Burn and Storm

I presented a case of two guys in a enclosed room found unconsious, sprawling in a pool of ...... paint thinner. Both of them were painting the bathroom, enjoying each other companion while inhaling the fume from the thinner. Presented to emergency department, GCS regained full. One of them sustained 6% deep partial thickness (2nd degree burn) and the other one 3% deep partial thickness burn.

Imp : chemical burn

Q - "Give me example of chemical burn?" - Prof Razman

A - "acid, alkaline, solvent i.e. organic or non organic" - myself

Q - "elaborate on acid and alkaline burn, which is more severe?" - Prof Razman

A - "alkaline burn is more severe than acid burn.... because it 'eats' up the body fat layers i.e. saphonication and makes the wound deeper.......... (can't remember what I mumble further)" - myself

Zamry presented a case of a lady with a known case of grave's disease presented with signs and symptoms of thyroid storm. Surgical was called because pt complain of abdominal pain which was clinically soft.

Q - "Pt with thyroid storm, which antithyroid do you give and why?" - Prof Jasmi

A - "in thyroid storm most of the conversion to T3, is peripheral conversion so PTU acts there" - Dr. Johann

* - "Pt presented with pyrexia in thyroid storm should be given paracetamol rather than aspirin which will make it worse" - Mr. Azim

Zairul

Surgical Family Day 2008

Photobucket Album

Appendicectomy gone rotten

Sadhana presented a case of an open appendicectomy 3 years ago presented with chronic pus discharge from the wound. Colonoscope done normal, no sign of colitis or no connection seen.

Q - "Cause of non-healing fistula?" - Prof. Ismail

A - "Why over three years this thing has not healed, either it is not being treated well or the collection is not being drained properly or there is  a chronic pathology that produce the chronic inflammation, those are the question you need to ask yourself as a surgeon" - Prof. Ismail

"Nowadays doing fistulogram does not add any information or won't change your management. Most of the time you will get that the track is not well defined, the dye/contrast go into don't know what.. so the best investigation if the contrast CT-Scan. Contrast Ct-Scan can outline if there is other collection, it can tell you if there is connection to the bowel also outlined the mucosa of the small bowel" - Prof Ismail

Q - "What are the features from Ct-contrast to suggest Crohn's?" - Prof. Ismail

A - "multiple strictures, some more?????... I know Crohn's is rare here" - Prof. Ismail

"Not so rare in Aberdeen.... ha Ngoo your're from Aberdeen..." - Prof. Hanafiah

Q - "What are the complication of Crohn's" - Prof. Hanafiah

A - "internal fistulation, small lumen" - Dr. Ngoo

Q - "Has foreign body been ruled out" - Mr. Imtiaz

Q - "What is the management for this patient" - Prof. Ismail

A - "After the Ct-Scan, exploration of the wound" - Dr. Sadhana

A - "Ya, you have to go in, debride and see the bowel if there is fistula you may need to resect the bowel and anastomosis, but there is a probability of right hemicolectomy. Also beware of the right ureter and deodenum" - Prof. Ismail

Q - "What will be the complication at the deodenum" - Prof. Ismail

A - "Bleeding from the paradeodenul veins" - Dr. Wahab

zairul

It has been a while

No sword during exams week....

Shankar presented a case of pseudoaneurysm at superficial femoral artery secondary to catherizatian/cannulation. Incident happened 6 days ago and claim expanding.

Q - "What is pseudoaneurysm?" - Mr. Hanafiah

"Commonest pseudoaneurysm if non micotic is due to iatrogenic, most common referral from cardiology unit" - Mr. Hanafiah

Q - "Why is it expanding / why doesn't the hole close?" - Mr Hanafiah

A - "it could be either the hole is big or blood to thin i.e. on aspirin / warfarin" - Mr. Hanafiah

Q - "If fail compression, what do you do?" - Mr. Hanafiah

A - "Injection of thrombin, but have to look at the size of the neck, if its>5mm it will be dangerous, afraid injected into blood vessels"

Q - "Can you ligate the external illiac artery?" - Prof. Razman

A - "If it done too early (ligation) there will be no collaterals formation which can lead to ischemia" - Chris

Q - "How to get proximal control?" - Prof Razman

Q - "If this is a micotic aneurysm??" - Mr. Hanafiah

A - "bypass extraanatomical - away from the infection" - Mr Hanafiah

Q - "How many percent if we ligate external illiac for micotic aneurysm in a drug addict will get amputation?" - Mr. Azim

A - "In a HKL series it is about 10%" - Mr. Azim

zairul

Burn day!!!

admitted second degree  50% burn over upper torso and face, electively intubated.

