Essential Notes for MRCS - Book 2(B)

Details of surgical resection of individual tumours are discussed in the relevant chapters in Book 2.

Curative surgery

Curative surgery involves removal of the entire tumour with an intact perimeter of normal tissue, leaving
resection margins free of tumour cells.

It may demand an aggressive approach that has higher risks of postoperative complications. Actual or
likely directions of tumour spread must be known in order to clear the surgical field (eg mesorectal
excision for rectal cancer). If the regional lymph nodes are involved or suspected and lymph node
clearance is planned, then this should be performed en bloc (ie without disrupting lymphatic connections
between tumour and nodes or between tumour and locally infiltrated tissue).

Curative surgery may be preceded by neoadjuvant therapies such as radiotherapy or chemotherapy to
‘downstage’ disease before surgery, increasing the chance that surgery will be curative; similarly it is
increasingly followed by adjuvant therapies aimed at reducing recurrence rates.

Surgical management of draining lymph nodes



In a nutshell ...

Management of the regional lymph nodes may take many forms:
Surgical lymph node sampling to predict involvement (eg sentinel node biopsy) • Surgical lymph node

clearance

The role of the regional lymph nodes in cancer is still up for discussion. Many believe that these nodes
may not act as filters for malignant cells and that fairly large tumour emboli may skip the regional nodes
altogether. These nodes may have an important role in the early immune response to tumours, allowing
appropriate antigen recognition and prevention of widespread tumour cell dissemination.

For many tumours, elective lymph node resection has not shown any survival benefit. However, the
presence of lymph node metastases is an important prognostic sign and requires treatment, hence there has
been much research directed at ways of ascertaining lymph node stage without the need for full regional
lymphadenectomy.

There has been much recent interest in directed methods of lymph node sampling, in order to gain
information about tumour staging in as sensitive and specific a manner as possible. Sentinel node biopsy
is one such method.

Sentinel node biopsy

Essentially there is a single node through which lymphatic drainage from the primary tumour passes to
reach the chain of regional lymph nodes. The node that predominantly drains the site of the primary
tumour (the sentinel node) is identified by the injection of a tracer substance into the area of the primary
tumour. This may be a visible blue dye or radioactive substance (eg human albumin nanocolloid).

Sentinel nodes can then be identified either visually and/or by a hand-held gamma probe at open surgery.
There is more than one sentinel node in up to 50% of patients. These nodes are excised and sent for
histopathology to look for metastatic deposits. The residual nodes are also scanned for evidence of
radioactivity (should have a ratio of at least 3:1 radioactivity for sentinel node vs other nodes in vivo,
and 10:1 ex vivo).

Following the success of the Almanac trial (Goyal et al. 2004), the principle of sentinel node detection
for breast cancer has been adopted as a mainstay of staging. This is associated with a significant
reduction in postoperative morbidity and loss of function when compared with radical axillary dissection.
It is also applied selectively to patients with malignant melanoma.

For further discussion about sentinel node biopsy see Chapter 2, Breast Surgery in Book 2.


Lymph node clearance
Regional lymph node clearance may be indicated for:
Visible involvement by tumour
Symptomatic involvement by tumour
Occult involvement by tumour (eg identified by lymphoscintigraphy above) • For staging (eg Dukes’
stage of colorectal cancer) • Prophylactically when shown to improve prognosis
It is associated with a higher morbidity, eg lymphoedema in axillary dissection. It is associated with
improved prognosis in certain tumour types (eg malignant melanoma).

Reconstructive surgery

May be performed at the same time as primary surgery or later. Includes:
Reconstruction or remodelling (eg breast reconstruction) • Restitution or restoration (eg continuity of the
bowel) • Replacement or substitution (eg free flaps)

Sugery in advanced disease

In general metastatic disease is indicative of systemic tumour spread and surgery has little role. However,
some metastatic disease is amenable to surgical resection. Resection of liver and lung metastases from
colorectal cancer is potentially curative, with 5- and 10-year survival rates post-resection of 25% and
10% respectively. Metastatic disease to the liver may also be treated by radiofrequency ablation. Some
solitary brain metastases (eg from breast cancer) may be managed with surgical resection.

In advanced disease surgery may be used to palliate symptoms, eg colonic bypass or stoma creation, or to
debulk disease, either to prolong survival or to allow use of another treatment modality. Stenting is often
carried out as a combined surgical and radiological procedure to palliate symptoms of oesophageal,
colonic or pancreaticobiliary cancers.

5.2 Radiotherapy

Types of radiation

Particulate: does not penetrate the tissue deeply and is used predominantly to treat cutaneous and

subcutaneous conditions:
Electrons
Protons
Neutrons
α Particles
Pi mesons

Electromagnetic: penetrates tissue deeply and is therefore used to treat deep tumour tissue:
X-rays
Gamma rays



In a nutshell ...

This is the therapeutic use of ionising radiation for the treatment of malignant conditions.
Radiotherapy
Radiation may be particulate or electromagnetic • Radiotherapy kills tumour cells by generating high-
energy molecular movement • Tumour susceptibility is related to tumour oxygenation and
radiosensitivity of the individual cells • Radiotherapy may be used as a primary, neoadjuvant, adjuvant
or palliative therapy • It causes damage to normal as well as tumour cells, resulting in local and
systemic complications

Mechanism of action

Radiation kills cells by causing high-energy interactions between molecules:
DNA damage is via release of kinetic energy from free radicals (an oxygen-dependent process) • Causes
deletions and strand breaks within the DNA • May trigger apoptosis in some cells due to severe DNA
damage • Cells are most sensitive during S phase

Killing cells leads to stimulation of other cells to divide, ie to enter the S phase:
Repair: normal cells take 4 hours to recover (6+ hours for central nervous system [CNS]); malignant cells
take longer • Repopulation: more cells are stimulated to divide due to death of others, after about 3–4
weeks of standard fractionated treatment
Redistribution: pushes cells into the S phase – more radiosensitive • Re-oxygenation: oxygen is a
radiation sensitiser; cell death facilitates re-oxygenation – increases cytotoxicity

