Thingsyouneedtoknowinsurgicaldept

(iv) Assessdegreeofdehydrationbasedon

1. FluidandElectrolytes
(i) Contentineachpintofsolution
Sol.
NS
HS
D5%
D10%
HM
3%Sal

Content
NaCl9g(0.9%)
NaCl4.5g(0.45%)
Dextrose50g/L
Dextrose100g/L
NaCl+KCl+CaCl2
+Nalactate
NaCl30g(3%)

Na
150
77

131

Ca

Cl
150
77

111

HCO3

29

513

513

(ii) Dehydration

Adult
Paeds*

Mild
5%
<3%

Moderate
7.5%
39%

Severe
10%
>9%

Mentalstatus
Eyesunkeneye/cryingwithtears
Breathing
Mucosa/tongue
Skinturgor
Pulsevolume
PR/BP
CRT
Peripherywarm/cold
Urineoutput*goodUO=0.51cc/kg/h

(v) Narequirement
Totalrequirement=Maintenance+Deficit
Maintenance=23mmol/kg/d
Deficit(inmmol)=(140x)Wt0.6
*toconverttog,dividewith23.3

*accordingtoAcuteDiarrhoeaProtocol2011

(iii) Fluidrequirement
Total=Maintenance+Deficit+Ongoinglosses
Maintenance=40cc/kg/day
ForPaeds:(useHollidaySegarFormula)
st
4cc/kg/hfor1 10kg
2cc/kg/hfornext10kg
1cc/kg/hforsubsequentkg

Deficit=10%Bodywt
*replaceover12hrs

Ongoinglosses=lossesfromRTAspiration,
Drainage,thirdspaceloss,plasmalossetc
*usuallyreplacepershiftwithHM/NS

InallheadinjurypatientgiveonlyNS
InburnpatientParklandcorrectionbyHM
InpaedspatientusuallyuseNSD5%
GKS2012/9r

(vi) Krequirement
Totalrequirement=Maintenance+Deficit
Maintenance=0.51mmol/kg/d
Deficit(inmmol)=(4x)Wt0.4
*toconverttog,dividewith13.3
RulesofKcorrection:
Rateshouldnot>1.5gperhour
Concentrationshouldnot>3gin1L(1.5gin500ml)

IfhypoKuseMistKCl15mlTDS
Ifseverehypoload1gKClin100ccNSover1hr
Or2gKClin200ccNSover2hr
*makesuretakeECG/putoncardiacmonitoringduring
loadingANDrepeatRPpostloading2hrs
IfhyperKuseoralKalimate15gTDS
Ifseverehyperinsulinchase
IVCaGluconate10%10ccover25minthen
IVDextrose50%50ccthen
IVActrapid10unit
Page 1

ECGchanges
HypoK
FlatTwave
NarrowQRS
STdepression
Uwave

(vii)

HyperK
SmallP
TalltentedTwave
WidenQRScomplex
Ventriculartachy/fibrillation

Hyperglycaemia

DKA
HHS/HONK
Absoluteinsulindeficiency
Relativeinsulindeficiency
Dx:
Dx:
pH<7.3
Serumosmolarity>320
Dxt>14
Dxt>33
BloodKetone>2(geta

ketonestick)
*Osm=2(Na+K)+Glu+Urea
Principleofmanagement:
1. Fluidresuscitation2largeboreIVcannula(green
18Gorgrey16G)in2antecubitalfossa1for
maintenance,1forbolus
2. Insulintherapy(nottostartfirstifKlessthan3.3),
targetDxtinDKA811,HHS1416thendoseof
insulin,ifhypodonotstopinsulin,insteadtouse
D10%drip
3. CorrectionofelectrolytesBUSE&VBG4hrly,
makesuregoodurineoutputandnoECGevidence
ofhyperKwhenplanningtoloadK
4. Treatunderlyingcauses(sepsis,MIetc)

*IndicationofHCO3ifHCO3<10,give100meq(10amp)

*ifresolvedandpatienttoleratingorallytochangetobasal
bolusregime0.50.8u/kg/dandtitratewithoverlapping1
2hrswithIVIslidingscale

(viii)
Elective
Minor
OHAgive
normalregime

Insulinomit
ondayof
surgery

DXTQID

PreparingDMpatientforelectiveand
emergencysurgery
Major
OHAomit
longacting
(glibenclamide)

DXTQID
*IfRBS>15,to
startinsulin
slidingscale

Emergency
TreatDKA

PostponesurgeryuntilRBS<20
unlesslifethreatening

Aim711mmol/Lduringsurgery
GiveD5%orDS+20mmolKCl
8hrly+IVIinsulinslidingscale

Together in Delivering Excellence (T.I.D.E.)

