Published and forthcoming titles in the Emergencies in . . . series:
Emergencies in Adult Nursing
Edited by Philip Downing
Emergencies in Anaesthesia, Third Edition
Edited by Keith Allman, Andrew McIndoe, and Iain H. Wilson
Emergencies in Children’s and Young People’s Nursing
Edited by E.A. Glasper, Gill McEwing, and Jim Richardson
Emergencies in Critical Care, Second Edition
Edited by Martin Beed, Richard Sherman, and Ravi Mahajan
Emergencies in Gastroenterology and Hepatology
Marcus Harbord and Daniel Marks
Emergencies in Obstetrics and Gynaecology, Second Edition
Edited by Stergios K. Doumouchtsis and S. Arulkumaran
Emergencies in Paediatrics and Neonatology, Second Edition
Edited by Stuart Crisp and Jo Rainbow
Emergencies in Palliative and Supportive Care
Edited by David Currow and Katherine Clark
Emergencies in Respiratory Medicine
Edited by Robert Parker, Catherine Thomas, and Lesley Bennett
Emergencies in Sports Medicine
Edited by Julian Redhead and Jonathan Gordon
Head, Neck, and Dental Emergencies, Second Edition
Edited by Mike Perry
Head, Neck, and Dental Emergencies
SECOND EDITION
Edit E d by
Mike Perry
Consultant Maxillofacial Surgeon Regional North West London Craniomaxillofacial Unit, Northwick Park and St Mary’s Major Trauma Service, Northwick Park Hospital, Harrow, Middlesex, UK
1
Great Clarendon Street, Oxford, OX 2 6DP, United Kingdom
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First Edition published in 2005
Second Edition published in 2018
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Preface
This second edition has been extensively revised to make its contents more practically useful for the user. The aim is to help the reader develop a targeted approach in their assessment and management of those ‘emergencies’ that occur in the anatomical regions above the collar bones. Such patients may attend an emergency department or general practice clinic, or they may present on the ward. Although this book is part of the ‘Emergencies in …’ series of books published by OUP, the strict application of the definition of an emergency to the head and neck (i.e. an immediately life- or sight-threatening condition) would result in just a handful of cases being listed and discussed. Therefore, a more broadly defined remit has been used, that is, to cover urgent and potentially worrying problems which may present to the non- specialist or novice.
How this book works
Generally speaking, patients do not present with a ready- made diagnosis, but rather with either a symptom located to an anatomical region (e.g. toothache, a lump/swelling, or a headache), or an obvious problem (such as a nose bleed or injury). This is the starting point in each of the anatomically based chapters (‘Common presentations’ and ‘Common problems and their causes’). For each symptom a variety of conditions may be the cause and these are listed. These conditions have also been categorized as common or uncommon, although it is accepted that individual clinicians, departments, and specialists will all have differing experiences of their frequency (depending on training and geographical location). We have tried to include the majority of conditions likely to be encountered in non- specialist practice, but clearly it is not possible (nor practical) to include the rare or obscure in view of the aims of this book.
Making a diagnosis
Diagnosis requires a history and examination. As undergraduate students, we are taught this must be all inclusive, with a full detailed history and full examination of the patient. However, the reality of any emergency department setting, busy practice, or assessment of an urgent problem is that a more limited, but targeted approach is required. By necessity the questions and examination are more focused. But at the same time these must not omit those key elements which are required to make an accurate diagnosis. In accordance with this, the next section in each chapter (‘Useful questions and what to look for’) lists relevant and important diagnostic cues, in relation to each presenting symptom. These questions should be regarded as an aide memoire and when appropriate can be tailored accordingly. Some overlap and repetition is inevitable. The aim of this section is therefore to equip the reader with the necessary knowledge to enable them to quickly and accurately triage and diagnose a problem.
The remainder of each chapter is self- evident with details on how to examine each anatomical site, useful investigations (in both the emergency department and outpatient setting), and some notes on the conditions themselves. Management is also covered, based on current evidence, but as guidelines continue to evolve this may change. Where available, local protocols should always be used (e.g. ‘clearing’ a cervical spine injury).