The degree of tumour destruction by radiotherapy is related to:
Radiosensitivity of tumour
• Sensitive: seminoma, Hodgkin’s lymphoma, • Resistant: tendency to repair DNA damage (eg melanoma)
• Similar tumour types tend to have similar radiosensitivity (eg all carcinomas) • Slow-growing tumours
may not respond or only respond slowly to radiotherapy • Tolerance of normal tissue: surrounding tissue
may be very sensitive to treatment (eg nervous tissue, small bowel), which limits the amount of
radiotherapy that can be delivered
Tumour size: larger tumours have areas of low oxygen tension and necrosis, and are more resistant. They
require more cycles and larger treatment volumes, which exposes normal tissue to higher doses of
radiation

Administration of radiotherapy

Locally, ie the source can be implanted into tissue to be treated (eg brachytherapy for prostate cancer) or
into a cavity, eg uterus
Systematically (eg iodine-131 for thyroid cancer) • External beam radiation via linear accelerator

Fractionation describes the number of individual treatments and their time course. The therapeutic ratio
is the relationship between the amount of radiation tolerated by the normal tissues and that delivered to
the tumour.

For radical treatments, aim for maximum possible dose in the smallest volume which will encompass all
the tumour and probable occult spread. This is called the treatment volume and it comprises:
Macroscopic tumour
Biological margin (0.5–1 cm)
Technical margin (allows for minute variations in positioning and set-up)

The site is accurately localised by imaging and permanent skin markings applied to ensure reproducibility
at subsequent sessions.

Complex multi-field arrangements divide the tumour into cubes. The radiation is targeted to divide the
dose between surrounding normal tissues, because different tissues can tolerate different amounts of
radiation (eg liver is more resilient than kidney). It is usually delivered intermittently, allowing normal
tissues to recover. This takes at least 4 hours, whereas malignant tissues take longer.

Improved imaging techniques now allow precise targeting of a tumour shape, which is important if it is
located near sensitive structures. Techniques are being refined so that there is an increase in the number of
sessions that can be given within a short period of treatment time; this is known as accelerated
radiotherapy (eg multiple sessions per day for 2 weeks).

Stereotactic radiotherapy is commonly used for brain tumours. The patient’s head is placed in a frame
and an accurate three-dimensional image of the tumour is obtained using high-resolution MRI. The beam
of radiation is focused on the tumour but rotation of delivery means that the surrounding normal tissues
receive minimal doses.

Uses of radiotherapy

Primary treatment

Sensitive tumours
Better cosmetic/functional result
Inoperable or high mortality/morbidity with surgery • Patient not fit for surgery

Adjuvant radiotherapy

Postoperative
Can be given at site of disease in order to reduce risk of local recurrence, eg in high-risk tumours or those
with compromised resection margins. The disease sites addressed may include the primary tumour and
any involved lymph nodes. Intraoperative clips placed around the tumour bed can help direct therapy

Neoadjuvant radiotherapy

Preoperatively, can downstage tumours to allow surgery to be technically feasible and increase the chance
of a clear margin (eg circumferential margin in rectal tumours)
Can reduce risk of seeding at operation • Does not cause additional surgical morbidity if performed within
4 weeks of surgery

Palliation

Palliative radiotherapy aims for symptom relief, from either primary or metastatic disease (eg relief of
bone pain, bleeding, dyspnoea, cord compression, superior vena caval obstruction)
It is given as short courses of treatment, with simple set-ups, to minimise toxicity • Single fractions are
often used to control bone pain

Complications of radiotherapy

Local complications

Itching and dry skin
Ulceration
Bleeding
Radiation enteritis
Fibrosis and stricture formation
Delayed wound healing
Lymphoedema
Alopecia
Osteoradionecrosis

Systemic complications

Lethargy
Loss of appetite
Premature menopause
Oligospermia
Acute leukaemia
Myelosuppression
Hypothyroidism/renal failure – after many years’ treatment

5.3 Chemotherapy



In a nutshell ...

Chemotherapeutics are drugs that are used to treat cancer by affecting cell proliferation. They may be
used as primary, neoadjuvant or adjuvant therapies.
Chemotherapeutic drugs include:

Alkylating agents
Antimetabolites
Antibiotics
Vinca alkaloids
Taxanes
Topoisomerase inhibitors

Side effects may be acute (related to dose) or chronic (related to duration of treatment). Tumours may
eventually become resistant to individual chemotherapeutics.

Chemotherapeutics are drugs that are used to treat cancer that inhibit the mechanisms of cell proliferation.
They are therefore toxic to normally proliferating cells (ie bone marrow, GI epithelium, hair follicles).
They can be:
Cycle-specific: effective throughout the cell cycle • Phase-specific: effective during part of the cell cycle

Tumour susceptibility depends on the concentration of drug delivered, cell sensitivity and cell cycling of
tumour. Drugs are less effective in large solid tumours because of:
Fall in the growth fraction
Poor drug penetrance into the centre • Intrinsic drug resistance of subclones

Indications for chemotherapy


Indications for chemotherapy
Primary treatment (eg lymphoma) • Neoadjunctive treatment to decrease tumour bulk before surgery
• Adjunctive treatment for prevention of recurrence • Advanced disease and palliation
Maintenance treatment (eg leukaemia)

Important treatment in:
Haematological malignancy
Germ cell tumours
Ovarian cancer
Small-cell lung cancer
Breast cancer (locally advanced)

Important neoadjuvant in:
Colorectal liver metastasis
Low rectal cancers

Important adjuvant in:
Colorectal cancer primaries (Dukes’ C) • Breast cancer

Methods of delivering chemotherapy

Methods of delivery for chemotherapeutic agents
Intravenous
Oral
Intra-arterial (eg for HCC)
Intramuscular
Intrathecal
Intracavitary (eg intravesicular for TCC of the bladder) • Intralesional

Doses are based on body surface area; affected by hepatic metabolism and renal excretion.

Efficacy of treatment for different tumours may be improved by:
Pulsed treatment
Combinations of drugs with different modes of action (synergy, reduces drug resistance) • Alternating
cycles
High-dose treatment with subsequent replacement of normal tissues (eg bone marrow transplantation) •
Scheduling with continuous low dose

Chemotherapeutic agents

Alkylating agents

Classic alkylating agents
Act by forming covalent bonds with nucleic acids, proteins, nucleotides and amino acids, and so
inactivate the enzymes involved in DNA production and protein synthesis.