Q - "What is second degree burn?" - Mr. Hanafiah

Q - "What is parkland formula?" - Mr. Hanafiah

A - "Parkland formula is used to guide initial fluid resuscitation during the first 24 hours. The formula calls for 4 ml/kg/TBSA burn (second and third degree) of lactated Ringer's solution over the fast 24 hours. Half of the fluid should be administered over the first eight hours post burn, and the remaining half should be administered over the next 16 hours. The volume of fluid given is based on the time elapsed since the burn."

Q - "Why is it 4ml in parkland formula?" - Mr. Hanafiah

Q - "Does burn pt needs transfusion?" - Mr. Hanafiah

Q - "Does burn causes blood loss?" - Mr. Hanafiah

Q - "Tell us about inhalation burn?, how do you pick it up?" - Mr. Hanafiah

A - "Soot, carbogenous odor, coated black tongue" - Reg (can't recall who)

"Stridor comes late" - Mr. Hanafiah

Q - "Why is carbomonoxide dangerous?" - Mr. Hanafiah

Q - "How to treat carbomonoxide?" - Mr. Hanafiah

Q - "50% burn what is the prognosis?" - Mr. Azim

A - "80% Mortality [50% + age (30)]" - Mr. Azim

"infection is a big problem in burns!" - Mr. Hanafiah

zairul

SWORD

Ngoo had a busy night, just came back from Termeloh posting in full throttle. He presented a case of a man with worsening chronic left medial maleolus ulcer. ABSI right leg was 0.62 and left leg 0.7.

Q - "Why do you think its venous ulcer?" - Mr Hanafiah
A - "the location of the ulcer is at the medial aspect where the long saphenous runs...." - Ngoo

Q - "How do you treat venous ulcer?" - Mr Hanafiah
A - "Dressing, graduated compression stocking...." - Ngoo

Q - "Why is it call graduated compression stocking?" - Prof Razman

Q - "Does ABSI matter before starting patient on compression stocking?" - Mr Hanafiah

Case 2:
74 year old bed bound after a stroke two days ago presented with obstructive jaundice. Per abdomen no mass palpable. CT scan showed mass at head of pancreas with necrotic centre.

Q - "How does pancreatic mets to the brain look like?" - Prof Ismail

everybody looked puzzled and turn their faces away from Prof.

A - "I also don't know the answer, I just know how to throw question only" - Prof Ismail....... ha.....ha.......ha

Q - "Why do CT scan?" - Prof Ismail
A - "The answer for a surgeon is to know resectability" - Prof Ismail

Q - "What are the resectability criteria in pancreatic head of tumour?" - Mr Hanafiah
A - "encasement of portal veins, liver metastasis, size does not matter for head of pancreas......" - Ngoo

"If there is present of only one liver mets, it won't change the management. i.e. palliative stenting" - Prof Razman

Q - "Which stent is better for palliative case?" - Mr Azim

SWORD (Surgical Ward Round Discussion)

Goh presented a man, which came in with hoarseness of voice and difficulty in breathing on exercition. Thyroid gland is enlarged. Clinically enlarge thyroid with a fix 3x3cm cervical LN and dull on percussion over the sternum. He is also pale with an HB 7.9

Q - "How often thyroid CA cause anemia" - Prof Naqiyah
"Incidence of bleeding in retrosternal qoitre is higher" - Prof Jasmi

Q - "What other investigation do you need to do for retrosternal goiter" - Prof Naqiyah
A - "CT-Scan, to look for its extension"

Q - "When to operate this patient?" - Prof Ismail

Case 2:
75 year old man presented with RIF pain and guarding

Q - "How common is right sided diverticulitis" - Mr Hanafiah
A - "Local study shows that 1600 pt from the beginning of HUKM, incidence of diverticulitis is 6.2% and right sided diverticulitis is 30%. Majority is still sigmoid colon" - Prof Ismail

Q - "Is the pathology the same with left sided diverticulitis" - Mr Hanafiah
A - "True diverticulum on the right side, which causes more problem" - Prof Ismail

SWORD goes international

Today SWORD was a bit different. There were Mongolian surgeons which attended the meeting.

Case 1:
Goh presented a 70 years old man post stapler heamorroidectomy day 4 presented with PR bleed. Hemodynamically stable, Hb 14.5. Brought to OT, EUA showed oozing at anastomotic site - figure of 8 suturing was done and bleeding stopped.