2. AcidBasebalance&Oxygentherapy
(i) ABGinterpretation

(iv) Oxygendissociationcurve

3. Painmanagement
(i) Effectofpain

Norms
pH7.357.45
pO280100mmHg
pCO23545mmHg
HCO32226
*ToconvertmmHgtokPadivide7.5

(ii) WHOpainmedicationladder
Painscore03
Mild
TPCM1gQID

(ii) IfpH>7.45
pCO2 <35
RespiratoryAlkalosis
Hyperventilation
stroke
SAH
meningitis
anxiety
hyperthermia
PE
salicylatespoisoning

HCO3>26
MetabolicAlkalosis
profusevomiting
hypoK
burn

(iii) IfpH<7.35
pCO2>45
Respiratory
Acidosis
Respiratory
failure

LeftsideofcurvepHTDPG(2,3dephosphoglycerate)
RightsideofcurvepHTDPG(2,3dephosphoglycerate)
p50pointwheresaturationofHbreaches50%(atpO2=26.6)
ICUpoint(PaO2,SaO2)=(60mmHg,91%)=lowestacceptable
paO2inICUpatientbecausefurtherdropbeyondthispoint
leadtodrasticdropinSaO2
MixedvenouspointatSaO2=75%

HCO3<22
MetabolicAcidosis
NAGMAHAGMA
Increaseinorganic
RTA
acidproduction
Diarrhoea
lactoacidosisshock,
Addisonds
sepsis,hypoxia
Pancreaticfistula
uricacid
NH4ingestion
Drugacetazolaminde ketoneDM,alcohol
drugmetformin,
metanol

(v) Indicationforintubation
Todeliverpositivepressureventilation
Airwayprotectionfromaspiration
Duringsurgicalproceduresinvolvingneckand
headinnonsupineposition
Neuromuscularparesis
Proceduresincreasesintracranialpressure
Profounddisturbancenconsciousness
Severepulmonaryandmultisystemicinjury

*aniongap=[Na+K][Cl+HCO3]

GKS2012/9r

Hypoventilation
Secretionretention
Mentalunrest

Page 2

46
Moderate
TPCM1gQID
+
CapTramadol
50mgQID

710
Severe
S/CMorphine5
10mg4hrly

TPCM/Cap
Tramadol
**UncontrolledtorefertoAPSforPCAorepiduraletc

Otheroptions:
TArcoxia(Etoricoxibe)90/120mgOD
TPonstan(Mefenemicacid)500mgTDS
IV/IMVoltaren(DiclofenacNa)75mgTDS
*forheadinjuryTPCMandTArcoxia
*forribinjurys/cmorphine

4. Operativecare
(i) Preoperativecare
Clinicalassessment,investigationandpreparation
Getinformedconsent
Hxtakingprevioussurgery,choiceofanaesthesia,
complicationofpreviousoperation
Underlyingcomorbid,smoking,alcoholic,
heart/respi/kidneydiseases
Currentmedicationtowithholdaspirin/warfarin
Physicalexaminationshortneck(difficultintubate),
obese,CVSRespistatus
Vitalsigns,sugarcontrol,bodyweight/height
FBC/Coag/RP/LFT/RBS/CXR/ECG
Correctionofcoagulationdisorder,electrolyte
imbalance,sugarlevel,bloodpressure
Prophylacticantibiotics
Anaestheticteampreopassessment

Together in Delivering Excellence (T.I.D.E.)

Choiceofprophylacticantibiotics
Operation
Preferredantibiotics
IVCefuroxime1.5g+
Laporopencholecystectomy
IVMetronidazole500mg
ERCP
Herniarepairwithmesh
IVCefuroxime1.5g
Laparoscopicrepair
Breastsurgery

PreferredantibioticinourdeptIVCefobid(Cefoperazone)
2g+Flagyl(Metronidazole)500mg

(ii) Postoperativecare(complications)
PODfever
1
Wind

>38.5C
Atelectasis

UTI/Pneumonia

Water

Walk

DVT

Wound

Woundinfection,
abscess

10

Wonder

Drugs

Prevention
Incentivespirometry,chest
physiotherapy,ambulate
EarlyoffCBD,propuppatient,
sitpatientonchair,hand
washingonhandling,RT
insert,oral/trachytoileting
Encourageambulation,S/C
Clexane0.4mgOD,TED
stocking
Preopshowerandskinprep,
continueantibioticspostop,
dressingofwound