Non-classic alkylating agents
Act by causing cross-linkage of DNA strands.



Side effects of classic alkylating agents

Indications Side effects


Mustargen

Hodgkin’s lymphoma Very toxic so rarely used
Non-Hodgkin’s lymphoma Vomiting
Chronic myelocytic leukaemia (CML)
Chronic lymphatic leukaemia (CLL) Bone-marrow depression

Cyclophosphamide

Many cancers including: Bone marrow depression
Lymphoma
Breast Nausea and vomiting (mil dunless high dose)
Lung Haemorrhagic cystitis (high doses)
Ovary
Pulmonary interstitial fibrosis

Chlorambucil

CLL Bone marrow suppression
Nausea, vomiting, diarrhoea

Non-Hodgkin’s lymphoma (low-grade) Jaundice, pulmonary fibrosis

Ovary

Melphalan

Bone marrow depression

Nausea and vomiting

Multiple myeloma Diarrhoea

Rash

Pulmonary fibrosis



Side effects of non-classic alkylating agents

Indications Side effects


Cisplatin (C-DDP) (toxic to cycling and resting cells)

Testis cancer

Ovary cancer Renal failure

Head and neck cancer Electrolyte disturbance (hypomagnesaemia)

Bladder cancer Peripheral neuropathy

Lung cancer Ototoxicity

Oesophageal cancer Bone marrow depression

Stomach cancer

Carboplatin

Ovary cancer Less toxic analogue, but more bone marrow suppression
Lung cancer
Seminoma



Side effects of antimetabolites

Indications Side effects



Methotrexate (S-phase specific)

Acute lymphocytic leukaemia Bone marrow depression
(ALL)

Breast cancer GI symptoms

Lung Stomatitis

Renal failure Hepatic failure

5-Fluorouracil (5-FU) (toxic to resting and cycling cells)

Colon Bone marrow depression

Breast GI symptoms

Stomach Alopecia
Oesophagus
Rash
Pancreas
Palmar–plantar syndrome and cardiotoxicity with high-dose
Gemcitabine infusional treatments
Pancreas
Lung Nausea
Flu-like symptoms
Oedema

Antimetabolites

Act by interfering with purine or pyrimidine synthesis and hence interfere with DNA synthesis.

Antibiotics

Act by intercalating between base pairs and prevent RNA production. There are several groups with
differing actions.

Anthracycline antibiotics
Complex actions (not fully understood):
Intercalate into DNA strands
Bind membranes
Produce free radicals
Chelate metals – producing cytotoxic compounds • Alkylation

Non-anthracycline antibiotics
Act by intercalation, free radical production and/or alkylation.

Vinca alkaloids

Act by inhibiting mitosis, by preventing spindle formation. M-phase-specific.

Note that intrathecal administration of vinca alkaloids is fatal!


Side effects of anthracycline antibiotics

Indications Side effects


Doxorubicin

Acute leukaemia

Lymphoma

Breast cancer Bone marrow depression
Small-cell lung cancer Nausea and vomiting
Sarcoma

Bladder cancer Alopecia
Ovary cancer Cardiac-dose-dependent congestive cardiac failure
Wilms’ tumour
Neuroblastoma Doxorubicin analogue with less cardiac toxicity

Epirubicin
Breast



Side effects of non-anthracycline antibiotics

Indications Side effects


Mitozantrone

Breast cancer Bone marrow depression

Congestive cardiac failure

Alopecia

Nausea and vomiting

Bleomycin

Lymphoma Bone marrow sparing

Testicular cancer Pneumonitis and pulmonary fibrosis

Head and neck cancer Rash

Fever

Mitomycin C

Breast cancer Bone marrow depression

Bladder cancer (intravesical) Renal failure (haemolytic–uraemic syndrome with tamoxifen)

Pancreatic cancer Stomatitis, rash, alopecia

Gastric cancer Nausea and vomiting



Side effects of vinca alkaloids Side effects
Indications


Vincristine Highly vesicant
Acute leukaemia Neuropathy
Lymphoma Bronchospasm
Neuroblastoma
Wilms’ tumour
Rhabdomyosarcoma
Vinblastine
Testis Highly vesicant
Hodgkin’s lymphoma Bone marrow depression
Non-Hodgkin’s lymphoma Bronchospasm
Choriocarcinoma Abdominal pain and ileus (mimics acute abdomen)

Peripheral neuropathy
Vinorelbine
Breast Highly vesicant
Lung Bone marrow depression
Abdominal pain and constipation
Local phlebitis


Taxanes

Act by inhibiting mitosis through stabilisation of microtubules.

Topoisomerase inhibitors

Inhibit topoisomerase I, an enzyme involved in DNA replication.


Side effects of topoisomerase inhibitors

Indications Side effects

Irinotecan

Cholinergic syndrome

Colorectal cancer Profuse diarrhoea

(may be life-threatening)



Side effects of taxanes Side effects
Indications


Docetaxel Allergic reaction
Severe neutropenia
Breast cancer Alopecia
Ovarian cancer Peripheral oedema
Myalgia
Paclitaxel Peripheral neuropathy

Ovary cancer
Breast cancer Anaphylaxis
Lung cancer Severe neutropenia
Sudden total alopecia
Myalgia
Peripheral neuropathy

Side effects of chemotherapy

Acute complications

Nausea and vomiting
Diarrhoea or constipation
Mucositis
Alopecia
Bone marrow suppression
Cystitis
Phlebitis
Renal and cardiac toxicity

Chronic complications

Carcinogenesis (especially alkylating agents that cause leukaemias; risk proportional to dose) • Pulmonary
fibrosis
Infertility

Drug resistance in tumours

Reduced drug uptake
Increased concentrations of target enzymes to minimise the effects of enzyme inhibition • DNA-repair
mechanisms (eg melanoma) • Mutations coding for cell pumps which extrude the drug • Salvage pathways
Drug inactivation

5.4 Hormonal therapy

Up to 15% of tumours may have hormone-responsive elements.

