During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to:
1- continue the hourly neurologic assessments.
2- inform the neurosurgeon of the patient's status.
3- prepare the patient for emergency surgery.
4- recheck the patient's neurologic status in 15 minutes.
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What is emergency surgery?
An emergency surgery is one in which the condition, illness or injuries that may have caused a trauma or accident, endanger the life or function of some important part of the body. This requires an immediate assessment, rapid diagnosis and prompt resolution, that is, to take the patient to the operating room quickly and efficiently in order to save his life.
What are the most frequent surgical emergencies?
On an abdominal level we have:
A. ACUTE ABDOMEN
Sudden onset abdominal pain, which can be caused by the following conditions:
1- Acute appendicitis: inflammation of the appendix that is an organ located at the beginning of the colon, in a portion called blind and that with the passing of the hours can cause its perforation and exit of the content into the cavity (peritonitis)
2- Acute cholecystitis: inflammation of the gallbladder usually due to the presence of a stone that obstructs the bile exit of this organ
3- Perforated gastroduodenal ulcer: ulcers are usually treated with medicines such as omeprazole or its derivatives, but sometimes they are very severe or have not been treated properly and are perforated causing an acute abdominal condition (chemical peritonitis due to gastric acid or intestinal fluids)
4- Colon perforation: by severe inflammatory processes that deteriorate the walls of the colon until perforated or by the presence of diverticula that are perforated within an acute condition
5- Intestinal obstruction due to flanges and adhesions: generally in patients who have had some previous intervention and who, as part of their evolution over time, formed flanges or adhesions that end up obstructing normal intestinal transit
6- Intestinal obstruction due to tumors or colon volvules: the growth of a tumor inside the colon can reach such large sizes that they end up obstructing the lumen and originate this picture. Likewise, an exaggeratedly large colon may at some time twist (volvulus), producing an obstruction that requires emergency treatment.
7- Gynecological pathology:
- Salpingitis: Infectious-inflammatory process of the ovarian tubes that causes pelvic abdominal pain due to the presence of pus in their lumen and that can flow into the cavity (pelviperitonitis)
- Ectopic pregnancy: it is a pregnancy whose embryo did not nest in the uterus but outside the uterus, in the ovarian tube or in the ovary, in a few weeks the sac that holds it is broken and bleeding into the cavity (hemoperitoneum) occurs, the same that can complicate the patient's life
- Complicated ovarian cyst: cysts are tumor formations that contain fluid, can be perforated (peritonitis) or twisted (ovarian torsion), causing acute conditions that require immediate attention
B. ABDOMINAL TRAUMATISMS
They can be caused by direct blows: car accidents, run-ins or quarrels; wounds with short-pointed weapons or firearms. They require an immediate assessment and probably a resolution within the operating room as soon as possible.
C. HERNIA DE HIATO COMPLICADA
With gastric volvulus: consequence of a hiatal hernia (open space in the diaphragm that is a muscle that separates the heart and lungs from the abdominal organs), the stomach can enter the stomach and also “twist” (volvulus), which causes a pain picture that requires immediate surgical resolution.
D. COMPLICATED INGUINAL HERNIA
These hernias are defects or weaknesses of the wall (abdominal muscles) through which real sacs that contain part of the organs of the abdomen, usually intestine, can protrude outward. When this sac no longer returns to its place and remains as a painful "mass or ball" in the groin it is called "incarcerated hernia", if with the passing of the hours it has not been resolved, the intestine that is contained in the Hernia sac may "gangrene" (rot) due to lack of blood circulation, which is called "strangulated hernia." Both states constitute a surgical emergency.
1- continue the hourly neurologic assessments.
2- inform the neurosurgeon of the patient's status.
3- prepare the patient for emergency surgery.
4- recheck the patient's neurologic status in 15 minutes.
----------------------------
What is emergency surgery?
An emergency surgery is one in which the condition, illness or injuries that may have caused a trauma or accident, endanger the life or function of some important part of the body. This requires an immediate assessment, rapid diagnosis and prompt resolution, that is, to take the patient to the operating room quickly and efficiently in order to save his life.
What are the most frequent surgical emergencies?
