Published by World Scientific Publishing Co. Pte. Ltd. 5 Toh Tuck Link, Singapore 596224 USA office: Suite 202, 1060 Main Street, River Edge, NJ 07661 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Acute surgical management / editors, Nian Chih Hwang, London Ooi. p. ; cm. Includes bibliographical references and index. ISBN 981-238-681-5 (alk. paper) 1. Medical emergencies. 2. Surgery, Operative. 3. Wounds and injuries--surgery. 4. Therapeutics, Surgical. I. Hwang, N. C. (Nian Chih), 1960 II. Ooi, London. [DNLM: 1. Emergencies. 2. Surgical Procedures, Operative. 3. Wounds and Injuries--surgery. WO 700 A1897 2004] RC87.A346 2004 616.0215--dc22 2003063108 Copyright 2004 by World Scientific Publishing Co. Pte. Ltd. All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher. For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher. Printed in Singapore.
Foreword One of the most important functions of the Singapore General Hospital (SGH) is Teaching & Training. In fact, SGH prides itself in being responsible for the biggest share in postgraduate medical training in Singapore. It is well known that SGH is the first hospital responsible for both Undergraduate and Postgraduate Medical teaching in Singapore. With the publication of this book, we confirm our strong commitment to this long tradition in Medical Education. In the choice of topics for the book, we took into consideration what is current and relevant in surgical practice in a very busy tertiary acute General Hospital (where half of the admissions comes through the portal of the Emergency Department and where the other half is electively admitted). The final content depended, to a great extent, on the choice of Surgeon Authors who were authorities in the topics they wrote. These were busy clinicians and teachers and under the dedicated supervision of our editor who are an anaesthesiologist and a surgeon, we hope this book will be treasured by all who train in surgery at SGH. The prime purpose of this book is to educate. The reason why we need to educate is to produce the next and subsequent generations of surgeons who will be required to look after patients, not only in Singapore but also, to a smaller extent, the surrounding region. The other important reason in producing this book is to document the current practice of surgery for posterity, so that those who come after can xi
xii Foreword build on the processes and structure that have been put into place. Finally, the strongest of reasons for this book is for the care of our patients. It is because of them and for them that this is published, so that we can always strive to improve their care. Boon-Keng Tay
Preface Singapore General Hospital (SGH) is the largest public sector hospital in Singapore. Established in 1821, SGH serves as the nation s main tertiary care and acute care hospital. Within the grounds of SGH are 21 specialty departments with close links to the four national centres (National Cancer Centre Singapore, National Heart Centre, Singapore National Eye Centre and the National Dental Centre) within the same compound. With a strong tradition of clinical excellence, SGH has been intimately involved in the training and teaching of both undergraduate medical students from the National University of Singapore and postgraduate students in the various specialties and sub-specialties of medicine since the days when the Medical Faculty was located at the Sepoy Lines (the current location of the Ministry of Health). SGH also prides itself on having extended training opportunities to clinical fellows and students from all over the world. The chapters in this book are written by surgeons, radiologists and anaesthesiologists from this hospital. Together with basic surgical principles, the unique local experiences and perspectives are presented. There are two parts to this book. Part I of the book deals with the principles of management of acute surgical emergencies. These emergencies include craniofacial, otorhinolaryngological, cardiovascular and thoracic, gastrointestinal, gynaecological, urological, perianal, orthopaedic and hand, as well as those involving the soft tissue and skin. The xiii