Prostate tumours

Subcapsular orchidectomy (bilateral) • Anti-androgens
Luteinising hormone-releasing hormone (LHRH) analogues • Stilbestrol (oestrogen)

Breast tumours

Tamoxifen: pre- and postmenopausal women if oestrogen receptor (ER) and/or progesterone receptor
(PR) positive • Aromatase inhibitors: prevent oestrogen production from peripheral fat – no effect on
ovarian oestrogens, so postmenopausal only. Recent evidence of superior disease-free survival even in
early disease compared with tamoxifen for third-generation aromatase inhibitors (eg anastrazole) •
Progestogens: now tend to be used third line, because aromatase inhibitors are superior • LHRH
analogues: monthly goserelin in premenopausal women (3-monthly preparation does not reliably
suppress menstruation in all)

Thyroid tumours

Thyroxine to suppress thyroid-secreting hormone secretion • Liothyronine used

5.5 Additional therapies



In a nutshell ...

Additional potential therapies include:
Immunomodulation: used in renal cell carcinoma, bladder carcinoma • Monoclonal antibodies
Cryotherapy and radiofrequency ablation

Experimental therapies include:
Gene therapy
Anti-angiogenic therapy

Immunomodulation

Renal cancer

Radioresistant
Chemoresistant
Some success with IL-2 and IFN-α

Bladder cancer

BCG vaccine used intravesically
Used in treatment of carcinoma in situ and high-grade (non-invasive) tumours • May be used long term as
‘maintenance therapy’

Monoclonal antibodies

The first two monoclonal antibodies in clinical use are rituximab and trastuzumab:
Rituximab (MabThera) is a monoclonal antibody that causes lysis of B lymphocytes and is licensed for
treatment of relapsed or advanced low-grade lymphoma, and as ‘maintenance’ therapy in the disease
Trastuzumab (Herceptin) is now licensed for use as an adjuvant therapy for breast cancer in high-risk
tumours that over-express human epidermal growth factor receptor -2 (HER-2). Around 16–18% are
likely to be strongly HER-2-positive.

Infusion-related side effects are common with both (chills, fever, hypersensitivity reactions) and both can
exacerbate chemotherapy-related cardiotoxicity.

Bevacizumab (Avastin) binds to VEGF and works as an anti-angiogenic agent. It is used in advanced
CRCs.

Cryotherapy and radiofrequency ablation

Probe inserted into tumour either percutaneously under radiological control or intraoperatively.
Freezing temperature causes ‘ice ball’
Mainly used in palliation

Increasing use in primary treatment for liver tumours

Experimental therapies

Gene therapy

There are ongoing trials of gene therapy with glioblastoma.

Anti-angiogenic agents

Most of the endothelial cells in an adult are quiescent during health. Therapies targeting the process of
angiogenesis are therefore directed specifically at tumour growth.

Current options include:
. Targeting endogenous pro-angiogenic factors, such as:

• Anti-VEGF antibodies (trials of adjuvant use of anti-VEGF agents in colorectal cancer are ongoing in
the USA) • Anti-angiogenic pharmacology (eg cyclo-oxygenase [COX]-2 inhibitors) 2. Administering
endogenous anti-angiogenic compounds or molecules, eg angiostatin, endostatin

SECTION 6

Palliative care and care of the dying

In a nutshell ...

Palliation is the care of patients who are not responsive to curative treatment and have a terminal
condition.
Palliative care (from the Latin palliare, to cloak) aims to address physical, mental and spiritual needs,
and achieve the highest quality of life possible (with the emphasis on quality rather than quantity), in a
manner that promotes dignity and provides support to both the patient and those close to them.
Patients may be nursed at home, in a hospice or as a hospital inpatient.

6.1 The palliative care team

Although providing support for patients with terminal disease is an important skill for all health
professionals, access to a multidisciplinary palliative care team with specialist skills, eg in control of
symptoms, is recognised as improving the quality of end-of-life care. The team usually includes palliative
care consultants and specialist palliative care nurses, and may include pharmacists, physiotherapists and
occupational therapists with a special interest. On an inpatient basis, the team is contacted by the medical
or surgical team in charge of a patient with palliative care needs. These may vary from control of
symptoms, to psychological support or financial advice. The National Institute for Health and Clinical
Excellence (NICE) guidelines advise that 24-hour access to palliative care advice should be available,
eg out-of-hours telephone advice may be given by local hospice staff. On an outpatient basis the patient’s
family may become a key part of the palliative care ‘team’; district nurses, community palliative nurses
and social workers are also involved in providing palliative care in the community.

6.2 Symptomatic control in palliative care


Common symptoms in palliative care
Pain
Shortness of breath
Fatigue

Dry mouth
Appetite loss, nausea, vomiting, diarrhoea and cachexia • Anxiety, depression and confusion

The Edmonton Symptom Assessment System (ESAS) is one of the scoring systems that can be used to
assess these ongoing symptoms. It comprises nine variables, each scored from 1 to 10, and can be
completed by the patient or a caregiver and plotted on a graph.

Managing pain

Assessing and managing pain

Determine the cause by history and examination • Grade the degree of pain
Is there a psychological component?
Use the analgesic ladder
Specific medications may be useful in particular kinds of pain (see below) • Teach the family how to give
painkillers and oral morphine • Consider adjuncts to pharmacological pain relief: • Emotional support
• Touch: stroking, rocking, vibration, massage • Cognitive methods: distraction, music etc

Analgesics in palliative care

By mouth (where possible) • By the clock (prescribe regularly, as prn, meaning pro re nata, Latin for ‘as
needed’, but to help = pain relief negligible!). The next dose of analgesia should be given before the last
dose has worn off and there should be an optional extra for breakthrough pain • By the analgesic:
• Start with simple analgesia (regular paracetamol, ibuprofen) • Add in codeine (with a laxative unless
the patient has diarrhoea) • Substitute an opioid (such as morphine) for codeine and titrate the dose. There
is no maximum limit

Parenteral analgesia

For patients who cannot take things by mouth • Subcutaneous (SC) administration has been shown to be as
effective as intramuscular in terminal care and is less painful • Diamorphine is the drug of choice:
• May need antiemetic in pump if not previously on opiate • Diamorphine SC dose is equivalent to a
quarter to a third of the oral dose of morphine • SC infusion preferable to intravenous (IV) infusion • Less
potentiation
Easier management
Can discharge to home/hospice with SC pump

