (Update). Otolaryngology–Head and Neck Surgery 2016:154(2):201–214

Indications for Functional Endoscopic Sinus Surgery (FESS)

• Failed medical therapy for chronic

rhinosinusitis

• Nasal polyps

Luong A, Marple BF. Sinus surgery: indications and techniques. Clin Rev Allergy Immunol. 2006 Jun;30(3):217-22.

Epistaxis

• Pressure
• Silver nitrate cauterization (only 1 side of nasal

septum at a time)

• Packing

– Anterior: F/U w/ ENT w/in 2-3 days, avoid ASA & NSAIDs but can continue warfarin – Posterior: Admit

Management of Acute Epistaxis. Author: Ola Bamimore, MD; Chief Editor: Steven C Dronen, MD, FAAEM http://emedicine.medscape.com/article/764719-

• verview#showall. Accessed February 24, 2017.

For which of the following patients with recurrent pharyngitis/tonsillitis is tonsillectomy indicated?

• A. History of peritonsillar abscess
• B. 2 episodes in each of the last 3 years
• C. 4 episodes in each of the last 2 years
• D. 7 episodes in the past year
• E. Allergies to or intolerance of multiple

antibiotics

H i s t

• r

y

• f

p e r i t

• n

s i l l a r a . . . 2 e p i s

• d

e s i n e a c h

• f

t h e . . . 4 e p i s

• d

e s i n e a c h

• f

t h e . . . 7 e p i s

• d

e s i n t h e p a s t y e a r A l l e r g i e s t

• r

i n t

• l

e r a n c . . .

6% 0% 13% 56% 24%

Tonsillectomy in Recurrent Pharyngitis/Tonsillitis: Paradise Criteria

• At least 7 episodes in past year, or 5/yr x 2yrs, or 3/yr x 3 yrs

– Each episode: sore throat + one of the following:

T>38.3, cervical adenopathy, tonsillar exudate, Group A beta hemolytic strep test +

• Episodes of strep throat properly treated with antibiotics
• Each episode documented OR subsequent observance by the

clinician of 2 episodes

• Modifying factors

– allergies to or intolerance of multiple antibiotics, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), history of peritonsillar abscess

Ref: Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310:674-683.

Peritonsillar Abscess

Heilman J. File:PeritonsillarAbsess.png [Wikimedia Commons Web site]. May 13, 2011. Available at: http://en.wikipedia.org/wiki/File:PeritonsilarAbsess.jpg.

UROLOGY

Urinary Retention

• Hellerhoff. File:Harnverhalt.jpg [Wikimedia Commons Web site]. January 8, 2010. Available at:

http://commons.wikimedia.org/wiki/Harnverhalt.jpg.

Urinary Retention: Treatment with Catheterization

• Look out for: hematuria, hypotension, postobstructive

diuresis

• How long to leave in?

– Unknown in pts with known or suspected BPH – Alpha blocker at time of catheter insertion x 3 d. can increase chance of returning to normal voiding

• Urinary retention from BPH: at least one trial of voiding

without catheter before considering surgical intervention

• Long-term treatment with 5-alpha reductase inhibitors can

prevent acute urinary retention in men with BPH

Kidney and Ureter Stones: Indications for Surgery

• No passage after reasonable period of time
• Constant pain
• Hydronephrosis
• Damaging kidney tissue
• Constant bleeding
• Ongoing urinary tract infection
• Too large to pass on its own or stuck
• Growing larger

Ref: National Kidney & Urologic Diseases Information Clearinghouses. Kidney Stones in Adults. http://kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/

Kidney and Ureter Stones:Treatment

• Extracorporeal shock

wave lithotripsy (ESWL)

• Percutaneous

nephrolithotomy

• Large stone
• Location does not

allow effective use of ESWL

• Ureteroscopic Stone

Removal

Case: 53 year old man with gross hematuria

Renal Cell Carcinoma: Risk Factors

• Men
• African Americans
• Exposure to household & industrial chemicals
• Hypertension
• Family history of RCC
• Occupational exposure to cadmium
• Dialysis patients w/ acquired cystic disease of the

kidney (30x)

• Hysterectomy (2x)

Higgins JC, Fitzgerald JM. Evaluation of Incidental Renal and Adrenal Masses. Am Fam Physician. 2001 Jan 15;63(2):288-295.

Renal Cell Carcinoma: Diagnosis

• Classic triad in 10-15%: hematuria, flank pain,

abdominal mass

• Often diagnosed incidentally at asymptomatic

stage

• Imaging

– Sensitivities: CT 94%, ultrasound 79% – MRI better than CT at distinguishing benign lesions

Renal Cell Carcinoma

• Treatment

– Nephrectomy – Doesn’t respond well to XRT or chemo

Incidental Adrenal Mass

• Depends on size

– Refer >6 cm for surgery (high incidence of cancer)

Incidental Adrenal Mass

–>3 cm < 6 cm:

• MRI, additional endocrine eval

–<3 cm:

• Look for Cushing’s syndrome,

pheochromocytoma, hyperaldosteronism (HTN, low K, high Na)

• No signs/symptoms and labs normal:

radiographic surveillance at 3 mos, then q6mo x 2 yr

• Anything abnormal: refer

Bladder Carcinoma

• Demographics: older Caucasian male smokers

– > 60 years old (80%) – men 3x > women – Caucasians > African Americans – mortality higher in African Americans because of delayed diagnosis