Q - "For pt with post stapler bleed, how to tackle or how far to examine in the ward or should bring them to OT instead?" - Prof Jasmi
A- "I don't have an answer how far to examine but I can assure you it is difficult to see it in the ward, better to bring to OT" - Prof Ismail

Q - "How about temponade dressing" - Prof Jasmi
A - "You can temponade it, but if active bleed it won't stop, most of the time bring to OT for suturing" -Prof Ismail

Q - "Empirical antibiotics?" - Mr Azim
A - "Flagyl" - Prof Ismail

Q - "If still bleeding?" - Mr Hanafiah
A - "Refer vascular!" - Prof Jasmi....... everybody laugh.. except surgeons from Mongolia
A - "More than 90% will stop, but if its still bleed I would packed and suture it (packed dressing)" - Prof Ismail


Case 2:
Fuad presented a man underwent lap chole 4/12 ago, presented again with obstructive jaundice signs and symptoms. US showed stone in mid portion of CBD.

Q - "Is it missed stone or primary stone?" - Prof Jasmi

Q - "How long after lap chole if develop stone define as primary stone?" - Prof Jasmi
A - "before 2 years missed stones, after 2 years primary stone" - Prof Jasmi

Q - "Difference in management?" - Prof Ismail
A - "if primary stone one has to consider chances of developing recurrent stone and also have to consider intrahepatic stone" - Prof Jasmi

Case 3:
Spontaneous DVT, no pelvic or abdominal mass. Medical refuse to take over, as usual surgical team save the day.

Q - "If pt DVT comes to A&E who will take?"
A - "DVT is a no mans land. Predict the cause of DVT, if spontaneous it goes to medical, if fracture goes to ortho" - Prof Ismail

zairul

SWORD

1. A case of undiagnosed AAA before which presented to A&E after an alleged MVA. Brought in GCS 13/15 hypotensive. US abd showed a leaking infrarenal AAA. Also sustained 5th rib fracture with no underlying hemo/pneumothorax. Operated on him, and aneurysm was repaired. Total of 12 pint of blood and 3 DIVC regime was given .Currently in ICU. New development respiratorty system not good, suggestive of transfusion related acute lung injury

Q - Define TRALI - Mr. Hanafiah
A - keyword to hear is non cardiogenic lung injury + the other criterias

Q - Why DIVC regime was ordered for this man? - Prof. Ismail

Q - Complication of massive blood transfusion? - Mr. Hanafiah

Mr. Lukman asked Mr. Hanafiah if this type of case was seen in other centre without vascular surgeon what will we do?
A - pray..... clamped the aorta and call for help (vascular surgeon) and pray

zairul

No SWORD

Too bad sword was canceled, UKM vice chancellor had to give a speech

Longest SWORD ever

A lot of cases being presented.... the juicy ones are..

Wahab presented:

1. an MVA case which sustained 4th rib # with pneumothorax. Clinically trachea was deviated, reduce air entry and resonant on percussion.
Unfortunately CXR was ordered and surgical team was referred before inserting a chest drain!

"Decision for CXR for a clinical suspicious pneumothorax is dangerous" - Prof Jasmi

"Take home msg, to put a chest tube first in a suspected pneumothorax.. it is not a mistake to put a chest tube" - Prof Jasmi


2. 36 year old Indian man complaining of abdominal pain, notice a mass in his abdomen for the past 5/12. There was also bilateral axillary LN which was matted and firm. The mass was supraumblical and mobile, hepatosplenomegaly present. Hb was 5.4........ A differential of lymphoma and TRO CA stomach was made

"if lymphoma the LN would be discrete and rubbery" - Prof Jasmi

"very unlikely CA stomach with present of axillary LN" - Prof Jasmi

Q - "how often gastric lymphoma present with axillary LN" - Prof Jasmi
A - everybody look away from Prof Jasmi....... looking for answers

"mysenteric LN in lymphoma is rare, there are usually paraaortic LN which are lobulated and fixed" - Prof Rohaizak

"LDH can carry prognosis of lymphoma" - Prof. Rohaizak

Wahab would like to transfuse PC in this pt but..

Q - "Hb of 5 in a asymptomatic chronic anemia why transfuse 2 pint PC, how much to bring up? how long to transfuse? when to transfuse?" - Prof. Jasmi

3. 17 year old Chinese Man presented with perianal abscess

Q - "what are the predisposing factors in a young man developing perianal abscess?" - Prof. Rohaizak

A - somebody answered homosexuality

Prof. Jasmi rebutted, "is it evidence base homosexuals are prone to develop perianal abscess,..... I am not trying to defend them" ha.....ha.....ha....ha..

Hasnul presented:

1. A 57 year old obese Chinese lady with late presentation of abdominal pain, amylase 51 TW 8.0, no free gas under diaphragm and clinically peritonitis. A differential dx of PGU was made and decision to operate. However a CT Abdomen was ordered

Q - "Why CT-Scan?" - Mr Lukman
A - "if CT shows severe pancreatitis, hold tight and not to go in" - Mr Hanafiah

"In obese pt, diagnostic laparoscopic would be ideal...less wound infection" - Prof Jasmi