Potential problems with pumps
Miscalculations of rate and delivery when setting pump • Mechanical failure of pump
Reaction at injection site (IV/SC)

Managing other symptoms



Managing symptoms in palliative care

Pain

Loperamide 2–4 mg four times daily

Colic

Gastric distension Domperidone

Relaxant (eg diazepam, baclofen)

Muscle spasm
Nerve pain–compression

Dexamethasone
Amitriptyline, carbamazepine, TENS, nerve blocks

Nerve irritation
Liver pain (capsular stretching)

Respiratory Dexamethasone


Morphine, diazepam, dexamethasone

Dyspnoea

Excess respiratory secretions Hyoscine

Morphine (short-acting better than MST)

Cough
GI

Antacid, metoclopramide, chlorpromazine

Hiccoughs
Prednisolone, dexamethasone, Megace

Anorexia
Lactulose, co-danthrusate

Constipation
Haloperidol (due to morphine)

Nausea and vomiting
Skin/mucous membranes

Pruritus Antihistamine
Artificial saliva, oral candidiasis treatments

Dry mouth
Neurological

Headache Dexamethasone if raised intracranial pressure

Hypoxia Oxygen
Confusion/sedation Consider drugs/hypercalcaemia/brain metastases
Confusion/agitation Phenytoin, carbamazepine, rectal diazepam

Haloperidol, chlorpromazine

Convulsions

Preventive palliative care

All patients should have:
Regular oral care
Bathing as required
Prevention of bedsores by changes in position • Prevention of stiffness in joints by regular active or
passive mobilisation

Other needs

Both patient and their families may have financial, psychological, social and spiritual concerns.

Many people don’t want to die in hospital and every effort should be made for them to be discharged
either to a hospice or to their own home.

There are a variety of charities and organisations that can help in the provision either of additional or
respite care for patients who are at home or financially.
Sue Ryder: offers specialist palliative and long-term care for people living with cancer, multiple
sclerosis, Huntington’s disease, Parkinson’s disease, motor neurone disease, stroke, brain injury and other
life-changing illnesses: www.sueryder.org/pages/care.html • Macmillan Cancer Support: works in a
huge number of ways to improve the lives of people affected by cancer. The charity offers a
comprehensive range of services including practical and emotional support at home and in cancer care
centres: www.macmillan.org.uk/Home.aspx

The Liverpool Care Pathway

The Liverpool Care pathway (LCP) is an integrated care pathway that was designed to use the best of
hospice care techniques to improve the quality of care delivered to the dying patient in other settings such
as hospitals and care homes.

The advantages of an integrated pathway are:
Explicit statement of the key elements of care based on evidence and best practice • Facilitates
communication between members of the medical team and with the patient and family • Coordinates and
clarifies care and activities of the members of the medical team • Standardises documentation into a
single generic type for use by all team members • Enables identification of resources

The recognition and diagnosis of dying are always complex and uncertainty is part of dying. There are
always times when a patient who is thought to be dying lives longer than expected or vice versa. Regular
assessment, involvement of senior clinical decision-makers and the experience of the palliative care team
are essential. The diagnosis of dying should be made by the multidisciplinary team and not an individual.
Good communication between team members and the patient and their family is also essential. The LCP is
designed neither to hasten nor postpone death, and its use should be discussed with the patient and family
if possible.

Key features of using the LCP
Non-essential medications should be stopped • Non-essential investigations (eg blood tests) should be

stopped • Oral nutrition is supplied as tolerated
Fluids and antibiotics may be used but should be prescribed on an individual basis in the patient’s best

interests • The LCP document provides guidance on the types and regimens of suitable medications for
symptom control • Records daily status, symptoms and treatments provided • Records and prompts
daily care measures such as mouth care, prevention of bedsores, hygiene

The ‘Do not resuscitate’ order

These decisions should be made by the most senior member of the team and should be discussed with the
patient and family. These can be difficult discussions and require excellent communication skills.
Survival to discharge rates after inpatient cardiac arrest remain low and a ‘Do not resuscitate’ (DNR)
order reflects the likelihood of the patient surviving such an attempt. DNR orders should be recorded on a
standardised form, and all members of the nursing and medical team should be aware of the patient’s
resuscitation status.

It is vital that everyone caring for the patient understands that DNR does not mean ‘Do not treat’.

6.3 Oncological emergencies



In a nutshell ...

Oncological emergencies include:
Neutropenia and sepsis
Hypercalcaemia
Superior vena cava (SVC) obstruction
Spinal cord compression

Neutropenia and sepsis

Neutropenia may result from:
Pancytopenia due to bone marrow replacement with malignant cells • Treatment resulting in bone marrow
suppression

These patients may be complicated and require aggressive antibiotic management. Discuss with
microbiology for advice before initiating therapy.

Hypercalcaemia

Often seen in tumours of the breast, bronchus, prostate, myeloma, kidney and thyroid. May be due to bone
metastases or ectopic parathyroid hormone (PTH) secretion.

Presentation of hypercalcaemia in neoplasia

Clinically – ‘bones, moans, stones and groans’:
Malaise
Nausea and vomiting
Constipation
Abdominal pain
Polyuria/polydipsia
Bone pain
Renal stones
Psychosis

Management of hypercalcaemia in neoplasia

May resolve with treatment of the primary malignancy • Optimise fluid balance
Stop thiazide diuretics
May use oral phosphates, calcitonin or non-steroidal anti-inflammatory drugs (NSAIDs)

SVC obstruction

Typically occurs with lung carcinoma or lymphoma.

Presentation of SVC obstruction in neoplasia

Plethoric congested facies
Obstructed dilated neck veins (if the patient elevates the arms then the veins on the affected side do not
empty) • Dizziness on bending forwards
Dyspnoea and pulmonary oedema
Headache
Risk of venous thrombosis (stagnation of blood)

Management of SVC obstruction in neoplasia

Diagnosis of underlying cause
Local radiotherapy
Dexamethasome 4 mg every 6 hours may help

Spinal cord compression

Distribution of malignant spinal cord compression is 70% thoracic, 20% lumbosacral and 10% cervical.
For further discussion see Chapter 9, Orthopaedic Surgery.

