Which ONE of the flowing statements describes the CORRECT management of abdominal wound dehiscence?
Answer: A: Wound dehiscence usually presents 7–10 days after surgery. Both patient factors and surgical factors contribute to the occurrence of wound dehiscence. Some predisposing factors include: emergency surgery, malnutrition, diabetes, immune-compromised host, intraabdominal infection, raised intraabdominal pressure, obesity and poor wound closure technique.
Dehiscence of abdominal wounds if left untreated can progress to evisceration. Generally surgical exploration is necessary to establish the extent of the dehiscence.
References:
With respect to subarachnoid haemorrhage (SAH), which ONE of the following is FALSE?
Answer: C: Arteriovenous malformations are usually the cause in younger patients who present with SAH. In older patients SAH is usually secondary to a berry aneurysm.
Risk factors for SAH include: previous history of SAH, family history of SAH, hypertension, smoking, excessive alcohol intake, connective tissue disorders such as autosomal dominant polycystic kidneys, Marfan’s syndrome, Ehler-Danlos syndrome and α1 -antitrypsin deficiency. Increasing age is also a risk factor. The average age at presentation is between 40 and 60 years.
The most common presenting feature is headache classically described as a sudden onset, severe thunderclap headache. The headache can last up to 2 weeks. Other presenting symptoms include sudden death, transient loss or prolonged loss of consciousness, nausea, vomiting, neck stiffness, photophobia, seizures, focal neurological deficit including III or VI cranial nerve palsy. Intraocular haemorrhages occur in one in seven patients with ruptured aneurysms and are more likely to be observed in patients with a reduced level of consciousness. They are as a result of obstruction of the central retinal vein from sustained elevation in cerebrospinal fluid pressure.
ECG changes can occur that can mimic those of acute myocardial infarction. Other ECG changes that can occur in SAH include deep T wave inversion and QT prolongation.
In the investigation and management of SAH, which ONE of the following is TRUE?
Answer: D: Re-bleeding is a recognized complication and usually occurs in the 3–5 days following the initial bleed. Vasospasm occurs in approximately one-third of patients and is detected between days 4 and 14. Other complications of SAH are fever, hypertension, hypotension, hyperglycaemia, hyper or hyponatraemia, hypomagnesaemia, cardiac failure, arrhythmias, pulmonary oedema and pneumonia. Diabetes insipidus, syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH) and cerebral salt wasting can develop in patients with SAH. Hydrocephalus is also a recognized complication that occurs in one-third of patients; it develops over days to weeks. Seizures occur in <25% cases.
A non-contrast head CT is an ideal investigation if it is performed soon after the onset of headache. As time passes the blood in the subarachnoid space degrades therefore increasing the likelihood of a normal-appearing CT. A non-contrast head CT is more reliable at 12 hours than it is at 48 hours. At 12 hours only 2–3% of SAHs are not detected, the pick-up rate at 48 hours is 80–85%, at 1 week it is only 50%. By day 10 almost all of the subarachnoid blood has been reabsorbed.
Lumbar puncture should be carried out 12 hours after the event occurred. By 12 hours blood in the subarachnoid space will have started to break down and bilirubin will have been formed as a result – xanthochromia. Xanthochromia is not present in a traumatic lumbar puncture because this blood has not been exposed to and broken down by the CSF enzymes.
Nimodipine 60 mg 4-hourly should be administered orally for 7 days. It has been shown to decrease the incidence of vasospasm, prevent secondary ischaemia and reduce the mortality associated with SAH.
A 4-week-old baby girl presents to the ED with sudden and persistent bilious vomiting. She is lethargic and mottled.
What is the next MOST appropriate step in her management?
Answer: D: This patient most likely has malrotation with volvulus. It is a life-threatening condition. In this case there is a strong suspicion that the patient is in shock as she is lethargic and mottled. She requires immediate resuscitation and surgical attention.
Malrotation occurs in one in 500 births. The majority of presentations are in the first year of life. Three quarters present within the first month. It has a mortality rate of 3–15%.
During embryological development the gastrointestinal tract rotates around the superior mesenteric artery (SMA) and the duodenum and caecum lie a good distance apart but loosely connected by mesentery. Bands of tissue called Ladd’s bands fix them in position. When malrotation occurs, the distal duodenum and the caecum do not completely rotate and end up in close proximity to each other. This results in a short pedicle of mesentery that can rotate easily on itself causing obstruction of the bowel and compression of the SMA. This can lead to ischaemia and eventually necrosis of the bowel. Ladd’s bands are also in the incorrect position and can cross over causing various degrees of duodenal obstruction when twisting of the pedicle occurs.
A patient with malrotation will look unwell and often presents with features of shock. Bilious vomiting is a characteristic feature of malrotation with volvulus. Differentials to consider include:
In this case the patient has bilious vomiting, is lethargic and mottled, suggesting she is extremely unwell and likely shocked. Answers A and B are suitable for mild and moderate dehydration/gastroenteritis and is inappropriate for the management of this patient. Answer C is appropriate management for a patient with pyloric stenosis not malrotation of the bowel with volvulus.
Pyloric stenosis is associated with which ONE of the following?
Answer: A: Pyloric stenosis is caused by progressive thickening of the pyloric muscles and results in gastric outlet narrowing and obstruction. It most commonly presents in the first 6 weeks of life (between 3–6 weeks of age) and is uncommon after the age of 6 months. There is a higher incidence in:
An infant with pyloric stenosis typically has non-bilious projectile vomiting after feeds; occasionally it can be bloodstained. The infant is usually hungry afterwards; however, if the condition goes unrecognized the patient may become dehydrated and either lose weight or fail to gain weight. There is a decrease in bowel movements. About 1% of infants with pyloric stenosis have jaundice secondary to unconjugated (indirect) hyperbilirubinaemia. On examination the infant may be dehydrated and gastric peristalsis may be visible, particularly following a feed and on palpation a small mass may be felt in epigastrum to the right of midline about the size of an olive or cherry.
A blood gas may demonstrate hypokalaemic and hypochloraemic metabolic alkalosis. Abdominal ultrasound is the investigation of choice. The infant should be fluid resuscitated and electrolyte imbalances corrected, kept nil by mouth and a nasogastric tube inserted if vomiting persists. The patient should be referred to the a paediatric surgeon for further management.
Click to expand