Preopbowelprep(Fleet/Foltran)toprevent
intraoperativecontaminationbyfaecalmasses
OPSIpreventionpenicillin(age<21),vaccinationpost
splenectomy(Haemophilusinfluenzab,meningococcal*,
pneumococcal)*pthavetoselfpurchase
Onceevidenceofbowelmovement(bowelsounds,
flatus/BO)encourageorallyASAPtoprevent
Refeedingsyndrome
Identifyrisk:malignancy,anorexia,alcoholism,GI
surgery,starvation
Closemonitoringduringperiodofrefeedingwith
involvementofnutritionist
Parenteralphosphateadministration18mmol/din
additiontooralsupplement

GKS2012/9r

5. PrimaryandSecondarySurvey
(i) PrimarysurveyABCresuscitation
Airway

Ifpatientgag/talk/coughairwaypatent

Cervicalcollarforallheadinjury

Sxofairwayobstruction:stridor,hoarsenessofvoice

LookforFBinthethroat

Performsuctionandcheckgagreflex

Ifgag,nasopharyngeal(notforbasalskull
fracture)/oropharyngealtubeorintubation
Breathing

Lookforchestexpansionsymmetry?
Pneumo/haemothorax?

Flailchestparadoxicalbreathing

RecheckETT,CXR

Tensionpneumothorax

Thoracocentesisifpneumothoraxchesttube
insertion

Oxygentherapy
Circulation

Listentoheartlookformuffledheartsound

Correcthypotension

Intraabdominalinjury

Abnormalbruits

CardiacBP/PRmonitoring

Beckstriad(muffledHS,JVP,hypotension)
Disability*

GCSassessment
1315mildheadinjury
812moderateheadinjury
<8severeheadinjury

Neurologicalassessmentcranialnerve,power,tone,
reflexes,sensation

Longbonefracturestenderness,crepitus

Pupilreflexes

ConsciousnessAlert,Verbalise,Pain,Unresponsive

Cervicalspineinjury

CTBrain/CervicalspineICB,pneumocranium,spine
disarticulation,fractures
Exposure*

Otherinjuries

Abrasion/lacerationwounds

Checkperineumbloodinurethralmeatus

Logrollstepdeformities,analtone,DPRexamination,
spinedeformities

Chestspring/pelvicspring
Page 3

LifethreateninginTrauma
Trachea

Chest
expan
sion

Breathing

Tension
pneumo
thorax

Deviate
away

Flailchest

Central

parado
xical

lung
contusion

Open
pneumo
thorax

Central

3sidedflap+
chesttube
PEEP

Cardiac
tamponade

Central

Heart
cannot
expand

Pericardio
centesis

BPlow
venou
sreturn
IVC
Pain
scareto
breath

Mx
Thoraco
centesisthen
chesttube
Analgesiaand
oxygen

ShorthistoryAMPLE
AllergyMedicationPMHxLastmeal
Eventsurroundinginjury

Afterprimarysurvey

Monitorcardiac,SPO2,BP,Urineoutput
LabGXM,ABG,toxicologyscreening,urine
analysis,UPT,otherbaselineIx
Adequateresusbasedonbloodgasandu/o
RadiographicIxCXR,PXR,FAST

GCSScore

6
5

Eye

Verbal

Orientated

Spontaneous

Confuse

Tocall

2
1

Topain
Close

Inappropriatebut
comprehensible
Incomprehensible
Mute

Motor
Obey
Localisepain
Withdraw
pain
Flexion
Extension
Nomovement

FASTscan(FocalAbdominalSonographyforTrauma)
6areasoffocalscan:

Morisonpouch(betweenliverandRtkidney)

SpacebetweenspleenandLtkidney

Leftparacolicspace

Rightparacolicspace

PouchofDouglas/Rectovesicalpouch

Pericardialcavity
Together in Delivering Excellence (T.I.D.E.)

