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EM200 > Abdominal Emergencies > Flashcards

Abdominal Emergencies Flashcards

1
Q

Case 1: • Paramedics arrive with a 65 year old man complaining of sudden severe left flank and epigastric pain • PMH: None • No medications, NKDA • SH: Smokes 1ppd x 30 years Exam: • VS: BP82/40 P110 RR16 T37.2°F • HEENT: Normal • Heart: Regular rhythm, tachycardic • Lungs: Clear all fields • Abdomen: Non-distended, + bowel sounds, soft, slightly tender in epigastrium • Guaiac negative brown stool Extremities: Diminished dorsalis pedis pulses, capillary refill time 3 sec • Skin: Clammy, cool • Neurologic: A+O x 3, anxious, moves all extremities, GCS 15 (1) DDx? (2) Initial steps in management for this patient (during first 5 minutes of ED arrival)? (3) Which lab studies are indicated based on your clinical suspicion? (4) Which radiographic studies are indicated based on your clinical suspicion?

A

(1) AAA, perforated peptic ulcer, acute pancreatitis, incarcerated hernia, nephrolitiasis, gastritis (2) Place 2 large bore IVs–14 or 16 gauge, hook up cardiac monitoring, supplemental O2 (3) CBC, BMP, coags, type and screen x 6u of blood (4) FAST and/or CT

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2
Q

Most common site for AAA

A

intrarenal

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3
Q

True aneurysm =

A

dilation of all 3 layers of the aorta

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4
Q

Normal abdominal aorta diameter:

A

≤ 2cm

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5
Q

Other health conditions associated with increased risk of AAA

A

Trauma Infection Connective tissue disease Arteritis

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6
Q

Size of dilation at which it is considered an abdominal aneurysm:

A

3cm or larger

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7
Q

Major risk factors for AAA

A

Atherosclerosis Peripheral Vascular Disease First degree relative with AAA

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8
Q

First degree relative with AAA increases risk by _____.

A

10x

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9
Q

Clinical presentation of unruptured AAA:

A

Asymptomatic. or… Gradual onset of vague, dull, constant abdominal pain

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10
Q

Risk of rupturing aneurysm via palpation during exam:

A

None

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11
Q

Abdominal bruit common in patients with AAA?

A

Not super common–10 to 30% will have one

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12
Q

Classic triad for AAA presentation:

A

Abdominal pain

Hypotension

Syncope

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13
Q

Common presenting signs of AAA:

A

Abdominal Pain

Hypotension

Syncope

Back pain

Flank pain

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14
Q

Size of AAA at which rupture become EXTREMELY likely:

A

Over 5.5 cm

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15
Q

Most common site of AAA rupture leakage and associated symptoms?

Outcome if leak is intraperitoneal?

A

Most common site = retroperitoneal and is associated with severe back and flank pain.

If leak is intraperitoneal then death is imminent

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16
Q

Role of plain films in AAA management:

A

Supine and lateral abdomen plain films can identify calcifications in the abdominal wall and there may be non-specific shadowings of the psoas muscle or kidney

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17
Q

Visualization of retroperitoneum with abdominal US:

A

You cannot visualize the retroperitoneum with US

18
Q

Role of angiography in emergent evaluation of AAA:

A

None

19
Q

Role of MRI in emergent evaluation of AAA:

A

None

20
Q

Surigical mortality rate in ruptured and elective AAA repairs:

A

Ruptured: 50%

Elective: 5%

21
Q

Treatment of AAA:

A
  1. Vascular surgery consult ASAP
  2. Traditional laparotomy
  3. Endovascular repair
22
Q

Explain how open AAA repair vs endovascular repair is done:

A

Open: aneurysm is opened, a graft is placed, the aneurysm is then closed over the graft.

Endovascular: stent is placed within the aneurysm via the femoral artery.

23
Q

Case 2

A 75 year old female presents with sudden onset of diffuse abdominal pain that woke her from sleep. She is in obvious pain, tearful

PMH: atrial fibrillation

Meds: coumadin (ran out a week ago)

NKDA

Exam:

VS: BP 146/90 HR 118 RR 24 T 37.0°F SaO2 98%

Heart: irregularly irregular, tachycardic

Lungs: CTA

Abdomen: non-distended, soft, non- tender, no palpable masses

Guaiac positive, brown stool

Extremities: no edema, moves all extremities, dorsalis pedis pulses intact

Diagnostic Adjuncts

Abdominal plain film: Non-specific bowel gas pattern, no free air

CT Abdomen/pelvis: Ischemia of small bowel, filling defect in proximal superior mesenteric artery

  1. Diagnosis?
  2. Next steps in management?
A
  1. Acute Mesenteric Ischemia
  2. Although we pretty much know that this is AMI, we could perform the gold standard diagnostic test and order an angiogram. Treatment would include heparin, glucagon, intra-arterial papverince, and laparotomy to remove the embolus, bypass the occlusion, and remove any dead bowel.
24
Q

Treatment of non-occlusive acute mesenteric ischemia

A

fewer good options, since this is caused by other underlying conditions in the patient.