Presentation of spinal cord compression in neoplasia

Back pain (worse on straining or coughing) • Leg weakness
Upper motor neurone and sensory signs
Urinary retention

Management of spinal cord compression in neoplasia

Emergency MRI for diagnosis
Discuss with neuro-orthopaedics
Radiotherapy to vertebrae may be helpful
May require surgery if histological diagnosis unclear or the spine is mechanically unstable • High-dose
steroids may be helpful

6.4 The psychological effects of surgery

Postoperative confusion

Acute confusional states are common after surgery, although reports of incidence vary.


In a nutshell ...

The psychological effects of surgery should be considered in all patients. All require a degree of
counselling and rehabilitation. Psychological problems after surgery include:
Confusion
Depression
The effects of chronic pain
Long postoperative recovery

Risk factors for postop confusion

Male > female
Elderly > young
Alcohol abuse
Preoperative dementia or cognitive impairment • Electrolyte imbalance

Exacerbating factors for postop confusion

Hypotension and poor cerebral perfusion
Sepsis
Hypoxia
Electrolyte imbalances
Drug effects, interactions and withdrawal
Pain and anxiety
Cerebral events (eg cerebrovascular accident [CVA] or transient ischaemic attack [TIA])

Management of postop confusion

Assess and correct underlying causes if possible • Be careful with prescription of sedatives in elderly
people; small doses of medication can be given pre-emptively rather than large doses in the middle of the
night
See section on management of delirium tremens

Postoperative depression

This affects 4.5% of surgical patients. Preoperative psychiatric illness, people with complications of
surgery and long-stay patients are at high risk of developing depression. Certain procedures are more
strongly associated with its development:
Cancer surgery
Cardiothoracic surgery
Transplantation
Breast surgery

Clinical features include low mood, tearfulness, insomnia, apathy and anorexia. Management should be
together with psychiatric referral and includes supportive measures and medication.

Chronic pain may contribute to depression.

Long-stay patients also have high levels of depression. Factors affecting the long-stay patient also
include:
Immobility (eg complications, bed sores, deep venous thrombosis [DVT]) • Colonisation (eg meticillin-
resistant Staphylococcus aureus [MRSA]) • Institutionalisation

Response to surgery and disease

Factors influencing the response to surgery and disease are:
Preoperative emotional state
Accuracy of expectations
Ability to choose and feelings of control over the outcome • Personality traits (eg type A personality is
associated with catecholamine release; optimists have better outcomes than pessimists) • Coping and
relaxation strategies
Social support



Additional sources of psychological support
Nurses
Social services (eg ward-based social workers) • Physiotherapists (encouragement and aims)
Counsellors and psychotherapists
Chronic pain team
Drugs (eg antidepressants)

The effects of critical care

There are physical and psychological effects of a period spent in critical care.

Physical complications of critical care

Reduced function due to disease process or pathology • Muscle wasting and weakness
Joint stiffness
Nerve injuries or peripheral neuropathy
Pressure sores

Sleep disturbance and loss of diurnal rhythm • Tracheal stenosis

Psychological impact of critical care

Do not underestimate the psychological impact of critical care. After recovery patients feel that they have
lost a portion of their memory or their memory may be hazy and disjointed. They may recall pieces of
conversation held around their bedside and have memories during periods of drifting in and out of
consciousness. They often feel a loss of control. They may experience anxiety, depression and nightmares.

Some ITUs run a post-discharge clinic where patients can attend to talk about their experiences. Patient
feedback may help the ITU to minimise the impact by altering practice.

6.5 Communication skills in surgery

Communication skills in surgery are covered in depth in the MRCS Part B OSCEs book of the Essential
Revision Notes series and are not discussed further here.

6.6 Breaking bad news

This is discussed in more detail in MRCS Part B OSCEs book of the Essential Revision Notes series.

Compassion and honesty are required.

Breaking bad news should not be done on the ward round in front of large groups of people, and
remember that the curtains around the bed are not soundproof.

If possible take the patient to an office or private space or return at the end of the round in order to speak
to the patient personally. Many patients already expect the worst and you should sound out their
expectations. They may not wish to have full knowledge of their diagnosis and prognosis, and you should
identify how much they want to be told by giving information in small amounts and assessing their
reaction. Patients may need information to be repeated several times in different ways at a later date.

The six steps to breaking bad news

Getting started

Get the physical context right. In person, not by phone or letter • Where? In a private room. Curtains
drawn around the bed. Both sitting down • Who should be there? A relative, friend or nurse, as the
patient wishes • Starting off. Normal courtesies apply: say hello, use the patient’s name, introduce
yourself. Start with a general question to get a two-way conversation going, assess the patient’s mental
state and make the patient feel that you care: How are you today? Are you up to having a chat for a few
minutes?

Find out how much the patient knows

How much has the patient been told? How much has he or she understood?
What is the style of the patient’s statements? This will guide you to the level at which you have to pitch

your information. Does he or she talk in simple terms? Or is he or she very well educated with good
medical knowledge and a wide vocabulary?
What is the emotional content of the patient’s statements? Distressed, anxious, brave, off-hand and
defensive, hostile or in denial?

