Abdominal Emergencies Flashcards
What is the progression of pain in an appendicitis?
Visceral pain which may migrate or become localized in the RLQ (McBurney’s point) and ends in somatic pain in the RLQ.
What are 5 diagnostics for a workup if an acute appendicitis is suspected?
CBC (usually elevated, but can be OK)
Chemistry panel (electrolytes and LFTs)
UA (usually OK, but can be abnormal)
Pregnancy test
Imaging
What imaging should be done for adults, kids, and pregnant women in an acute appendicitis?
Adults: CT abdomen and pelvis w/ oral contrast
Kids: US of RLQ first, and if negative try CT
Pregnancy: MRI
Initial therapy for acute appendicitis may include… (5)
And the ultimate treatment is…
NPO IV fluids Anti-emetic Pain meds Possibly pre-op antibiotics
Surgery
Early appendicitis may mimic…
Gastroenteritis or viral illness
80-90% of ingested foreign bodies will…
How many need surgical intervention?
Pass without the need for intervention
<1% require surgical intervention
Most common ingested foreign body in kids vs. adults:
Kids - coins
Adults - food bolus
Most common site of obstruction in the GI tract:
Esophagus
Drooling and inability to swallow liquids indicative are indicative of…
What should be done?
Esophageal obstruction
Stat EGD (don’t get imaging first - begin with this)
Approach and management of ingested foreign bodies depends on: (3)
Presence/severity of symptoms
Type of object (size, shape, content)
Location
Under what 3 circumstances would you get an emergent endoscopy within 6 hours after ingestion of foreign bodies in the esophagus?
Complete obstruction as evidenced by drooling and an inability to handle oral secretions
Disk batteries
Sharp-pointed objects in the esophagus
All foreign bodies in the esophagus require removal within how much time?
24 hrs
How long will it take for foreign bodies to be passed if they are in the stomach or proximal duodenum?
What is the management in the meantime?
Should you ever do an EGD?
4-6 days
Weekly XRs until the object passes
Resume normal diet and monitor stools
Still, if the object is deemed to be more dangerous, an endoscopy can be done if not passed within 24 hrs.
What is the management of ingested foreign bodies distal to the ligament of Treitz?
When might you want to use some kind of intervention?
Expectant management - weekly imaging and stool monitoring
If these is evidence of inflammation or obstruction (fever, abdominal pain or vomiting)
What is the most common type of hernia?
Of them, which sub-type is most common?
75% are inguinal hernias
2/3 are indirect
1/3 are direct
What are the 3 ways hernias are classified?
Anatomic location - ventral, groin
Hernia contents - usually bowel or fat
Status of its content - reducible, incarceration, strangulated
2 most common ventral hernias
Epigastric and Umbilical
Direct vs. indirect inguinal hernias
Direct: passes directly through a weakness in the transversalis fascia in Hesselbach triangle
Indirect: passes from the internal to the external inguinal ring and through a patent process vaginalis and then into the scrotum
Reducible hernia =
Incarcerated hernia =
Strangulated hernia =
Reducible hernia = herniated sac is soft and easy to push back through the defect
Incarcerated hernia = herniated sac is firm, often painful, and non-reproducible by direct manual pressure with NO signs of systemic illness
Strangulated hernia = herniated sac is firm and very painful, usually with signs of systemic illness (fever, N/V) and implies an impairment of blood flow
Which hernia is an acute surgical emergency?
Strangulated hernia
What should be assumed, in terms of treatment, in a patient with a hernia?
Assume a strangulated hernia:
- surgery consult
- broad-spectrum abx.
- fluids and pain meds
- pre-op labs
If a hernia is incarcerated, what is the treatment?
Attempt to reduce, and if unsuccessful, consult surgery
If a hernia is reducible, what is the treatment?
Outpatient surgery follow-up
Age population of patients with AAA
Disease of older patients: almost always >60 y/o
At what size is an AAA diagnosed?
What is the most common location?
When the aorta becomes >3 cm (2 cm normally)
Below renal aa.
Most AAAs are..
Asymptomatic and found incidentally
What are the symptoms (classic triad) of a patient with a symptomatic and ruptured AAA?
Patient looks poor and have a high morbidity/mortality
Triad - Abdominal/flank pain, hypotension, shock
How often is AAA misdiagnosed?
What is it mistaken for?
30% of the time
Renal colic, perforated viscus, diverticulitis, GI bleed, ischemic bowel
Describe the diagnostic testing for:
Screening AAA
Asymptomatic AAA
Symptomatic (stable vs. unstable) AAA
Screening AAA: one time for at risk patients over 65 with US
Asymptomatic AAA: if known AAA, 6 mo. or annual US or CT abdomen/pelvis
Symptomatic AAA: CT abdomen/pelvis w/ IV contrast (stable); OR w/o imaging (unstable)
What sized AAA suggests a good surgical candidate?
> 5.5 cm
Blunt trauma causes:
Deceleration causes:
Blunt trauma - rupture of hollow organs
Deceleration - shearing injuries
What is the most common type of trauma seen in the ED? What is it caused by?
What are the 2 most commonly affected organs?
Blunt abdominal trauma, 75% by MVC
Spleen and liver
ABCDE’s of trauma evaluation
Airway - maintenance with C-spine control
Breathing and ventilation
Circulation - with hemorrhage control
Disability/neurologic status
Exposure/environmental control - prevent hypothermia
Diaphragm injuries most commonly occur on which side?
What causes them?
What should not be used when putting in a chest tube?
Left side
Blunt high impact trauma (MVC)
Trochar
Causes of duodenal injuries (2 major ones)
What imaging should be done?
Unrestrained drivers and handlebar injuries
CT abdomen and pelvis w/ IV and oral contrast
Imaging for pancreatic injury:
Check what labs?
CT abdomen and pelvis with IV and oral contrast
Amylase and lipase
What may cause a GU trauma injury?
What may cause you to suspect it?
What imaging?
Suspect what with an anterior pelvic injury?
Direct blows to the back or flank
Gross or microscopic hematuria
CT abdomen and pelvis with IV contrast
Urethral disruption (urine coming from EUS)
What can cause mortality in patients with pelvic fractures?
Disruption of the pelvic ring can tear the pelvic venous plexus and occasionally disrupts the internal iliac arterial system
Mortality of patients with:
All types of pelvic fractures
Closed fractures and hypotension
Open pelvic fractures
All types of pelvic fractures: 1 in 6
Closed fractures and hypotension: 1 in 4
Open pelvic fractures: 1 in 2
The goal of a FAST scan is to evaluate for… (5)
Free intraperitoneal fluid
Pericardial fluid
Pleural fluid
Hemothorax
PTX
What is a vital thing to consider regarding the FAST scan?
It is not sensitive enough to rule stuff out
Morrison’s pouch =
Space that separates the liver from the right kidney