Ref: Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder Cancer. Am Fam Physician. 2009 Oct 1; 80(7):717-723

Bladder Carcinoma

• Risk factors:

– smoking 4-7x > nonsmokers – Occupational exposure (aromatic amines – chemical dyes and pharmaceuticals; gas treatment plants)

– Schistosoma haematobium – Radiation treatment to pelvis – Cytoxan – Arsenic in well water – Chronic infection

Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder

• Cancer. Am Fam Physician. 2009 Oct 1; 80(7):717-723

Bladder Carcinoma: Presentation

• Painless hematuria
• “Irritative” symptoms (dysuria, frequency)
• Urinary obstructive symptoms
• Symptoms of advanced disease

– lower extremity edema, renal failure, suprapubic palpable mass

Bladder Carcinoma: Diagnostics

• Urine cytology

– 66-79% sensitive, 95-100% specific

• Cystoscopy, bladder wash cytology
• Evaluate upper urinary tract – CT preferred
• Metastatic workup

– CBC, chemistries (alkaline phosphatase, LFT’s), CXR, CT or MRI, Bone scan if alkaline phosphatase is elevated or other symptoms suggest bone metastases

Bladder Carcinoma

• Treatment:

–Non-muscle invasive: transurethral resection +/- intravesical chemotherapy (mitomycin) or immunotherapy (intravesical BCG) –Muscle-invasive: radical cystectomy +/- chemotherapy –Metastatic: chemotherapy

NEUROSURGERY

Case: 30 year old man with progressive sciatica

Herniated Disc

• Edave. File:L4-l5-disc-herniation.png [Wikimedia Commons Web site]. April 3, 2009. Available at:

http://commons.wikimedia.org/wiki/File:L4-l5-disc-herniation.png.

When do patients need surgery for low back pain?

• Severe or progressive neurologic deficits
• Serious underlying conditions are suspected
• Persistent low back pain and signs or symptoms of

radiculopathy or spinal stenosis

– Only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy)

• MRI (preferred) or CT

Chou R, Qaseem A, Snow V et al, Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007 Oct 2;147(7):478-91

Herniated Disc

Which patients need neuroimaging (noncontrast head CT) for headaches?

• Emergent:

– headache and new abnormal neurologic findings (e.g., focal deficit, altered mental status, altered cognitive function) – new sudden-onset severe headache (thunderclap) – HIV-positive patients with a new type of headache (consider)

• Urgent:

– Patients > 50 years old w/ new type of headache but normal neuro exam

Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management

• f adult patients presenting to the emergency department with acute headache. Ann

Emerg Med 2008 Oct;52(4):407-36.

Which patients need neuroimaging for headaches?

• Atypical headaches and change in headache

pattern (CT)

• Unexplained focal neurological findings and

recurrent headache (MRI)

• Unusual precipitants

– Exertion, cough, Valsalva (MRI) – Standing (MRI w/ gadolinium) – Lying down (CT, MRI)

• Late onset (> age 50), no other red flags (CT)

Toward Optimized Practice. Guideline for Primary Care Management of Headache in Adults. Edmonton (AB): Toward Optimized Practice, 2012 Jul. 71 pp.

Which patients need lumbar puncture for headaches?

• Sudden-onset, severe headache + negative

noncontrast head CT (rule out subarachnoid hemorrhage)

• Who needs neuroimaging before LP?

Adult patients with headache and signs of increased intracranial pressure

– papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation

Can this patient w/ HA go home?

• Patients with a sudden-onset, severe

headache who have

– negative findings on a head CT – normal opening pressure – negative CSF findings

do not need emergent angiography can be discharged from the ED with follow-up

When do you order head CT in patient with mild traumatic brain injury (TBI)?

• headache
• vomiting
• age greater than 60 years
• drug or alcohol

intoxication

• short-term memory

deficits

• physical evidence of

trauma above the clavicle

• posttraumatic seizure
• Glasgow Coma Scale

(GCS) score less than 15

• focal neurologic deficit
• coagulopathy

With loss of consciousness or posttraumatic amnesia

• nly if one or more of the following is present:

Jagoda AS, Bazarian JJ, Bruns JJ Jr et al, American College of Emergency Physicians, Centers for Disease Control and Prevention. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008 Dec;52(6):714-48.

When do you order head CT in patient with mild traumatic brain injury (TBI)?

• age 65+ yrs
• GCS < 15
• focal neurologic deficit
• vomiting
• severe headache
• physical signs of a basilar

skull fracture

• coagulopathy
• dangerous mechanism of

injury – ejection from a motor vehicle – a pedestrian struck – fall from a height of more than 3 feet or 5 stairs

Consider in patients with no loss of consciousness or posttraumatic amnesia if there is

Can this patient w/ mild TBI go home?

• Isolated mild TBI + negative head CT

– May be safely discharged from the ED – However, inadequate data to include patients

• with a bleeding disorder
• receiving anticoagulation therapy or antiplatelet

therapy; or

• had previous neurosurgical procedure
• Inform about postconcussive symptoms

Phew!

• Questions?
• Ronald.Labuguen@ucsf.edu