xiv Preface importance of computed tomography imaging in blunt abdominal trauma and the role of interventional radiology in acute haemorrhage; as well as peri-operative anaesthetic care of the patient requiring acute surgical management are described in Part II of the book. London Lucien Ooi Nian-Chih Hwang
Contents Foreword Preface PART I ACUTE SURGICAL MANAGEMENT 1 Section I Craniofacial Emergencies 3 Chapter 1 The Acute Management of Head Injuries 5 Alvin Hong Chapter 2 Intra-cerebral Haemorrhage in Adults 24 John Thomas Chapter 3 xi xiii Paediatric Neurosurgical Emergencies: A Problem-Based Approach 36 Keith YC Goh Chapter 4 Acute Management of Craniofacial Trauma 56 Vincent KL Yeow and Andrew Tay Chapter 5 Emergencies in Oral and Maxillofacial Surgery 74 Asher Lim and Luan-Yook Teh v
vi Contents Section II Otorhinolaryngological Emergencies 93 Chapter 6 Management of Epistaxis 95 Dharambir S Sethi and Jern-Lin Leong Chapter 7 Managing the Difficult Airway in an Emergency Setting 127 Ruban Poopalalingam, Nian-Chih Hwang and Eugene Chin Chapter 8 Tracheostomy 151 Abhilash Balakrishnan Chapter 9 Management of Ingested Foreign Bodies 171 Wong-Kein Low and Hin-Ngan Tay Section III Cardiovascular and Thoracic Emergencies 189 Chapter 10 Blunt Cardiac Injury 191 Yeong-Phang Lim, Richard Lupinski and Yeow-Leng Chua Chapter 11 Aortic Trauma 200 Kenny Yoong-Kong Sin and Yeow-Leng Chua Chapter 12 Acute Arterial Disease 212 Meng-Keng Teoh Chapter 13 Vascular Trauma 222 Mathew G Sebastian Chapter 14 Penetrating Trauma to the Chest 232 Chong-Hee Lim and Thirugnanam Agasthian Section IV Gastrointestinal Tract Emergencies 245 Chapter 15 Management of the Acute Abdomen 247 Melissa Teo and Kee-Chee Soo
Contents vii Chapter 16 Management of Intestinal Obstruction 268 Choong-Leong Tang and Francis Seow-Choen Chapter 17 Management of Upper Gastrointestinal Bleeding 284 Wai-Keong Wong Chapter 18 Massive Lower Gastrointestinal Bleeding 302 Kong-Weng Eu and Kok-Sun Ho Chapter 19 Surgical Emergencies of the Hepato-Pancreato-Biliary System 310 Pierce Chow Chapter 20 Abdominal Trauma 327 Allen Yeo Section V Gynaecological Emergencies 353 Chapter 21 Female Genital Bleeding 355 Sun-Kuie Tay and Ann Tan Chapter 22 Ectopic Pregnancy 375 Hak-Koon Tan, Su-Ling Yu and Sun-Kuie Tay Chapter 23 Emergency Management of Ovarian Cysts 387 Sun-Kuie Tay Section VI Urological Emergencies 405 Chapter 24 Acute Non-traumatic Urological Emergencies 407 Weber Lau and Keong-Tatt Foo Chapter 25 Renal and Ureteric Injury 428 Sidney Yip and Michael Wong Chapter 26 Trauma to the Bladder and Urethra 443 Lay-Guat Ng and Chris Cheng
viii Contents Section VII Perianal Emergencies 455 Chapter 27 Genitoperineal (Fournier s) Gangrene 457 Yik-Hong Ho Chapter 28 Acute Management of Haemorrhoids 461 Sieu-Min Heah Section VIII Orthopaedic Emergencies 477 Chapter 29 Treatment of Multiple Fractures 479 Tet-Sen Howe Chapter 30 Acute Management of Pathological Fractures 494 Mann-Hong Tan Section IX Hand Surgical Emergencies 505 Chapter 31 Open Injuries of the Hand Assessment and Treatment 507 Lam-Chuan Teoh Chapter 32 Infection of the Hand 539 Fok-Chuan Yong and Lam-Chuan Teoh Section X Skin and Soft Tissue Injuries 549 Chapter 33 Acute Burn Care 551 Erik SW Ang, Colin Song and Kok-Chai Tan Chapter 34 Soft Tissue Injuries 566 Colin HJ Tham, Ying-Chien Tan, Karen WE Sng and Vincent KL Yeow PART II SUPPORT SERVICES 577 Section XI Radiology 579 Chapter 35 Computed Tomography Imaging of Blunt Abdominal Trauma 581 Siew-Kune Wong
Contents ix Chapter 36 The Role of Interventional Radiology in Acute Haemorrhage 601 Kiang-Hiong Tay, Winston Eng-Hoe Lim and Bien-Soo Tan Section XII Perioperative Anaesthetic Care 637 Chapter 37 Optimisation of Patients for Emergency Surgery 639 Christine JC Cheng and Nian-Chih Hwang Chapter 38 Anaesthesia for Emergency Surgery 656 Sook-Muay Tay and Chee-Seng Kong Chapter 39 Early Postoperative Care of the Acute Surgical Patient 675 Huei-Leng Chee and Claire Ang Index 691