For the pedants among us, it is accepted that not every known condition is covered. It must also be remembered that some symptoms may be the result of systemic disease (e.g. bleeding gums, halitosis, and headaches), while other head and neck pathologies may present with symptoms outside this site (e.g. cervical rib, overactive thyroid, or secretory pituitary adenoma). Nevertheless, if this book is used as a practical guide, or a manual, we are confident the reader will find it a useful diagnostic aid. Undergraduates may also find it useful when preparing for clinical examinations.
Contributors to the second edition
Wing Chuen Chan
Consultant Ophthalmologist, Royal Victoria Hospital, Belfast, UK
Chapter 10
Ramesh Gurunathan
Consultant Head and Neck Surgeon, Darlington Memorial Hospital and James Cook University Hospital, Middlesbrough, UK
Chapters 5, 6, and 8
Peter Gordon
Registrar in Oral & Maxillofacial Surgery, Southern General Hospital, Glasgow, UK
Chapter 12
John Hanratty
Consultant Oral & Maxillofacial Surgeon, Ulster Hospital, Belfast, UK
Chapters 9 and 11
Gina Hooper
Trainee in Emergency Medicine, Northern Ireland Deanery, UK
Chapter 4
Nida T Ilahi
Medical Student, University of Glasgow, UK
Chapter 7
Vasuki Gnana Jothi
Consultant Ophthalmologist, Royal Victoria Hospital, Belfast, UK
Chapter 10
Kevin Maguire
Consultant in Emergency Medicine, Ulster Hospital, Dundonald, UK Chapter 4
Jonathan Poots
Specialty Registrar, Neurosurgery, Royal Victoria Hospital, Belfast, UK Chapter 3
Brian Purcell
Core Surgical Trainee, ENT, Royal Victoria Hospital, Belfast, UK Chapter 6
Anna E Raymond
Formerly General Dentist, TFI Dentistry, Thornlands, Queensland, Australia Chapter 13
Henry Neil Simms
Consultant Neurosurgeon, Training Programme Director, Neurosurgery, Royal Victoria Hospital, Belfast, UK
Chapter 3
Gavin Smith
Anaesthetics and ICM Trainee, Ulster Hospital, Dundonald, UK Reviewer
Christopher Vinall
Specialist Registrar, Oral & Maxillofacial Surgery, Peninsula Deanery, UK
Chapters 1, 2
Contributors to the first edition
Howard Brydon FRCS
Consultant Neurosurgeon, University Hospital of North Staffordshire, UK
Anne Dancey MRCS
Specialist Registrar in Plastic Surgery, West Midlands Rotation, UK
Nick Grew FRCS, FDS
Consultant Maxillofacial Surgeon, Wolverhampton, UK
Manoli Heliotis FRCS, FDS
Specialist Registrar in Maxillofacial Surgery, South Thames Rotation, UK
Ian Holland FRCS, FDS
Consultant Maxillofacial Surgeon, West of Scotland, UK
William Kisku FRCS
Staff Grade in Burns and Plastic Surgery, University Hospital of North Staffordshire, UK
Professor Nick Maffulli BSc, PhD, MBBS, MD, FRCS
Consultant Orthopaedic Surgeon, University Hospital of North Staffordshire, UK
Kamiar Mireskandari FRCOpth
Specialist Registrar in Ophthalmology, Moorefields Eye Hospital, London, UK
Jehanzeb Mughal FDS
Maxillofacial Unit, University Hospital of North Staffordshire, UK
Mike Perry FRCS, FDS, BSc
Consultant Maxillofacial Surgeon and Trauma Team Leader, University Hospital of North Staffordshire, UK
Mr Philip Roberts MBBS, FRCS
Specialist Registrar Orthopaedic and Trauma Surgery, University Hospital of North Staffordshire, UK
Mr Mike Shelly FRCS, FDS
Specialist Registrar in Maxillofacial Surgery, South Thames Rotation, UK
Richard T Walker RD, BDS, PhD, MSc, FDS RCS, FDS, RCPS
Formerly Centre Director, International Centre for Excellence in Dentistry, Eastman Dental Institute for Oral Health Sciences, University College London, UK
Lt Col. Mike Williams, FRCS, FDS
Specialist Registrar in Maxillofacial Surgery, South Thames Rotation, UK
Symbols and abbreviations
E cross- reference
AACG acute angle- closure glaucoma
ABG arterial blood gas
AC air conduction
ACE angiotensin- converting enzyme
APD afferent pupillary defect
ATLS ® Advanced Trauma Life Support ®
AVM arteriovenous malformation
BC bone conduction
BNBM nil by mouth
BP blood pressure
BPPV benign paroxysmal positional vertigo
BRONJ bisphosphonate- related osteonecrosis of the jaw
Taking a history and examining the patient in the emergency department 2
History of the presenting complaint 3
Other useful information 5
The significance of the past medical, social, and drug history in assessing emergencies and admissions 6
Rapid assessment of patients requiring emergency/urgent surgery 10
Getting patients ready for urgent surgery: medical considerations 11
The elderly patient: some specific problems 16
Examination of the head and neck: an overview 17
