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Emergency Medicine Exam 3 > Abdominal Pain in the ED > Flashcards

Abdominal Pain in the ED Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Belly pain in the ED should start with

A
  • ABCDE
  • large bore IV
  • cardiac monitoring
  • IV fluids
  • NPO
  • symptom mangament (zofran, analgesics)
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2
Q

when to worry?

A
  • Extremes of age
  • abnormal vital signs
  • sudden onset of severe abdominal pain
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3
Q

what are three main types of abdominal pain

A

Visceral peritoneal pain

  • inflammation/stretching of visceral peritoneum
  • dull, poorly localized

Parietal peritoneal pain

  • inflammation of the parietal peritoneum
  • localized and distinct

referred pain

  • pain felt away from the source
  • i.e gallbladder pain referred to the right shoulder
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4
Q
  • Sharp = risk of perforation
  • larger = risk of ischemia, aspiration, tracheal encroachment
  • button batteries= risk of erosion/perf (thermal burn, alkaline injury, fistula formation)

Presentation

  • ped, cognitivie impairment, mental health hx, incarcerated
  • drooling/refusing P/O
  • dysphagia
  • tracheal involvement = Stridor/dyspnea
A

Esophageal Obstruction

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5
Q

diagnosis of esophageal obstruction

A

plain films

  • button battery = “stacked sign”, flat FB shows circle in coronal plane
  • typically “O” on cOronal = in esOphagus

If not radio-opage

    • CT soft tissue neck
    • exploratory EGD
  • gastrograffin swallow study
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6
Q

Management of Esophageal obstruction

A

Emergent EGD

  • button battery- erosioin starts in 15 min, can perf within a few hours
  • sharp
  • airway compromise
  • aspiration risk

Output Xray 24 hours

  • no emergent indication, no pain, tolerating PO
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7
Q

Boerhaaves syndrome

  • effort rupture: ++ vomiting, abdominal trauma, defecating

Iatrogenic

  • EGD

Presentation

  • Hx of ETOHism, bulimia, recent EGD
  • severe retrosternal/upper abdomen pain
  • odynophagia
A

Esophageal perforation

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8
Q

Diagnosis of esophageal perforation

A
  • CXR- mediastinal or free peritoneal air
  • CT
  • gastrograffin esophagram
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9
Q

management of esophageal perforation?

A
  • NPO
  • IVF
  • Broad spectrum abx
  • surgery: primary repair, stent, diversion
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10
Q

Esophageal varices

  • enlarged veins d/t portal hypertension
  • risk factors = ETOH use, liver disease

Peptic ulcer disease

  • gastric or duodenal
  • risk factors= h.pylori, NSAIDs, high dose steroids, smoking, ETOH
  • complications= deep ulceration causing UGIB or perforation

Presentation

  • hematemesis (red or coffee grounds)
  • melena
  • tachycardia, hypotension, LH/syncope, shock
  • PUD: abdominal rigidity
A

Upper GI bleed

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11
Q

diagnosis of upper GI bleed?

A
  • Decreased h/h, increased BUN
    • hemooccult or melena on DRE
  • PUD: xray= free air, if stable- CT= air, defect

Variceal bleed

  • clinical
  • EGD
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12
Q

Management of Upper GI bleed?

A
  • IV x 2
  • type and crossmatch blood
  • +/- blood transfusion
  • prophylactic abx
  • bleeding/perforated ulcer: PPI, surgery cautery/omental patching
  • Variceal bleed: octreoctide, intubate, GI or EGD/banding
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13
Q
  • Post op adhesion
  • hernias
  • IBD
  • tumors

Presentation

  • abdominal distention
  • diffuse crampy pain
  • n/v
  • inability to pass gas or stool
  • dehydration
A

Small bowel obstruction

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14
Q

diagnosis of SBO?

A

X-ray

  • obstruction series, air-fluid levels

CT

  • can determine grade
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15
Q

management of SBO?

A
  • IVF
  • NPO
  • NG tube

Partial SBO: medical admit
high grade SBO= surgical consult
closed loop SBO= surgical emergency

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16
Q
  • protrusion of viscous through abdominal wall defect
  • risk factors: increased intra-abdominal pressure (pregnancy, ascites, obesity) surgical incision sites
  • reducible
  • incarcerated
  • strangulated

Presentation

  • severely painful, tender, non-reducible mass
  • sbo presentation (N/V, inability to pass gas/stool)
  • hematochezia
  • if strangulated–> gangren–>perforation–> peritonitis–> septic shock
A

Incarcerated and strangulated hernia

17
Q

Diagnosis of hernia?

A

Clinical= redness, severe tenderness at hernia
labs: Leukocytosis, elevated lactate
X-ray: SBO signs
+CT

18
Q

managment of incarcerated hernia

A
  • IV, Pain/nausea management, NPO, IVF
  • uncertain duration of incarceration? = don’t reduce
  • incarcerated = surgical consult
  • strangulated= IV abx, surgical emergency
19
Q
  • median age 22, but can occur at any age
  • most common gen surg problem in pregnancy

Presentation

  • visceral pain–migrates to McBurney’s
  • anorexia
  • N/V
  • resisting movement
A

Appendicitis

20
Q

diagnosis of appendicitis?

A
  • Rosving sign: pain to RLQ with palpation of LLQ
  • obturator sign: pain with internal rotation of R hip
  • iliospoas sign: RLQ pain with passive extension of R hip
  • labs: +/- leukocytosis, up 30% with normal WBC
  • imaging: +CTAP most sensitive, +US= children, pregnant patients, MRI= pregnancy
21
Q

management of appendicitis?