Find out how much the patient wants to know

You could ask the patient:
Would you like me to give you the full details of the diagnosis?
Are you the type of person who wants to know all the details of what’s wrong, or would you prefer if I just
tell you what’s going to happen next?
If your condition is serious, how much would you like to know about it?
That’s fine. If you change your mind or want any questions answered at future visits, just ask me at any
time. I won’t push information at you if you don’t want it

Share information

Decide on your agenda (diagnosis, treatment plan, prognosis, support) • Start from the patient’s
starting point (aligning) • Repeat to patients what they have said to you and reinforce those things that
they have said that are correct. This shows them that you take their point of view seriously and respect
them
• Give them the information that you need to, clearly, to educate them • Give information in small chunks
with warning shots: Well, the situation does appear to be more serious than that • Do not use jargon: say
tumour AND THEN cancer, not space-occupying lesion or malignancy • Check how they receive this and
clarify: Am I making sense? Do you follow what I’m saying?
• Make sure that you both mean the same thing: Do you understand what I mean when I say it’s incurable?
• Repeat the important points
• Use diagrams and written messages
• Use any printed or recorded information available • Check your level: Is it too complicated or too
patronising?
• Listen for the patient’s agenda: Is there anything that you particularly want to talk through or are worried
about?
• Try to blend your agenda with the patient’s agenda • Be prepared for a ‘last minute’ query, a hidden
question or the patient trying to ‘lead’ the interview

Respond to the patient’s feelings

Identify and acknowledge the patient’s reaction • Allow silence if needed
Denial is perfectly natural and should be challenged only if causing serious problems for the patient •
Anger and blame need to be acknowledged; exploring the causes can follow later • Despair and
depression must be acknowledged. Allow the patient to express his or her feelings and offer support •
Awkward questions such as ‘How long have I got?’ may have no honest answer and you may have to reply
with an open question, an empathic response or silence in some situations
Collusion, where relatives ask the doctor not to tell the patient, is a common request. It must be made clear
that the duty of the doctor lies first to the patient, but the reasons for collusion need to be explored

Planning and follow-up

Planning for the future is a good way to alleviate the bewildered, dispirited, disorganised thoughts of a
patient who has just received bad news.
Demonstrate an understanding of the patient’s problem list • Identify problems that are ‘fixable’ and those
that are not • Make a plan: put ‘fixable’ problems in order of priority and explain what you are going to
do about each one • Prepare the patient for the worst and give them some hope for the best • Identify
coping strategies for the patient and reinforce them • Identify other sources of support for the patient and
incorporate them • Make a contract and follow it through
Summarise the plan that you have formulated • Check that there are no outstanding issues • Outline what
will happen next and what the patient is expected to do • Make sure that you leave an avenue open for
further communication (eg follow-up appointment with doctor or associated medical professional, such as
a breast-care nurse)

Grief

Be aware of the normal stages of grief as shown in the box.


Response to bad news or grief
Denial
Anger
Bargaining
Depression
Acceptance

These responses to bad news may not occur in a predefined order and there is no predictive timeline
for how long these feelings will last. The intensity of the reaction may depend on the intensity of the
feeling of loss on hearing the bad news.

6.7 Dealing with death

Withdrawal of treatment

Over the duration of admission to the ITU and after a period of stabilisation and treatment it may become
apparent that the patient will not recover.

Decisions may be taken that active treatment may be withdrawn, reduced or not increased. Withdrawal of
supportive treatment such as inotropes, ventilatory support or renal replacement therapy may be
considered. Most units also have an upper threshold for certain types of treatment (eg inotrope doses) that
represents what they consider to be maximal support.

In cases where there is a consensus from the medical and nursing staff that continued treatment would be
futile, there is no medicolegal requirement to continue with treatment. This should be discussed in depth
between the relevant family members and members of the medical and nursing teams caring for the
patient.

Deaths that should be reported to the coroner

Report to the coroner all deaths occurring:
Within 24 hours of admission
Related to surgery or anaesthesia
In theatre
Due to accidents and trauma (report all cases of fractured neck of femur) • Due to self- or external

neglect
Due to poisoning or drugs
Due to industrial or notifiable diseases

If in doubt, discuss the case informally with the coroner’s office. They are an invaluable source of help
and advice. You will need to tell them all the patient’s details, the dates of admission and death, and give
an outline summary of the case with suggested causes for completion of the death certificate.

It is very important that death certificates are filled in correctly because a great deal of epidemiological
information is garnered from them and this has effects as far-reaching as funding for service provision.

CHAPTER 6

Trauma
Part 1: Head, Abdomen and Trunk

George Hondag Tse

Head injury: Paul Brennan
Burns: Stuart W Waterston

Overview of trauma
1.1 Historical perspective
1.2 The trimodal distribution of death
1.3 Pre-hospital care
1.4 Triage and major incidents
1.5 Trauma severity scoring

Injury and shock
2.1 The biomechanics of injury
2.2 The physiology of shock

Resuscitation: the primary survey
3.1 Airway and C-spine
3.2 Breathing
3.3 Circulation
3.4 Disability
3.5 Exposure and environment
3.6 Monitoring and important investigations

Assessment: the secondary survey

4.1 Patient overview
4.2 Head injury
4.3 Facial injuries
4.4 Chest trauma
4.5 Abdominal trauma
4.6 Trauma to the soft tissues and skin
4.7 Trauma to peripheral nerves
4.8 Spinal cord injuries
4.9 Vascular trauma

Special cases in trauma
5.1 Burns
5.2 Paediatric trauma
5.3 Trauma in pregnancy
5.4 Post-traumatic stress disorder
5.5 Brainstem death
5.6 Complications of IV drug abuse
5.7 Human and animal bites

SECTION 1

Overview of trauma

1.1 Historical perspective

Trauma care and surgery have been inextricably entwined since the beginnings of society. Battlefield
surgeons such as Ambrose Paré (1510–1590) used empirical observation, common sense and ‘hands-on’
personal experience to improve the treatment of battle wounds during the Napoleonic Wars. The plastic
surgeon Archibald Hector McIndoe (1900–1960) improved the treatment of burns in RAF pilots during
World War II. He noted that those who ditched in the sea had less scarring and infection of their burn
sites, leading to the use of saline soaks instead of tannins. Both men found that conventional practice was
inadequate and sought to improve care and techniques for the sake of their patients and for the common
good.

In 1976 an orthopaedic surgeon crashed his light aircraft in Nebraska, resulting in the death of his wife
and injuring his children. The emergency care that he and his family received was inadequate and this
became the impetus for the development of the Advanced Trauma Life Support (ATLS) training course.

The Royal College of Surgeons of England was one of the first bodies outside the USA to implement
ATLS training (in November 1988).

This system has provided a framework and approach to acute trauma care so that trauma team personnel
can communicate and prioritise in a similar way, allowing parallel or simultaneous treatment in the
multiple injury patient, by a coordinated team approach. This has increased the speed with which injuries
are identified and treated, making the most use of the ‘golden hour’, in order to improve survival and
patient outcome.