Taking a history and examining the patient in the emergency department
History taking is the first stage in diagnosis. Even though this can be an arduous task, being repeated every day, one must not lose sight of the fact that for the patient this may be a sensitive or private issue. He or she may be asked questions for which the answers may not be normally shared even with their close contacts (e.g. circumstances resulting in an injury, alcohol/recreational drug usage, and sexual contacts/HIV risk). Therefore be sensitive to this. Introduce yourself and any member of your team who is present. Take time and be clear in the introductions. Try not to interrupt patients when they are talking. Not everyone is able to express themselves clearly in a few words. Know how to contact interpreters if the patient is having problems in communicating or expressing themselves in English. Remain in control.
Setting and privacy
Make sure that you have enough space to be able to create a comfortable environment. For patients accompanied by a carer or member of their family, ask them to join you, as they might be able to provide additional information. However, only include them if the patient consents to this (unless of course the patient is of non- consenting age or deemed mentally unable to give consent).
Sometimes your patient may wish to talk in private. In such a situation, make sure that you take the necessary precautions to safeguard yourself; include a member of staff as a chaperon. If this is not possible, then leave the door or curtains of the consultation area partially open. Document everyone present in the notes.
Documentation and handwriting
This should be clear enough for all future use. Many ‘alleged assaults’ will result in criminal proceedings and you or your seniors may be called upon to write a report many months later. Be careful what you write. Stick to the facts and what the patient tells you. avoid speculation. Try to note as much detail as you can of what is told to you— this may avoid the patient having to repeat potentially embarrassing information to another colleague. It may help to highlight important information with a different coloured pen or a sticker, i.e. allergies, HIV, hepatitis C status, and sensitive topics (where the patient does not want others to know).
What is written in the notes is accepted as an accurate account of events, anything more is inadmissible unless a chaperon testifies to it. It is difficult to defend oneself in a court of law on the basis of memory and the law may favour the patient in this regard. Legible writing ensures that colleagues who continue the patient’s care can read what you have written.
Photography
p hotographs can be very helpful, but can be difficult to take in an emergency department. Make sure that the patient has consented in writing to
these if you can. a lternatively, get the consent in retrospect. Nowadays many hospitals are limiting the ability to take photographs so follow your local policies on this.
The presenting complaint
This is best recorded briefly and if possible in the patient’s own words. The most common complaint is pain and it is important to be able to differentiate its different origins. This can be difficult in the head and neck. patients may also present with a whole host of other problems that may or may not be associated with pain. There are of course many other clinical reasons why someone may seek urgent care and the following list gives an idea of the more common ones. These will be covered in more detail in the relevant sections. Some presenting complaints tend to be common in certain age groups, and this becomes more recognizable with experience. However, be warned not to prematurely make a diagnosis without completing the history and examination. It is tempting to do just that and you may miss a rare or unusual condition— these may still be seen in an emergency department.
Some reasons why patients go to an emergency department
Common
• pain
• Injuries
• Bleeding
• Trismus
• Lumps or swellings
• Rashes and ulcers
• Social- related problems.
Uncommon
• a ltered sensation or weakness
• Facial asymmetry
• Stiffness
• a bnormal function (e.g. vision, bite).
History of the presenting complaint
When asking about the presenting symptom, consider the following questions. These are of course just a starting point but will hopefully enable you to identify most problems. Questions can be tailored accordingly and this is discussed in the relevant chapters.