Safetytriangleforchesttubeinsertion

Anteriorborderof
mlatissimusdorsi
(anterioraxillary
line)

Lateralborderof
mpectoralismajor

th

46 rib

(ii) Secondarysurvey(*)
=headandtoecompleteexaminationafter
primarysurvey

Signofbasalskullfracture

Periorbitalhaematoma(racooneyes)

Mastoidhaematoma(battlesign)

Haematympanum

CSFrhinorrhoea

CSFotorrhoea

6. Managementofdrowsyandunconscious
patient
(i) Causes
1.

Bilateralcorticaldiseases/processes
a. Traumaheadinjury
b. HypoxiaHIE,sinusthrombosis,CVA
c. Infectioncerebralabscess,meningitis,
encephalitis
d. HaemorrhageSAH,SDH
e. MetabolicDKA,HHS,hypoorhyperNa/K,
hypoglycaemia
f. Organfailureliverorrenal
g. Postictal
h. Endocrinethyroidstorm,myxoedema,Addison
crisis
i. Drugsopiates,alcohol,opioid,alcohol,cocaine,
benzodiazepine,antidepressant
2. Brainstemdisorder~Supratentoral/infratentoral
lesionsSDH,EDH,ICB

(ii) Diagnosisandmanagement
GKS2012/9r

PriorityshouldbegiventoABCresuscitationandperform
examinationsimultaneously,then:
1. Obtainquickhistoryfromwitness
a. Onsetabrupt/gradual
i. Acute(sec/min)CVA,cardiacarrest,SDH,
headinjury
ii. Subacute(minhrs)sepsis,infections,drug,
hypo
iii. Protracted
b. Recentcomplaintsheadache,depress,weakness,
vertigo
c. Recentinjury
d. Previousmedicalillness
2. Examination
a. VitalsT,PR,BP,RR
b. Skinpetechialrashes,ecchymosis
(meningoencephalitis)
c. Neurologicalassessment
i. Posture
Lackofmovementofoneside
Intermittenttwitching
Multifocalmyoclonus
Decortication
decerebration
ii. Levelofconsciousness
iii. Neckrigidity
iv. PupilsizesHornerSyndrome(ptosis,myosis,
anhydrosisandenophthalmus),atropine
overdose,opioidpoisoning,ICBetc
v. Funduscopy
vi. Brainstemreflexpupilreflexes
vii. Cornealreflex
viii. Dollseyereflex(eyemovetooppositesideof
movementsoitalwaysgoestocentre)if
negativebrainsteminjured
d. Racooneyes~basalskull#
e. Otorrhoea/rhinorrhoea
f. Nails,dxtmarks
g. Breathing
i. CheyneStrokerapid,shallowwithperiodic
apnoeicepisodesheartfailure,strokes,
traumaticbraininjuries,tumours,COpoisoning,
morphine,toxicmetabolicencephalopathy
ii. Kussmauldeeplabouredbreathing(usuallymet
acidosis)e.g.DKA,renalfailure
iii. Biotbreathingclusterpattern~pontine
malfunction
iv. Gaspingseverehypoxia

Page 4

3.

4.

5.

6.

Ix
FBC
Urinetoxicology
RBS
ABG/VBG/Lactate
ESR/CRP
KIVLP
LFT/RP
Serumtoxicology
BloodC+S
CTBrain
ECG/CXR
SkullXrayetc.
ImmediateMx
MaintainIVline,O2therapy
BloodsampleforRBS
Controlseizures
ConsiderIVglucose,thiamine,naloxone,flumazenil
FurtherMx
DependingontheHxandexaminationfindings,TFT,
carboxyHblevels,BFMPandplasmaosmolarity
(increasedinmethanol,ethyleneglycolandisopropyl
alcohol)mayberequired.
DefinitiveMxdependsonthecause.
However,whilethepatientisundergoingevaluation,it
isessentialto:
pressureareacare
careofthemouth,eyesandskin
physiotherapytoprotectmusclesandjoints
risksofdeepveinthrombosis
risksofstressulcerationofthestomach
nutritionandfluidbalance
urinarycatheterization
monitoringoftheCVS
infectioncontrol
maintenanceofadequateoxygenation,withthe
assistanceofartificialventilationifnecessary

Algorithm
ABCoflifesupport

OxygenandI.Vaccess

Stabilizecervicalspine

Bloodglucose

Controlseizures

ConsiderI.Vglucose,thiamine,naloxone,flumazenil

Briefexaminationandobtainhistory

Investigate

Reassessthesituationandplanfurther
Together in Delivering Excellence (T.I.D.E.)