On an abdominal level we have:
A. ACUTE ABDOMEN
Sudden onset abdominal pain, which can be caused by the following conditions:
1- Acute appendicitis: inflammation of the appendix that is an organ located at the beginning of the colon, in a portion called blind and that with the passing of the hours can cause its perforation and exit of the content into the cavity (peritonitis)
2- Acute cholecystitis: inflammation of the gallbladder usually due to the presence of a stone that obstructs the bile exit of this organ
3- Perforated gastroduodenal ulcer: ulcers are usually treated with medicines such as omeprazole or its derivatives, but sometimes they are very severe or have not been treated properly and are perforated causing an acute abdominal condition (chemical peritonitis due to gastric acid or intestinal fluids)
4- Colon perforation: by severe inflammatory processes that deteriorate the walls of the colon until perforated or by the presence of diverticula that are perforated within an acute condition
5- Intestinal obstruction due to flanges and adhesions: generally in patients who have had some previous intervention and who, as part of their evolution over time, formed flanges or adhesions that end up obstructing normal intestinal transit
6- Intestinal obstruction due to tumors or colon volvules: the growth of a tumor inside the colon can reach such large sizes that they end up obstructing the lumen and originate this picture. Likewise, an exaggeratedly large colon may at some time twist (volvulus), producing an obstruction that requires emergency treatment.
7- Gynecological pathology:
- Salpingitis: Infectious-inflammatory process of the ovarian tubes that causes pelvic abdominal pain due to the presence of pus in their lumen and that can flow into the cavity (pelviperitonitis)
- Ectopic pregnancy: it is a pregnancy whose embryo did not nest in the uterus but outside the uterus, in the ovarian tube or in the ovary, in a few weeks the sac that holds it is broken and bleeding into the cavity (hemoperitoneum) occurs, the same that can complicate the patient's life
- Complicated ovarian cyst: cysts are tumor formations that contain fluid, can be perforated (peritonitis) or twisted (ovarian torsion), causing acute conditions that require immediate attention
B. ABDOMINAL TRAUMATISMS
They can be caused by direct blows: car accidents, run-ins or quarrels; wounds with short-pointed weapons or firearms. They require an immediate assessment and probably a resolution within the operating room as soon as possible.
C. HERNIA DE HIATO COMPLICADA
With gastric volvulus: consequence of a hiatal hernia (open space in the diaphragm that is a muscle that separates the heart and lungs from the abdominal organs), the stomach can enter the stomach and also “twist” (volvulus), which causes a pain picture that requires immediate surgical resolution.
D. COMPLICATED INGUINAL HERNIA
These hernias are defects or weaknesses of the wall (abdominal muscles) through which real sacs that contain part of the organs of the abdomen, usually intestine, can protrude outward. When this sac no longer returns to its place and remains as a painful "mass or ball" in the groin it is called "incarcerated hernia", if with the passing of the hours it has not been resolved, the intestine that is contained in the Hernia sac may "gangrene" (rot) due to lack of blood circulation, which is called "strangulated hernia." Both states constitute a surgical emergency.
What are the symptoms for an emergency?
They will depend on the picture that is presented, characteristically most of them have the initial symptom of pain, which becomes more acute and becomes more intense with the passing of the hours and is located at the site of the compromised organ. Sometimes it can be generalized throughout the abdomen.
The intestinal obstruction pictures are always accompanied by persistent vomiting that are gradually becoming similar in nature to the feces of diarrhea. Then there is the absence of elimination of gases and feces through the anus.
Fever, distention of the abdomen and poor general condition are also characteristic of emerging cases.
Generalized pallor, diffuse sweating and loss of consciousness are characteristic of traumatic conditions due to sharp wounds or firearms, as are ulcers or organs punctured with significant internal bleeding.
What diagnostic elements are used?
-The pictures are very acute and the clinical evaluation should be carried out quickly and efficiently, the clinical suspicion after the physical examination is very important to decide which diagnostic resource is the most appropriate and that occupies the shortest time possible to avoid deterioration or death of the patient:
- Abdominal ECO: in most cases, it can be done in the same emergency room and will mainly determine the presence of fluid inside the abdomen, which may be due to blood (hemoperitoneum) or intestinal fluids and pus (peritonitis)
- Tomography: not very useful in an acute condition that requires immediate resolution due to the time it takes to carry out the study
- Diagnostic laparoscopy: it must be done in the operating room under general anesthesia, it allows, through small incisions, to introduce a video camera and adequately and safely explore the entire abdominal cavity, at the same time it allows the surgeon to resolve and treat the same route patient suffering
- Complementary examinations: a blood count and renal or hepatic functional tests can help to see the patient's conditions, the samples can be taken at the same time that a vein is channeled for hydration or fluid replacement to the patient in an emergency room
How are emergencies resolved?
These emergencies described are of resolution by surgery. The best access route is laparoscopy, although sometimes, due to the serious conditions of an injured or traumatic patient it is necessary to do it by open route (exploratory laparotomy).
There are also cases in which having used the laparoscope to establish the diagnosis and a possible treatment, the conditions of the organs inside the abdomen, presence of adhesions or other factors, can determine a conversion of the laparoscopy to open procedure.
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