Useful key questions
Pain
• Site of pain— this must be documented with reference to trigger points and/or referred pain. Use a diagram.
• Description of pain— constant, intermittent, dull, aching, throbbing, sharp, burning, or shooting?
• periodicity— speed of onset, duration, frequency.
Principles of assessment
• Influences— does anything affect the pain, e.g. movement, heat, or cold?
• a ssociated symptoms— swelling, dysfunction, numbness or dysaesthesia, pain anywhere else?
• p revious therapies— has anything to date improved the pain?
Assaults/injuries
• Time and place
• Mechanism of injury
• a ny loss of consciousness?
• Where did the patient go afterwards (emergency department, home etc.), and how did they get to hospital (walk, ambulance, or other transport)?
• a ny other injuries apart from on the head/face?
• a re the police involved? Get consent to speak to them if they arrive later.
• a ny previous injuries (the broken nose may be old)?
Bleeding
• How long/often?
• Where from?
• Underlying cause?
• p redisposing history or medication?
• Symptoms of hypovolaemia/shock/anaemia?
Trismus (limitation of mouth opening due to muscle spasm)
• Duration?
• p rogression?
• Symptoms of underlying infection or possible tumour?
• Difficulty swallowing?
• Difficulty breathing?
Lumps or swellings
• How long?
• Is it growing?
• Related to mealtimes (salivary obstruction)?
• Is it painful (infected or rapid growth)?
• a ny obvious cause/lumps elsewhere?
Rashes and ulcers
• Dermatological history.
• a ssociated with vesicles/blisters?
• a ny ocular/genital/gastrointestinal (GI)/joint symptoms?
• Drug history.
Altered sensation or weakness
• Where (anatomical or diffuse)?
• a ny underlying cause?
• a ny associated swellings/ulcers (possible tumours)?
• a ny other neurological symptoms?
Facial asymmetry
• Localized or generalized?
• painful/painless?
• Is it static/progressive/speed of swelling?
Stiffness
• Which joint?
• a ny preceding cause?
• When is it most stiff (in the morning/evening)?
• Does movement improve the stiffness (‘rusty gate’)?
• a re other joints affected?
• Is there associated swelling or pain?
• a ny neurological symptoms (especially with neck stiffness)?
• a ny symptoms to suggest a connective tissue disease?
• a ny family history?
Abnormal bite
(See E Chapter 12.)
• When did it change?
• Is it painful?
Infections
• How long?
• a ny obvious cause (toothache/viral/injury etc.)?
• Is it getting worse?
• a ny signs of systemic upset?
• Has the patient been taking antibiotics?
Other useful information
Systems review
Document the patient’s general health. This is important in order to assess the fitness of the patient should surgery be required and to decide on the type of anaesthesia required. It may also modify treatment. There is no real indication to listen to the chest of a medically fit and healthy 18-year- old who complains of pain from a wisdom tooth.
Past medical history, medication, and allergies
a ny medication currently in use must be recorded, as well as allergies to medication and any other substances. This will help reduce the risks of a prescription error being made. a nticoagulants are of relevance following
trauma. Knowledge of chronic steroid use is important when dealing with infections. If there is an allergy, is it a true allergy? Or is it drug intole rance (e.g. diarrhoea with penicillin)?
Social history
Occupation, family situation, living conditions, smoking, alcohol consumption, employment, and hobbies. Do they require care? a sk ‘On a good day, what is the most active thing you could do?’.
Religious beliefs
a sk about these in certain circumstances. Jehovah’s witnesses, for instance, will not accept blood transfusions. This is a potential minefield medico- legally, especially in the unconscious patient (where relatives have been known to be wrong about the patient’s beliefs). Seek help in these cases, and preferably find out local protocols before the situation arises.
Remember the possibility of anatomical variations and age- related changes (especially when examining radiographs).