1.2 The trimodal distribution of death



In a nutshell ...

Mortality from trauma can be considered in three phases – immediate, early and late (Figure 6.1). Of
deaths caused by trauma 50% occur in the first 10 min after the accident.

Immediate-phase death: these deaths are almost always unpreventable. They include massive brain
injuries, or great vessel injuries (eg aortic avulsion associated with a fall from a height), airway
occlusion, cord transection and exsanguination • Early-phase death: occurs within the first few minutes
to hours when the opportunity for prompt and appropriate diagnosis and intervention can prevent loss of
life or limb (the so-called ‘golden hour’). The ATLS system mainly addresses this phase of care, and
emphasises the need for rapid assessment and resuscitation
Late-phase death: occurs days to weeks after the injury, during which time deaths can occur due to sepsis
and multiple organ system failure, or complications arising as a consequence of the initial injury or
surgery. The quality of care in phases 1 and 2 will obviously have an impact on mortality in phase 3, and
on overall outcome



Figure 6.1 M ortality from trauma – trimodal dis tribution

1.3 Pre-hospital care



In a nutshell ...

The primary role of pre-hospital care is to:
Temporarily stabilise the patient
Expedite transport of the severely injured patient to the site of definitive treatment

Pre-hospital treatment is driven by rapid assessment and the principles of ATLS.

Pre-hospital care in the UK is delivered in a variety of ways depending on illness or injury severity.
These include:
NHS Direct: this scheme provides information via the telephone or internet from senior nurses on minor
illness or injury, with the emphasis on self-care. Patients may be diverted to primary care or the
ambulance service if necessary • Minor injury units: care is delivered by emergency nurse practitioners
and these centres have links with local accident and emergency departments (A&E) and radiology

services
Primary care: general practitioners may manage minor injury • Road ambulance service: the emergency
ambulance service is usually mobilised by telephone (999) from either the patient or a witness at the
scene. Vehicle tracking is used to mobilise the nearest resource, and clinical information is relayed to the
ambulance team. Calls are prioritised according to clinical need (A for life-threatening, B for serious but
not life-threatening and C for neither serious nor life-threatening) by computer software used in the
ambulance control room. Road ambulances are usually staffed by a paramedic and a technician, and an
ambulance officer or manager may also be sent to manage the scene of complex incidents. Clinical care at
the scene is delivered in accordance with national clinical protocols. Clinical information is relayed by
ambulance staff at the scene to the proposed A&E to allow advance preparation of facilities and staff to
receive the patient (eg preparation of the resus room and trauma call). Patients are usually delivered to
the nearest A&E but some may subsequently require secondary transfer to a tertiary referral centre for
definitive care
Air ambulance: air ambulances are primarily staffed by suitably trained paramedics and technicians, but
in some regions these teams also include trained senior doctors and nurses (eg the Helicopter Emergency
Medical Service [HEMS] in London) • Mobile medical teams (MMTs): these teams consist of trained
medical personnel, often from the A&E of the nearest hospital, or doctors trained by organisations such as
the British Association for Immediate Care (BASICS). They may be mobilised to entrapments or major
incidents. Extrication requires close coordination between medical and fire services

The techniques of pre-hospital care vary from country to country. In the USA, pre-hospital care personnel
are taught to ‘scoop and run’, with the aim of delivering the patient to the place of definitive care as
quickly as possible. This may involve bypass of the local facilities and targeting of tertiary facilities (eg
delivery of cardiothoracic injuries direct to a cardiothoracic unit). In France, pre-hospital care involves
the mobilisation of intensive therapy units (ITUs) to the scene with more emphasis on stabilising the
patient before transfer.

The value of information obtained from the emergency agencies in the field cannot be underestimated.
Detailed and early information allows mobilisation of the trauma team, including laboratory services,
porters and the radiology department. Advance knowledge of the number of casualties and the type and
extent of injuries allows for preparation of the appropriate equipment (such as chest drains, thoracotomy
sets and O-negative blood), so that they are available as soon as the patient arrives. Ideally, continual
updates should be provided by the emergency services so that the receiving team is appropriately
prepared.

Principles of immediate care

The principles of immediate care have been outlined by the American College of Surgeons’ Committee on
Trauma (ACS-COT) in a format similar to ATLS.
Assess potential safety issues at the scene and take steps to make it as safe as possible • Quickly assess
the patient: observe vital signs and level of consciousness, determine the nature of accident and
probable mechanism of injuries



Indications of potential significant trauma
Penetrating injury to thorax, abdomen or head • Major bony injury: two or more proximal long-bone

fractures, pelvic fracture, traumatic amputation proximal to wrist or ankle • Burns involving more than
15% of the body surface area or to face and potentially to airway • Evidence of high-energy impact:

• Fall from a height (>6 metres) • Pedestrian in a road traffic accident (RTA) (hit at more than 20 mph
or thrown by impact) • Car occupant in an RTA (unrestrained; speed >20 mph, intrusion into passenger
compartment of >30 cm, ejection of passenger from vehicle, roll-over of vehicle, death of another car
occupant, extrication time >20 minutes)

Pre-hospital resuscitation follows ATLS principles:
C-spine immobilisation: in-line immobilisation with a hard collar, sandbags and tape • Airway
management: can be difficult. Can often be maintained with basic measures. Intubation without
anaesthesia and rapidsequence induction is ill-advised because it can induce vomiting and raise
intracranial pressure • Breathing: give oxygen • Circulation: haemorrhage should be controlled with
direct pressure; ensure good venous access before releasing from vehicle. Fluid resuscitation should be
given to a systolic blood pressure of 90 mmHg
Disability: fractured limbs should be splinted and the patient prepared for transport • Analgesia: can be
achieved with ketamine or Entonox (contraindicated if possibility of pneumothorax or basal skull
fracture)

Initial hospital care

Most Emergency Departments in the UK that deal with trauma cases have a designated area for receiving
trauma cases. This is obviously essential for rapid access to specialist equipment and services.


ESSENTIAL RESOURCES FOR TRAUMA MANAGEMENT

Airway management Circulatory support Infrastructure

Large-bore cannulas

Laryngoscope Rapid communication links
Endotracheal (ET) tubes