Abdominal Emergencies

Question 1

What is the progression of pain in an appendicitis?

Answer 1

Visceral pain which may migrate or become localized in the RLQ (McBurney’s point) and ends in somatic pain in the RLQ.

Question 2

What are 5 diagnostics for a workup if an acute appendicitis is suspected?

Answer 2

CBC (usually elevated, but can be OK)

Chemistry panel (electrolytes and LFTs)

UA (usually OK, but can be abnormal)

Pregnancy test

Imaging

Question 3

What imaging should be done for adults, kids, and pregnant women in an acute appendicitis?

Answer 3

Adults: CT abdomen and pelvis w/ oral contrast

Kids: US of RLQ first, and if negative try CT

Pregnancy: MRI

Question 4

Initial therapy for acute appendicitis may include… (5)

And the ultimate treatment is…

Answer 4

NPO
IV fluids
Anti-emetic
Pain meds
Possibly pre-op antibiotics

Surgery

Question 5

Early appendicitis may mimic…

Answer 5

Gastroenteritis or viral illness

Question 6

80-90% of ingested foreign bodies will…

How many need surgical intervention?

Answer 6

Pass without the need for intervention

<1% require surgical intervention

Question 7

Most common ingested foreign body in kids vs. adults:

Answer 7

Kids - coins

Adults - food bolus

Question 8

Most common site of obstruction in the GI tract:

Answer 8

Esophagus

Question 9

Drooling and inability to swallow liquids indicative are indicative of…

What should be done?

Answer 9

Esophageal obstruction

Stat EGD (don’t get imaging first - begin with this)

Question 10

Approach and management of ingested foreign bodies depends on: (3)

Answer 10

Presence/severity of symptoms

Type of object (size, shape, content)

Location

Question 11

Under what 3 circumstances would you get an emergent endoscopy within 6 hours after ingestion of foreign bodies in the esophagus?

Answer 11

Complete obstruction as evidenced by drooling and an inability to handle oral secretions

Disk batteries

Sharp-pointed objects in the esophagus

Question 12

All foreign bodies in the esophagus require removal within how much time?

Answer 12

24 hrs

Question 13

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?

Answer 13

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.

Question 14

What is the management of ingested foreign bodies distal to the ligament of Treitz?

When might you want to use some kind of intervention?

Answer 14

Expectant management - weekly imaging and stool monitoring

If these is evidence of inflammation or obstruction (fever, abdominal pain or vomiting)

Question 15

What is the most common type of hernia?

Of them, which sub-type is most common?

Answer 15

75% are inguinal hernias

2/3 are indirect
1/3 are direct

Question 16

What are the 3 ways hernias are classified?

Answer 16

Anatomic location - ventral, groin

Hernia contents - usually bowel or fat

Status of its content - reducible, incarceration, strangulated

Question 17

2 most common ventral hernias

Answer 17

Epigastric and Umbilical

Question 18

Direct vs. indirect inguinal hernias

Answer 18

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

Question 19

Reducible hernia =

Incarcerated hernia =

Strangulated hernia =

Answer 19

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

Question 20

Which hernia is an acute surgical emergency?

Answer 20

Strangulated hernia

Question 21

What should be assumed, in terms of treatment, in a patient with a hernia?

Answer 21

Assume a strangulated hernia:

• surgery consult
• broad-spectrum abx.
• fluids and pain meds
• pre-op labs

Question 22

If a hernia is incarcerated, what is the treatment?

Answer 22

Attempt to reduce, and if unsuccessful, consult surgery

Question 23

If a hernia is reducible, what is the treatment?

Answer 23

Outpatient surgery follow-up

Question 24

Age population of patients with AAA

Answer 24

Disease of older patients: almost always >60 y/o

Question 25

At what size is an AAA diagnosed?

What is the most common location?

Answer 25

When the aorta becomes >3 cm (2 cm normally)

Below renal aa.

Question 26

Most AAAs are..

Answer 26

Asymptomatic and found incidentally

Question 27

What are the symptoms (classic triad) of a patient with a symptomatic and ruptured AAA?

Answer 27

Patient looks poor and have a high morbidity/mortality

Triad - Abdominal/flank pain, hypotension, shock

Question 28

How often is AAA misdiagnosed?

What is it mistaken for?

Answer 28

30% of the time

Renal colic, perforated viscus, diverticulitis, GI bleed, ischemic bowel

Question 29

Describe the diagnostic testing for:

Screening AAA

Asymptomatic AAA

Symptomatic (stable vs. unstable) AAA

Answer 29

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)

Question 30

What sized AAA suggests a good surgical candidate?

Answer 30

> 5.5 cm

Question 31

Blunt trauma causes:

Deceleration causes:

Answer 31

Blunt trauma - rupture of hollow organs

Deceleration - shearing injuries

Question 32

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?

Answer 32

Blunt abdominal trauma, 75% by MVC

Spleen and liver

Question 33

ABCDE’s of trauma evaluation

Answer 33

Airway - maintenance with C-spine control
Breathing and ventilation
Circulation - with hemorrhage control
Disability/neurologic status
Exposure/environmental control - prevent hypothermia

Question 34

Diaphragm injuries most commonly occur on which side?

What causes them?

What should not be used when putting in a chest tube?

Answer 34

Left side

Blunt high impact trauma (MVC)

Trochar

Question 35

Causes of duodenal injuries (2 major ones)

What imaging should be done?

Answer 35

Unrestrained drivers and handlebar injuries

CT abdomen and pelvis w/ IV and oral contrast

Question 36

Imaging for pancreatic injury:

Check what labs?

Answer 36

CT abdomen and pelvis with IV and oral contrast

Amylase and lipase

Question 37

What may cause a GU trauma injury?

What may cause you to suspect it?

What imaging?

Suspect what with an anterior pelvic injury?

Answer 37

Direct blows to the back or flank

Gross or microscopic hematuria

CT abdomen and pelvis with IV contrast

Urethral disruption (urine coming from EUS)

Question 38

What can cause mortality in patients with pelvic fractures?

Answer 38

Disruption of the pelvic ring can tear the pelvic venous plexus and occasionally disrupts the internal iliac arterial system

Question 39

Mortality of patients with:

All types of pelvic fractures
Closed fractures and hypotension
Open pelvic fractures

Answer 39

All types of pelvic fractures: 1 in 6
Closed fractures and hypotension: 1 in 4
Open pelvic fractures: 1 in 2

Question 40

The goal of a FAST scan is to evaluate for… (5)

Answer 40

Free intraperitoneal fluid

Pericardial fluid

Pleural fluid

Hemothorax

PTX

Question 41

What is a vital thing to consider regarding the FAST scan?

Answer 41

It is not sensitive enough to rule stuff out

Question 42

Morrison’s pouch =

Answer 42

Space that separates the liver from the right kidney