The significance of the past medical, social, and drug history in assessing emergencies and admissions
In all patients requiring admission, or an anaesthetic, a full medical, social, and drug history will eventually be taken. However, when dealing with an emergency this may not be possible in the early stages. This is seen in the management of the seriously injured patient, discussed in Chapter 2. In all sick patients it is essential to rapidly identify those factors which may have an immediate impact on either establishing the diagnosis or managing the clinical problem. These include the following:
Age
a lthough not a medical condition, the elderly have a decreased physiological reserve and need close monitoring. This is particularly the case following blood loss where prompt fluid replacement is necessary. Care is required not to overload their cardiovascular system. Elderly patients are often taking a variety of medications, each with the potential for problems from withholding, or from drug interactions. Children are also at risk of fluid overload and hyponatraemia. Fluids must be administered with caution (see http://learning.bmj.com/learning/home.html).
Pregnancy
a sk about this in all women of childbearing age. In trauma, the best treatment for the fetus is to treat the mother first. Get the obstetricians involved early. In other emergencies, pregnancy may influence the choice of local anaesthesia and medications. Certain drugs are potentially teratogenic, and affect fetal maturation (closure of ductus arteriosus) or the onset of delivery. If in doubt, refer to medication information sheets or
a drug reference book such as the British National Formulary. In reality, radiographs (and computed tomography (CT)) of the face carry very little risk to the fetus, but by and large, most units will restrict or minimize these to those regarded as essential.
Ischaemic heart disease
This increases the risks of general anaesthesia and local anaesthesia containing adrenaline (epinephrine). Cardiac pain can occasionally present as discomfort in the neck or mandible or as ‘toothache’. It should therefore be considered in the diagnosis. pain on exertion, relieved by rest or glyceryl trinitrate, is highly suggestive. Nicorandil, a vasodilator prescribed for angina, can cause major solitary ulceration of the oral cavity (and the anus and penis). These ulcers can be confused with malignancy. They typically resolve completely on cessation of the medication within a few weeks.
Hypertension
This increases the risks of general anaesthesia and local anaesthesia. Hypertensive ‘crises’ (where the blood pressure (B p) is extremely high) can present with headaches and drowsiness.
Rheumatic fever, artificial valves, and endocarditis
Not all abscesses need antibiotics if they are adequately drained (e.g. dental abscess, boils). However, patients with a history of rheumatic fever, prosthetic heart valves, or previous endocarditis are at risk from bacteraemia. In these cases it is important to liaise with the cardiologist and microbiologist. These patients may require a specific antibiotic that covers organisms that cause infective endocarditis (see ‘ p rophylaxis against infective endocarditis’, http://www.nice.org.uk/CG064).
Chronic obstructive pulmonary disease
Do not give oxygen over 28%. The exception to this rule is in the multiply injured patient with life-threatening injuries (see British Thoracic Society guidelines on emergency oxygen, https:// www.brit- thoracic.org.uk/ guidelines-and-quality-standards/emergency-oxygen-use-in-adult-patientsguideline).
patients with Chronic obstructive pulmonary disease (COpD) should receive targeted oxygen therapy with the aim of maintaining targeted oxygen saturations. Hypoxia can kill rapidly and is more of a threat than the slower development of hypercapnia. The use of oxygen in respiratory failure is therefore not contraindicated. The vital aspect is that therapy is adjusted after arterial blood gas (ABG) results are available. Current guidelines suggest these patients are given high priority and that they are not just put on oxygen and then walked away from.
Asthma
avoid aspirin and other non- steroidal anti- inflammatory drugs (NS a IDs) if possible. However, not all patients are sensitive to NS a IDs and they are not absolutely contraindicated— they just need to be used with care and the patient reassessed or warned about possible worsening of their asthma. a sthmatics may be taking inhaled steroids which predispose
Principles of assessment
to thrush etc. Rarely, they are taking oral steroids. Get an idea of their asthma control (previous intensive care unit (ICU) admissions, recurrent exacerbations, frequent courses of oral steroids, etc.).
Diabetes
Consider hypoglycaemia in all confused, drowsy, or aggressive headinjured (and non- head- injured) patients, even if they appear to be intoxicated. patients with diabetes are also at risk of infections, which can spread rapidly (notably dental). Occasionally a severe infection may be the presenting feature of diabetes. a ll patients with facial abscesses should be screened for this.
Hepatitis
Risks of cross infection. Check liver function tests (LFTs) and clotting.