7. Approachtopatientinshock
(i) Differencebetweenseptic,spinaland
hypovolaemicshock

Skin
JVP
Cardiac
output
Systemic
vascular
resistance
Mixed
venous
O2
content
Inotropes
Mx

Septic
EarlyLate
Warm
Cool
Pink
Pale

Spinal

Hypovolaemic

Warm
Pink

Cool
Pale

Dopamine
IVAbx

Dopamine
Methypred
*unrespons
ivetofluid
resus

Noradrenaline
Fluid
resus/blood
transfusion

Hypovolaemicshock("Tennis"staging)
I
<15%
750ml

II
1530%
750ml1.5litre

III
3040%
1.52litres

IV
>40%
>2litres

(ii) Conceptof:
a. Thirdspaceloss
Fluidaccumulationininterstitial
tissue/lumenofparalyticbowels
egpostGITsurgery,pancreatitis
(acuteparapancreaticfluid
collection)
Tendstomobilisebackto
intravascularspaceinPOD3
Bewareoffluidoverloadsign

GKS2012/9r

GIT/GUT/Respiprocedurewithout
spillage
Woundopenfordrainage
c. Contaminated
SpillagefromGIT/Biliary/GUT
d. Dirtyinfected
Traumaticwoundfromdirtysource
Woundembeddedwithforeignbody
Indicatedforwounddebridementto
removenecrotictissues

b. Plasmaloss
Occurafter1st12hrspostburn
injury
Slowlydecreaseatthe2nd12hrs
Plasmalosscausesoedemaof
tissueinvolved
c. Acutebloodloss
d. Spinalshock
Lossofsensationaccompaniedby
motorparalysiswithinitialloss
andgradualrecoveryofreflexes
followingspinalcordinjury
Phase1(01day)
arreflexia/hyporeflexia,lossof
descendingfacilitation
Phase2(12day)initialreflex
retain,denervation,
supersensitivity
Phase3(14wks)hyperreflexia,
axonsupportedsynapsegrowth
Phase4(112mths)
hyperreflexia,spasticity,soma
supportedsynapsegrowth

8. Managementofwound
(i) Typesofwoundsbydegreeof
contamination
Clean
Nontraumaticwithoutinflammation
e.g.vascular,endocrine,eye
procedure,withoutinvolving
respiratory,GIT/GUT
b. Cleancontaminated
Highpotentialforinfection

(ii) Woundclosure
a.

Primarywoundclosure
woundclosedimmediatelyafterop
b. Secondarywoundclosure
woundleftopenandletithealed
overtime
c. Delayedprimaryclosureorsecondary
suturing
Duetoinfected/contaminatedwound,
unabletocloseatthetimeafterop
done
Doneafterwoundisclean

(iii) Stagesofwoundhealing
a. Early(D1)haemostasisand
inflammatorystage
b. Intermediate(D2D3)proliferative
withmigrationofmesenchymal
tissues,angiogenesisand
epithelisation
c. Late(D45)woundcontractionand
scarring(D21)

a.

Page 5

Together in Delivering Excellence (T.I.D.E.)

9. Burnresuscitation
(i) Pathophysiologyofburn

Zoneofcoagulation:irreversibletissueloss(necrosis)
Zoneofstasis:reducedtissueperfusion,potentially
salvageabletissue(lossoftissueinthiszonecanlead
towounddeepeningandwidening)
Zoneofhyperaemia:increasedtissueperfusion,
mostlikelyrecovertissueunlessuntreatedsevere
sepsisandprolongedhypotension

Systemicresponsedevelopedoncetheburn
reaches30%ofTBSA,asaresultofcytokinesand
otherinflammatorymediators

CVS
(i)
increasedcapillarypermeabilityleadsto
lossofintravascularproteinandfluidinto
interstitialcompartment
(ii)
peripheralandorganvasoconstriction
causedbyTNFmyocardialcontractility
systemichypotensionandorgan
hypoperfusion

RespibronchoconstrictionALI

MetabolicBMR3,catabolism

Immunedownregulating

GKS2012/9r

AccordingtoLundandBrowder

(ii) Burnclassification
Accordingtodepth(degree)
Isuperficialepidermis:onlyerythema,noblister,healin34
days
IIAsuperficialpartialthicknessinvolvedpapillarydermis:
redwarm,oedematous,blistered,sensoryintact,healless
than2weeks
IIBdeeppartialthicknessinvolvedreticulardermis:damage
dermalappendages,sweatgland,nerves,hairfollicles,heal
atleast3weeks
IIIfullthicknessburninvolvedalllayersofskinandsome
subcutaneoustissueinitiallypainlessinsensatedrysurface
thatappearwhitecrackwithexposedunderlyingfat
IVfullthicknesswithinvolvementoffascia,muscles,and
bones