A
  • IV, NPO, IVF, pain/nausea control, abx if per
  • surgical consult- appendectomy, drain/wash out if complicated (abscess or perf)
22
Q
  • inflammation/infection of out-pocketing of the colon
  • risk factors= constipation/low fiber diets, increased intraluminal pressures
  • complications: abscess, perforation

Presentation

  • LLQ pain/ tenderness
  • diarrhea
  • N/V
  • +/- fever
  • hematochezia
  • hx of diverticulosis on colonoscopy
A

Acute diverticulitis

23
Q

diagnosis of acute diverticulitis?

A
  • labs (+/- leukocytosis)
  • imaging: CTAP, shared decision making if forego CTP, prior episode with exact same sxs, not sick
24
Q

management of acute diverticulitis?

A
  • IV, NPO, IVF, pain/nausea control
  • Uncomplicated = discharge home (bowel rest- clear liquid diet) abx (cipro and flagyl or augmentin)
  • complicated= IV abx, admit/OR (perforation= surgery, abscess = IR drainage)
25
Q
  • Perforation through the wall of hollow organs (small intestine, colon)
  • PUD
  • Complicated apendectomy
  • complicated diverticu
  • complicated SBO

Presentation

  • sick
  • abdominal distention
  • septic shock
A

Rupture hollow viscus

26
Q

diagnosis of rupture hollow viscus?

A

labs

  • leukocytosis
  • elevated lactate (sepsis)

Xray

  • pneumoperitoneum (air cresent- under diaphragm on upright, rigler sign- double wall sign)
    • CT
27
Q

Managment of rupture hollow viscus

A

IV, NPO, IVF, pain/nausea control, IV abx
sugery

28
Q
  • average size < 2 cm diameter
  • aneruysmal = >3 diameter
  • higher rupture risk > 5cm diameter
  • risk factors: age, atherosclerosis, HTN, connective tissue disorders, family hx

Presentation

  • Classic triad: abdominal or flank pain, hypotension, pulsatile abd mass
  • LH/ syncope
  • tachycardia and hypotension
  • hemorrhagic shock
  • pain is severe, ripping or tearing
  • retroperitoneal hemorrhage (cullen sing, grey-turner sign)
A

Ruptured abdominal aortic aneurysm

29
Q

diagnosis of Ruptured abdominal aortic aneurysm

A
  • POCUS esp in the setting of known AAA
  • aorta > 5.5cm diameter with shock
  • CT if stable
  • labs: decreased h/h, elevated lactate
30
Q

management of AAA?

A

ABCDE

  • emergency surgery, vascular
31
Q

septic ureteral stones

A
  • dont miss AAA
  • typically 20s to 50s
  • 75% calcium- increased intake, immobilization, hyperparathyroidism
  • 10-15% magnesium phosphate, “struvite”
  • staghorn calculi- very prone to infection, abx penetration poor
  • 10% uric acid
32
Q

presentation of

  • colicky pain, follows trajectory of ureter
  • if septic + sick sxs
  • pacing, vomiting, extremely painful
  • hang up uteropelvic and uterovesicular junctions
A

Septic ureteral stones

33
Q

diagnosis of septal ureteral stones?

A
  • clinical clues
  • UA: blood, infection
  • CBC/cmpt
  • CT Renal stone protocol (no contrast)
  • US- pregnancy, may miss smaller stones
34
Q

management of Ureteral stones?

A
  • IV, NPO, IVF, pain/nausea control (septic stone = urine culture, blood cultures, IV abx)
  • emergency urologic surgery (obstructing stone+ infection, staghorn infection+)
  • urology consult (renal dysfunction on labs, obstructing stone or staghorn, > 6mm)
  • admit (intractable pain or vomiting)
  • home (no infection, baseline renal function, pain and nausea managed PO)
35
Q
  • severe hepatocellular injury in pt with normal liver or well-compensated liver disease
    • toxin induced (acetaminophen) or viral (Hep B)
  • Presentation: AMS, abdominal pain, generalized weakness, anorexia, jaundice, N/V/D, RUQ tenderness
  • dx: Elevated LFTs (very high AST and ALT), prolonged INR, +/- elevated ammonia, APAP level
A

fulminant hepatic failure/ acetaminophen OD

36
Q

management of acetaminophen OD?

A
  • +/- activated charcoal if within 4 hours
  • N=aceytlcysteine (NAC = antidote) prevents APAP metabolites from futher damaging liver cells (almost 100% effective if given within 8 hours post ingestion)

Rumack matthew nomogram

  • acute, single ingestion
  • known time of ingestion
  • above the nomogram line= treat with NAC to decrease hepatotoxicity
  • ICU, +/- care at liver transplant facility
37
Q
  • ascites fluid infection without apparent intra-abdominal treatable source
  • associated with large volume ascies
  • up to 30% cirrhotic pts
  • presentation: large volume ascites, fever, diffuse abdominal pain/ttp/ peritoneal signs, AMS
A

Spontaneous bacterial peritonitis

38
Q

diagnosis of spontaneous bacterial peritonitis?

A
  • basic labs
  • paracentesis with fluid analysis
  • 60% of patients will be culture negative, abx still indicated
39
Q

management of spontaneous bacterial peritonitis

A
  • abx for typical enteric flora
  • consider albumin infusion
  • large volume paracentesis => 5 L fluid taken off
  • ICU admission

Emergency Medicine Exam 3 (7 decks)

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