Epilepsy
Fitting can occur after head injuries, especially in children. It also makes assessment difficult. Status epilepticus aggravates secondary brain injuries (as a result of fluctuations in B p and hypoxia). Intubation, ventilation, and transfer to ICU/intensive therapy unit (ITU) may be required.
Blood dyscrasias
Clotting disorders (haemophilia, platelet disorders, etc.) predispose to the same problems as anticoagulants. Leukaemic patients are also at risk of severe infections. Sickle cell disease requires care with general anaesthesia. It can present acutely with severe pain in the mandible.
Previous injuries
Old facial fractures (e.g. nose, zygoma, or mandible) may make it difficult to decide whether a new injury is a new fracture or just bruising. acute chest injuries preclude the use of Entonox ®, which is particularly helpful in reducing dislocations of the mandibular condyle.
Tetanus status
This is relevant to all lacerations, bites, abrasions, and other penetrating wounds. Wounds can be classified as tetanus prone or non- tetanus prone and depending on the patient’s immunization status, a booster, course, or immunoglobulin may be required (see http://www.hpa.org. uk/ Topics/InfectiousDiseases/Infections a Z/ Tetanus/Guidelines).
Drug interactions
Commonly prescribed drugs in the emergency department include opiates, antibiotics, NSa IDs, and sedatives. Each has the potential to interact with commonly prescribed medication that the patient may already be taking. Remember herbal medicines as well (e.g. St John’s wort)— they can also interact.
Anticoagulants (e.g. warfarin and aspirin)
Reduced clotting may have an impact following trauma in several ways. Head injuries are at an increased risk of intracranial bleeding and may require admission for observation. Similarly, retrobulbar haemorrhage, and bleeding into easily distensible tissues (floor of mouth, upper airway,
and eye), are more likely to occur following trauma to these sites. panfacial injuries may even require airway protection. Some authorities recommend avoidance of nerve blocks. Bleeding into large body cavities (chest, abdomen, pelvis) around fractures (limbs, retroperitoneum) and externally can rapidly result in haemorrhagic shock. Check clotting and if necessary reverse the anticoagulant. Discuss with haematology.
More recently, new oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban) have become available. These also carry risks of haemorrhage but with these drugs there is no specific reversal agent available (see http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/ CON322347 ).
Steroids/bisphosphonates
patients on long-term steroids may require extra steroid cover during infection, trauma, or other periods of stress to prevent adrenal insufficiency. Usually a doubling of their normal dose or conversion to intravenous (IV) is sufficient to ensure reliable administration. Never abruptly stop long-term steroids. The British National Formulary has a handy section on this including dose reduction in chronic use. Chronic steroid use also predisposes the patient to the risks of infection, poor wound healing, osteoporosis, and a diabetic potential, each with their own attendant problems. Bisphosphonates may have been prescribed to reduce osteoporosis in the elderly and in patients with metastatic bone disease. These can affect bone healing in the mandible following fracture or dental extractions.
Alcohol intake
acute alcohol intoxication can result in agitation and unconsciousness, with loss of protective airway reflexes and vomiting. In the head- injured patient, this always makes assessment difficult. Never assume that the drowsy state is simply due to too much ‘booze’. Chronic alcoholics are often malnourished and self- neglected and at an increased risk of infection. If it is anticipated that the patient will not be able to drink alcohol for some time, get help in setting up an appropriate withdrawal protocol. They should be given high- potency vitamins B and C, such as pabrinex ® , and require close observation for withdrawal symptoms (see http:// publications.nice.org.uk/alcohol- use- disorders- diagnosis- and- clinicalmanagement- of- alcohol- related- physical- complications- cg100 ; http:// www.nice.org.uk/nicemedia/live/12995/49004/49004.pdf ).
Home circumstances
One of the criteria for discharge of head- injured patients is appropriate home support. This involves regular observations for at least 24 hours by a responsible adult who can either bring the patient back to casualty or phone for an ambulance if required. If the patient lives in a remote area, it might be better to consider overnight observation.
Allergies
Notably with antibiotics used to treat facial infections.
