Acute Abdomen and Surgical Emergency **** Flashcards
List some causes:
- Inflammation - 7
- Rupture/perforation - 8
Appendicitis Diverticulitis Cholecystitis GE Salpingitis (PID) IBD Pyelonephritis
Spleen AAA Peptic ulcer Appendix Bowel Gallbladder Ectopic pregnancy Ovarian cyst
List some causes:
- Torsion and strangulation - 3
- Chest - 2
- Bowel - 1
- Gynae - 1
- After surgery - 1
Strangulated hernia
Ovarian cyst torsion
Testicular torsion
Lower lobe pneumonia
Inferior MI
Bowel obstruction and ischaemia
Endometriosis
Adhesions
S+S - Visceral (organ) pain:
Is it well or poorly localised?
What type of pain do you get with obstruction and why?
Where is the pain for foregut structures (oesophagus to the ampulla of Vater)?
Where is the pain for midgut structures (to transverse colon)?
Where is the pain for hindgut structures (to proximal rectum)?
Poorly localised pain
Colicky pain due to waves of peristalsis push against obstruction
Epigastric pain
Umbilical pain
Suprapubic pain
S+S - Parietal pain (peritonitis):
Is it well or poorly localised?
Why does the patient lie still?
What is guarding?
What is rigidity?
They can also get pain or tenderness that occurs upon sudden release of pressure on the abdomen. What is this called?
Well localised
Pain is made worse by movement
Involuntary contraction of abdo muscles when palpated
Contraction of abdo muscles at rest
Rebound tenderness
S+S:
What do rigors suggest?
Cholangitis
Pyelonephritis
Intra-abdominal abscess
Investigations:
- Bedside and why? - 2
- Bloods and why? - 6
- Imaging - 4
Urine dip - UTI
ABG - acid/alk
FBC and U&E - WBC for infection and dehydration
Coag and group and save - if surgery is needed
LFT - function
Beta hCG - ectopic
CRP - inflammation
Lactate - sepsis
USS
Erect CXR
AXR
CT abdo
Initial management:
Medications
What should be instructed to the patient?
What should be considered in young women?
Analgesia
Antibiotics
IV fluids
NMB - nil-by-mouth
Consider USS and/or exploratory laparoscopy before CT abdo, due to the radiation risk (including to foetus) and CT is less useful for many gynae problems.
Investigations - RIF pain:
Bedside and why - 1
Bloods and why - 3
Tests for females - 2
What should be done on their bedside and what should they be instructed to do if you suspect appendicitis?
Urine dip - UTI
FBC - WBC and coag
U&E - dehydration
CRP - inflammatory
Beta hCG and USS
IVT and NBM
Investigations - LIF pain:
Tests for females - 2
What should be suspected if they are older and how should they be managed?
Beta hCG and USS
Diverticulitis - ABs IV fluids and CT
Investigations - RUQ pain:
Key history questions? - 2
Bloods and why? - 4
Why is an USS done? - 3
Previous gallstones or USS
FBC - WBC and coag
U&E - dehydration
LFTs - liver function
Amylase - pancreatitis or obstruction
Gallstones or common bile duct dilation
MRCP should be done if CBD dilated and LFTs are raised
Investigations - Epigastric pain:
Key history questions? - 4
Bloods and why? - 4
Imaging done? - 1
Previous OGD, peptic ulcers, gallstones or pancreatitis
FBC - WBC and coag
U&E - dehydration
LFTs - liver function
Amylase - pancreatitis or obstruction
Erect CXR
Investigations - Generalised pain:
Key history questions - 4
Bloods and why? - 6
Why should an ABG be done?
Imaging - 2
Bedside and why? - 1
How should this person be managed int he meantime?
Bowel habit
Features of obstructions
Perforation
Ischaemia
FBC - WBC and coag U&E - dehydration LFTs - liver function Amylase - pancreatitis or obstruction CRP - inflammation Lactate - sepsis
Lactic acidosis
CXR and AXR
Urinalysis - UTI
Analgesia
NBM
IV fluids
Lower Gi Bleed:
List some causes
Diverticular disease Colorectal carcinoma or polyps Vascular - haemorrhoids, angiodysplasia Anal fissure IBD usually UC Ischaemic colitis GE
Lower GI bleed:
What is haematochezia?
What symptom could you have in IBD or GE?
What symptom could you have with cancer?
Fresh red blood PR
Fever
Weight loss
Lower GI bleed - investigations:
What should be done initially if it is acute?
Bloods and why? - 2
Imaging? - 2
ABCDE + fluids
FBC - Raised WBC - infection
Coag and cross match
CT abdo-pelvis
Lower GI bleed - investigations:
Colonoscopy is used to localise the source. How can the bleeding be stopped if it is acute and the patient is unstable? - 3
What can be done?
Haemostasis using adrenaline, thermal coagulation and/or clipping
Mesenteric angiography and embolisation - visualisation of mesentery using contrast
Nasogastric tube placement:
Indications - 3
Contraindications
Nasogastric decompression (e.g. due to bowel obstruction - drip and suck)
Feeding
Giving drugs
Basal skull fracture
Severe facial or nasal trauma
Varices or stricture, coagulopathy
Nasogastric tube placement:
NEX is used to determine what length of tube to put in. What does this stand for?
How can the passage be made easier?
Nose to ear to the xiphoid
Wetting tube - NO LUBRICANT
Nasogastric tube placement:
What if first-line to check placement?
CXR is next line. What would you look for that indicates it has entered the stomach? - 3
pH paper (should be <5.5) with the aspiration of gastric contents
Bisects the carina
Crosses diaphragm in the midline (as oesophagus enters the abdomen with the aorta and IVC)
Tip visible beneath the diaphragm
Nasogastric tube placement:
Complications - 5
Local trauma (nosebleed) Tube into lungs and aspiration pneumonitis Oesophagitis Perforation Vocal cord paralysis
Complications of abdominal surgery - Immediate (<24 hrs):
Intubation complication - 1
Anaesthetic complication - 1
Complications in the surgery itself?
Mouth or teeth trauma
Anaphylaxis
Infection
Primary haemorrhage during operation (vessel trauma)
Reactionary haemorrhage occurs within 24 hours of operation
Most cases of reactive haemorrhage are from a ligature that slips or a missed vessel. These vessels are often missed intraoperatively due to intraoperative hypotension and vasoconstriction, meaning only once the blood pressure normalises post-operatively will this bleeding occur
Damage to surrounding structures
Complications of abdominal surgery - Early (<1 wk):
Fever - what are the 7C’s for causes?
Cut (wound) Chest Catheter Cannuka Central line Collection Calves (DVT)
Complications of abdominal surgery - Early (<1 wk):
What is atelectasis?
What is the cause?
What may it lead to?
What else could occur due to immobility to the lungs and legs?
The collapse or closure of a lung resulting in reduced or absent gas exchange.
Shallow breathing due to pain
Pneumonia
PE and DVT
Complications of abdominal surgery - Early (<1 wk):
What can happen to the GI tract?
GU - you can also get reduced urine output. What may cause it?
Paralysis of GI tract causing obstruction
Retention Blocked catheter AKI Pain (post-hernia) BPH Drugs (opioids, anticholinergics)
Complications of abdominal surgery - Early (<1 wk):
The wound could reopen. What is this called?
Wound dehiscence
Approach to post-op sick patient MNEUMONIC:
SIMPLE
Sepsis Ileus MI Pneumonia Anastomotic (L)eak Embolus - PE/DVT