However you should attempt to:

  • Remove the affending stimulus
  • Correct the underlying conditions
  • Acheive vasodilation, anticoagulation, mesenteric regional blockade, and intra-arterial papaverine.

**Laparotomy is only necessary if dead bowel is suspected.

25
Q

Treatment of mesenteric venous thrombosis:

A

Heparin

IV thrombolytics and thrombectomy occasionally used.

26
Q

Mortality rates for:

  1. Arterial AMI:
  2. Acute venous thrombosis AMI:
  3. AMI from chronic venous thrombosis:
  4. Non-occlusive ischemia:
A
  1. 70-100%
  2. 30-40%
  3. 20%
  4. 70-80%
27
Q

Case 3:

A 56 year old male presents with 3 days of epigastric abdominal pain and vomiting dark blood approximately 1 hour PTA

PMH: Arthritis

Medications: Naproxen

NKDA

• Social: Smokes 1 ppd x 20 years, occasional alcohol use

Physical exam:

VS: BP 100/55 HR 122 R 18 T 37.5°F

General: Middle aged male appears uncomfortable

Heart: Regular, tachycardic

Lungs: CTA

Abdomen: Non-distended, soft, + BS, epigastric tenderness, no rebound or

guarding, guaiac negative stool

Extremities: Cool and clammy

  1. Diagnosis:
  2. Next steps in management:
A
  1. Upper GI bleed–likely from a perforated peptic ulcer based on naproxen use.
  2. Establish 2 large bore IVs and start crystalloid resuscitation with normal saline solution. Type and cross x 4-6 units of blood, and perform NG lavage only after stabilizing the patient
28
Q

Number 1 cause of upper GI bleeding:

A

PUD

29
Q

Possible etiologies of upper GI bleeding:

A

PUD

Gastric erosions

Variceal bleeding

Mallory Weiss

Esophagitis

Duodenitis

Aortoenteric fistula (rare)

Renal Disease

30
Q

Most common presenting sign of perforated peptic ulcer:

A

Melena

31
Q

% cases of hematochezia caused by UGIB:

A

10%

32
Q

Tricky part of heme-testing stool in PUD upper GI bleeding cases:

A

Early on these tests are often negative

33
Q

Preferred solution to use when performing NG lavage in upper GI bleeding:

A

Most people use tap water at room temp

34
Q

Main relative contraindication to NG lavage:

A

prior gastric bypass surgery

35
Q

Common electrolyte abnormality seen in UGIB:

A

elevated BUN

36
Q

Who are the typical consults for upper and lower GI bleeds:

A

UGIB: GI

LGIB: Surgery

37
Q

Which GI bleeding patients are admitted and which are D/Ced?

A

Pretty much all are admitted, unless:

Cause is hemorrhoids or fissue

the patient is stable and has a negative w/u (Hb, NG lavage, no active rectal bleeding)

38
Q

Which GI bleeder patients are taken to ICU vs the floor:

A

ICU: hemodynamically unstable, active bleeding, severe anemia, coagulopathy, need for urgery endoscopy, blood transfusion needed.

Floor: hematemesis that quickly clears in stable patient, stable vital signs.

39
Q

Treatment for upper Gi bleeds:

A

Octreotide / Somatostatin

PPI

Sengstaken-Blakemore Tube for intractable hemorrhage

Endoscopy (mainstay)

40
Q

What increases the risk of rebleeding and mortality in upper GI bleeds:

A

Hb < 11

Shock or hypotension on presentation

Tachycardia > 110-120 per minute

Age > 60

Coagulopathy

Co-morbidities like cancer

41
Q

Most common causes of LGIB:

A

Diverticulosis

Angiodysplasia

Cancer

Rectal Disease

Ischemic colitis

IBD

(Brisk upper GI bleed)

42
Q

Management of LGIB:

A
  1. Resuscitate
  2. Perform diagnostic maneuvers:
    • Anoscopy
    • Colonoscopy
    • Nuclear RBC tagging
    • Angiography
  3. Treatment with:
    • Embolization
    • Intra-arterial vasopressin
    • Surgery

EM200 (15 decks)

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