Principles of assessment
Family/occupational history
This may sometimes indicate potential risks from anaesthesia and patients should be asked about a history of malignant hyperpyrexia, porphyria, and, if of non- European decent, sickle cell disease. people in certain occupations may be exposed to hazards that can produce respiratory disease. These include cancers (e.g. asbestos workers), infections (e.g. bird breeders), asthma (e.g. painters), pneumoconiosis (e.g. coal miners), and allergic alveolitis (e.g. farmers). Travel abroad can occasionally result in exotic infections and cervical lymphadenopathy.
Rapid assessment of patients
requiring emergency/urgent surgery
Consider the impact of the following in planning management
The initial care of a patient can be considered under several headings. These are applicable to varying extents, but a useful checklist is:
• Treating coexisting medical conditions
• Fluid balance and nutritional support (patient may already be in deficit)
• Deep vein thrombosis (DVT) prophylaxis
• a ntibiotic cover
• Steroid cover
• Effective pain relief
• Stress ulcer prophylaxis
• Early involvement of specialists, including physiotherapists and social services.
Whereas patients undergoing elective surgery can be pre-assessed in good time, those requiring emergency surgery cannot and may only be rendered as fit as possible within the time allowed, depending on the degree of urgency. Relatively few emergencies in the head and neck require immediate intervention (such as airway obstruction, extradural haematoma, and retrobulbar haemorrhage) and most can be delayed by at least a few hours, so that the patient’s general health can be improved if possible. In selected cases, some patients may benefit from a brief period of intensive management on a high dependency unit (HDU) or ICU. In all cases, early input from an anaesthetist is essential, particularly in those patients with conditions affecting the airway.
Getting patients ready for urgent surgery: medical considerations
Cardiorespiratory assessment
Risk factors for cardiac disease include:
• Smoking
• Diabetes
• Hyperlipidaemia and obesity
• Hypertension
• Male sex
• Family history of cardiac disease.
Thorough assessment of the cardiovascular and respiratory systems is particularly important in patients undergoing surgery. Ischaemic heart disease (myocardial infarction, heart failure, angina), hypertension, asthma, CO pD, chest injuries, and chest infections all significantly increase the risks of anaesthesia. Myocardial infarction within the preceding 6 months is a recognized major risk factor in anaesthesia and surgery. There is a 20– 50% risk of a further infarction and perioperative death. patients with a history of ischaemic heart disease should have an up-to- date electrocardiogram (ECG) preoperatively. patients with a past history of rheumatic fever are predisposed to valvular heart disease, which can lead to heart failure or infective endocarditis. Intraoral procedures, especially those involving the teeth (e.g. removal), are wellrecognized risk factors in the development of endocarditis and some patients may require antibiotic cover, depending on the surgical procedure (although not every patient does). Similarly, some types of congenital heart disease and patients with artificial heart valves may require appropriate antibiotic cover.
Chronic obstructive airways disease/tuberculosis
This predisposes to postoperative chest infections and hypoxia. p reoperative measures to reduce postoperative chest infection include:
• Being aware of high- risk patients
• Forbidding smoking for at least a few days before surgery
• Nebulized beta agonists and steroids preoperatively
• p hysiotherapy
• Using high dependency or intensive care beds for patients who are particularly at high risk.
Tuberculosis is still seen even in developed countries especially among the homeless and in deprived inner city areas where poverty and overcrowding contribute to its incidence.
Asthma
Lung function in asthmatics can be improved with nebulized beta agonists and steroids preoperatively. avoid aspirin and other NS a IDs.
Diabetes
Principles of assessment
Surgical risks in diabetic patients
• acute hypoglycaemia
• Ketoacidosis
• Ischaemic heart disease
• Hypertension (renal disease)
• Increased risk of infections (chest, urinary, wound)
• p redisposed to pressure sores (spinal injured patients).
postoperative complications and mortality are more common in diabetic patients. This is partly due to controllable factors such as blood glucose, but also due to established complications such as ischaemic heart disease and infection, both of which are more common in these patients.
The problems with diabetic patients undergoing major surgery are related to the period of starvation (nil by mouth (NBM)) and the metabolic effects secondary to the surgery itself. The main source of nutrition to the brain is glucose, yet persistently high blood sugar predisposes to infections, poor wound healing, and ketoacidosis. The aim of management is therefore to minimize gross variations in blood sugar by ensuring an adequate glucose, calorie, and insulin intake. Blood glucose needs to be within normal limits preoperatively and maintained until normal feeding is resumed following surgery. For many patients, normal feeding may be delayed by many days, especially following major procedures in the head and neck. p reoperative blood glucose control can be determined by urinalysis or preferably, a random blood sugar. Blood urea and electrolyte (U&E) concentrations, creatinine, and estimated glomerular filtration rate should also be checked to exclude renal disease.