Accordingtothesurfacearea:
Smallarearulesofpalm(1%patientspalmSA)
Largearearulesofnine

(iii) Fluidresuscitation
IVfluidinexcessofmaintenanceisgiventoallpatientwith
burn>20%bodysurfaceareausingParklandformulafor
reducingtheoccurrenceofburninducedshock

Choiceofsolution=Ringerlactate/HM(crystalloid)

ParklandFormula=4BWBSA%.
*Firsthalftobegiveninfirst8hrsafterinjury
*Secondhalftobegiveninnext16hrsafterinjury
st
*Colloidshouldnotbeusedin1 24hrspostburnbecauseit
mayleadtoseverepulmonarycomplication(ARDS)dueto
excessivecapillaryleakage

Page 6

Together in Delivering Excellence (T.I.D.E.)

10. Bloodandbloodproduct
(i) ABOandRhesusgroup
a. UniversaldonorforFBCOnegative
b. UniversaldonorforFFPAB

1unitPCexpectedtoincrease24%
Haematocrite

Hb3=Hct

(ii) Typeofcrossmatching

GSH(GroupScreenHold)
Patientsbloodtypeisdetermined,
bloodisscreenedforantibody
Typeandcrossfromthesamplecan
beorderedifneededlater

GXM(Groupcrossmatch)
Patientsbloodsenttobloodbankand
crossmatchforspecificdonorunitfor
possiblebloodtransfusion

(iii) Typeofbloodproductandindication
Packedcell1unit=350450cc
Indicatedatacutebloodloss
Hb<10forpatientwithh/oCAD/COPD
HealthysymptomaticpatientwithHb<8
1unitPCexpectedtoincrease11.5gofHb

Plateletindicatedif<20
1unitshouldincrease>20
Plateletcountbeforesurgeryhavetobe>50

GKS2012/9r

FFPtoreplaceclottingfactor
Incaseofwarfarinoverdose,DIVC,liverdisease,
TTP

Cryoprecipitatetoreplacefibrinogen,vWF,and
otherclottingfactors

HAS4.5%or20%
Temporarilyforpatientwith
hypoproteinaemia(liverds/nephrotic)with
fluidoverload
Replaceinabdominaltapping

1DIVCregime=2platelet,4cryoprecipitate,6
FFP

(iv) Rateoftransfusion
1pintpackedcellusuallytransfusedover4hrs
withIVfrusemide30mginbetweentransfusion

(v) Transfusioncomplication
Early
(Within24hrs)

Acutehaemolyticreaction
Anaphylaxis
Bacterialcontamination
Febrilereaction
Allergicreaction
Fluidoverload
Transfusionrelatedacutelung
injury

Peritonismmotionless,oftenwithkneeflex

(ii) Indicationofsurgicalreferral

Infection(Hep
B/C/HIV/protozoa
/prion)
Ironoverload
Posttransfusion
purpura

Acutesevereabdominalpainthatcausespatienttoseekfor
medicalattention

Ruptureoforgan
Peritonitis
Colic
Obstructionofboweletc

(iii) Management

Late
(>24hrs)

11. Acuteabdomen
(i) Definition

Page 7

Peritonealsign

Tendernessonpalpation

Percussiontenderness

Voluntaryguearding

Involuntaryguarding

Rigidity

Reboundtenderness

Inspectionsurgicalscar,distention
Palpationtenderness,hernia,motiontenderness,CVAP
(costovertebralanglepain)
Auscultationbowelsoundsandbruises
Percussionliverandspleensize

ABCresuscitation
Treatshock
Antibiotic
IVfluidresuscitation
Analgesics
KeepNBM
BloodIx:FBC,RP,LFT,CRP,Amylase,ABG,
UFEME,BloodC+S
US/CTtolookforfreefluid
AXR/ECG
Consent

(iv) Painrelief
NonopioidPCM,ibuprofen,diclofenac,aspirin
(musculoskeletalpain,renal,biliarycolic)
Contraindication:pepticulcer,floatingdisorder

OpioidMorphine,dimorphine,pethidine,tramadol
Contraindication:notusedintraumaticheadinjuryorhepatic
failure
Together in Delivering Excellence (T.I.D.E.)