AMTS (Abbreviated mental test score)
1. How old are you?
2. What’s your date of birth?
3. What is the year?
4. What is the time of the day?
GIVE ADDRESS to remember (42 West Street)
5. Where are we? (What building?)
6. Who is the current monarch?
7. What was the date of the 1st world war?
8. Can you count backwards from 20 to 1?
9. Recognise two people
10. Can you remember that address?
Mental state examination
All Sane Men Think That Pizza Is Italian
- Appearance and behaviour
- Speech
- Mood
- Thought form/process
- Thought content (e.g. delusions)
- Perception (e.g. hallucinations)
- Insight
- IQ (cognitive function)
https://www.rcemlearning.co.uk/foamed/mental-health-in-the-ed/
https://pathways.nice.org.uk/pathways/self-harm/managing-self-harm-in-emergency-departments
Thursday 24 October 2019
Complications of Bariatric Surgery
Avoid "blind placement" of NG tubes
Avoid NSAIDs, ASA, plavix, steroids
Remember thiamine deficiency
Avoid overload of oral fluids
Consider compartment syndrome
Negative CT doesn't rule out a leak
Dysphagia - band slipage or gastric ischaemia
GI bleed - needs an endoscopy. May be from the anastamosis, gastric remnant. Consider octreotide.
Obstruction - may be a stricture, internal hernia. Bloating, hiccups, nausea, vomiting and abdo pain. Look on the AXR for an air fliud level in the gastric pouch. May be exacerbated by post op oedema.
Chest pain - may be PE, MI, pouch problem or anastomotic leak
Abdominal pain - subacute obstruction, anastomotic leak
Reflux - band slip, gastrojejunal stenosis. May have more nausea and vomiting than non surgery.
Vomiting is not normal and needs a work up- may be due to a band slip or stomal ulcers (less common. 2-4 months after surgery. Epigastric and retrosternal pain, dyspepsia, nausea and vomiting or an upper GI bleed.)
Gallstones ARE common after a roux-en-y
Remember thiamine and wenicke's, dehydration, and infection
Dumping Syndrome - for 12-18 months after the surgery. The small gastric pouch leads to rapid emptying of gastric contents into the small bowel, especially in carbohydrates. Treatment is to correct the hypotension, tachycardia, electrolyte disturbances and educate the patient to eat small, frequent, slow meals.
Roux-en-Y gastric bypass
Causes PE and anastomic leak are most common - most common in first week post op but can be a month after surgery. Symptoms may be subtle - tachycardia, dyspnoea, restlessness or mental state changes. The abdominal examination is often of limited value with no peritoneal signs.
Early post op complications include wound infection, dehiscence, acute GI obstruction, stomal stenosis, stomal/marginal ulcers, upper GI bleeding and dumping syndrome.
Stomach size shrinks and you get less gastric acid production
Band Gastroplasty
Lots of different options - less invasive option. Band is placed around the proximal stomach creating a restrictive pouch. The band is secured with sutures to prevent slipage, and can be adjusted
http://emergencymedicineireland.com/2015/10/tasty-morsels-of-em-058-bariatric-surgery-and-its-complications/
https://litfl.com/problems-after-bariatric-surgery/
https://www.bmj.com/content/352/bmj.i945
Avoid NSAIDs, ASA, plavix, steroids
Remember thiamine deficiency
Avoid overload of oral fluids
Consider compartment syndrome
Negative CT doesn't rule out a leak
Dysphagia - band slipage or gastric ischaemia
GI bleed - needs an endoscopy. May be from the anastamosis, gastric remnant. Consider octreotide.
Obstruction - may be a stricture, internal hernia. Bloating, hiccups, nausea, vomiting and abdo pain. Look on the AXR for an air fliud level in the gastric pouch. May be exacerbated by post op oedema.
Chest pain - may be PE, MI, pouch problem or anastomotic leak
Abdominal pain - subacute obstruction, anastomotic leak
Reflux - band slip, gastrojejunal stenosis. May have more nausea and vomiting than non surgery.
Vomiting is not normal and needs a work up- may be due to a band slip or stomal ulcers (less common. 2-4 months after surgery. Epigastric and retrosternal pain, dyspepsia, nausea and vomiting or an upper GI bleed.)
Gallstones ARE common after a roux-en-y
Remember thiamine and wenicke's, dehydration, and infection
Dumping Syndrome - for 12-18 months after the surgery. The small gastric pouch leads to rapid emptying of gastric contents into the small bowel, especially in carbohydrates. Treatment is to correct the hypotension, tachycardia, electrolyte disturbances and educate the patient to eat small, frequent, slow meals.
Roux-en-Y gastric bypass
Causes PE and anastomic leak are most common - most common in first week post op but can be a month after surgery. Symptoms may be subtle - tachycardia, dyspnoea, restlessness or mental state changes. The abdominal examination is often of limited value with no peritoneal signs.
Early post op complications include wound infection, dehiscence, acute GI obstruction, stomal stenosis, stomal/marginal ulcers, upper GI bleeding and dumping syndrome.
Stomach size shrinks and you get less gastric acid production
Band Gastroplasty
Lots of different options - less invasive option. Band is placed around the proximal stomach creating a restrictive pouch. The band is secured with sutures to prevent slipage, and can be adjusted
http://emergencymedicineireland.com/2015/10/tasty-morsels-of-em-058-bariatric-surgery-and-its-complications/
https://litfl.com/problems-after-bariatric-surgery/
https://www.bmj.com/content/352/bmj.i945
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