Preoperatively determine:
• The type of diabetes
• The adequacy of blood glucose control
• The treatment regimen (diet, oral hypoglycaemic agent, or insulin)
• The presence of any organ impairment (e.g. cardiovascular, renal)
• The likely delay in resumption of oral feeding.
Many regimens exist for stabilizing diabetic patients in the preoperative period.
General principles in diabetic management
• Get expert help— liaise early with the anaesthetist or diabetic specialist.
• Establish good control of blood sugar before surgery if possible.
• avoid long- acting insulin preparations or oral hypoglycaemic agents 12–24 hours preoperatively, to prevent hypoglycaemia.
• Regularly monitor blood sugar.
• Fast from midnight (if on morning theatre list).
• p lace patient first on the list.
• Control blood sugar on the day of surgery using IV short- acting insulin and IV dextrose (many regimens exist).
• Check potassium and supplement if necessary.
• postoperatively, continue sliding scale until an adequate oral diet is re- established and then restart normal regimen.
a ll type 1 and type 2 diabetics on insulin should never be left without insulin. They may develop ketoacidosis. Do not withhold insulin because the patient is fasting. Seek advice.
In acute cases, blood glucose may be grossly abnormal secondary to infection, trauma, or reduced oral intake. patients are often hyperglycaemic, which can lead to diuresis, dehydration, and ketoacidosis. These patients require IV rehydration, correction of sodium depletion (beware of pseudohyponatraemia), potassium supplementation, and infusion of short- acting soluble insulin. Regular monitoring of blood glucose, sodium, potassium, and acid– base balance is essential. The CO2 reported with U&E results give an indicator of the acid– base balance. Check a BGs. When rehydration is underway and some correction of acidosis and hyperglycaemia has been achieved, urgent surgery may then be performed while continuing management during and after surgery.
Sliding scales
These involve the continuous infusion (sometimes subcutaneously) of a short- acting insulin, using a syringe pump. The rate of infusion varies according to the patient’s blood glucose which is checked regularly (e.g. hourly, depending on its stability). The higher the blood glucose, the more insulin is given. In this way hyperglycaemia can be controlled without risking profound hypoglycaemia. Sliding scales should be reviewed constantly and adjusted to achieve a relatively steady infusion rate. The aim is to establish a steady blood glucose rather than constantly oscillating below low and high infusion rates. Ketoacidosis guidelines include those from the Joint British Diabetes Societies Inpatient Care Group: http:// www.diabetes.org.uk/Documents/a bout%20Us/ What%20we%20say/ Management- of- DK a -241013.pdf.
Bleeding disorders and anticoagulants
The undiagnosed presence of blood dyscrasias and other causes of delayed clotting should be considered whenever there is prolonged bleeding following apparent minor injury or minor surgery. The commoner problems include haemophilia a , haemophilia B, von Willebrand disease, liver disease, and patients on anticoagulants. patients with known or suspected bleeding problems need to be fully assessed by an appropriate specialist. With appropriate prophylactic measures (e.g. local measures, tranexamic acid, DDaV p, factor replacement, or adjustment/reversal of warfarin), urgent surgery can usually be safely performed. Opinions vary considerably as to what is an ‘acceptable’ international normalized ratio (INR) for surgery, although this depends on the site (superficial vs deep, or within a cavity).
Stopping warfarin: a guide (refer to your local policy)
patients undergoing low- bleeding- risk procedures (dental extractions, minor skin procedures) do not require alteration of their anticoagulation regimen. In these patients, the procedure can be performed at the therapeutic range. patients undergoing high- bleeding- risk procedures (e.g. abdominal surgery, intracranial or spinal surgery) require discontinuation of warfarin preoperatively. If the patient has a metallic heart valve, this should be discussed with their cardiologist. a metallic mitral valve is at higher risk of thrombosis.
