Approach to the Pt with Abd Trauma & GI emergencies Flashcards
what is the first approach to take for Tx of ingested FB
expectant (wait/watch) - majority of ingestions
make sure:
signs of airway compromise (choking, stridor, wheezing, difficulty breathing) must be addressed immediately (ENT or GI)
what are the 3 ways to classify hernia by the status of contents
reducible: soft & easy to replace back through the hernia neck defect
incarcerated: firm, painful and nonreducible by direct manual pressure, no signs of systemic illness
strangulated: firm, very painful w/ signs of systemic illness present (fever, N/V) implies impairment of blood flow (A, V or both)
when do genitourinary injuries occur
how do you assess these
direct blow to back of flank
suspect w/ gross/microscopic hematuria
CT abd/pelvis w/ IV contrast
suspect urethral disruption w/ anterior pelvic injuries
when do hollow viscus injuries occur
how do you assess these
sudden deceleartion injury (MVC)
suspect w/ deceleration injuries of chance fracture
early US & CT
what population is most likely to present w/ AAA
older pts
7% of > 50 yo, 4-8% M 65-80 yo
one of top 15 causes of mortality in US for 85-89
(USA- ruptured AAA = 4-5% sudden deaths)
what diagnostic imaging is used to evaluate ingestion FB
only in pts w/o sign/sxs suggestive of esophageal obstruction (dont delay EGD for imaging)
X-ray: anteroposterior & lateral views from neck, chest, and abd; not all FB can be seen on radiograph (fish/chicken bones, wood, plastic, glass, thin metal objects, food)
CT: suspected perforations, sharp/pointed FB, ingestion of packet of narcotic
which type of hernia is an acute SRG emergency
stragulated hernia
=severe, exquisite pain at the hernia site w/ sxs of intestinal obstruction, toxic appearance and possibly, skin changed over the hernia sac
when do duodenal injuries occur
how do you assess these
unrestrainted drivers prontal impact
bike handlebar injury
CT abd/pelvis w/ IV/oral contrast
what is the epidemiology of ingested foreign bodies
80% in kids
MOST pass W/O need for intervention
<1% require surgical intervention
what is the PE for the abd
inspect
ausculatate/percussion
palpation
assess pelvic stabilty
assess other areas: urethral meatus, perineal rectal, vaginal
what diagnostic tests are used for AAA
one time screening for at risk pt > 65
asymp (& known): 6 month or annual US/CT abd/pelvis
symp:
- stable: CT abd/pelvis w/ IV contrast
- unstable: if known Hx - straight to the OR; if unknown but suspected - CT abd/pelvis w/ IV contrast if possible
compare direct vs indirect inguinal hernias
MC = indirect; pass from internal to external thru the patent process vaginalis and then to the scrotum
direct = pass thru weakness in the tranversalis fascia in the hesselback triangle
when do pancreatic injuries occur
how do you assess these
direct blow to the pancreas that compress it against the vertbral column
check & trend amylase & lipase
CT of abd/pelvis w/ IV/oral contrast
a ruptured AAA can be misdiagnosed as
renal colic
perforated viscus
diverticulitis
GI hemorrhage
ischemic bowel
what is the pathophysiology of ingested FB
esophagus = most freq site of obstruction in GIT
often impacted at the sites of physiologic/pathologic luminal narrowing: UES, level of aortic arch and diaphragmatic hiatus
structural/fxnal esophageal abnormalities can increase risk of impaction (diverticula, webs, rings, strictures, achalasia and tumors
about 1/2 impactions - eosinophilic esophagitis
compare ingested FB in kids vs adults
kids:
6 months - 3 yrs (coins, buttons, batteries, toys, magnet, safety pins, screws, marbles)
adult:
accidental (95%) - MCC esophageal obstruction by food, more freq in elderly
intentional: psychiatric dz or intoxicated, prison, drug trafficking
what are the anatomic locations of hernias
ventral: epigastric, umbilical, spigelian, incisional, parastomal
groin: inguinal (direct/indirect), femoral, obturator
what are the treatments used for the different types of hernias
strangulated: SRG consult immediately, broad spectrum IV Abx, fluid resuscitation and adequate narcotic analgesia, preop lab studies
incarcerated: attempt to reduce, if unsuccessful - SRG
reducible: outpt SRG
what will be the historical and physical findings for appendicitis
RLQ abd pain (starts w/ visceral pain and then localizes)
anorexia, N/V, (+/-) fever
(+) McBurney’s point tenderness, Rovsing’s sign, Obturator sign and Psoas sign
what are RFs for AAA
old
male
white
Fhx
smoking
presence of other large vessel aneurysm
artherosclerosis
what are hernias
a protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contain it
75% = inguinal; 2/3 of these = indirect
constant/intermittent mass in groin, gradually increasing in size
What are the mechanisms of trauma
blunt trauma: direct blow causes rupture of hollow organs and bleeding; deceleration cause shearing injuries
penetrating trauma: stab wound and low velocity GSW - lacerating and cutting damage; high velocity -increased damage by cavitation
explosive: injuries by several mechanisms (blunt/pentrating, blast injury to lung & hollow viscus from blast overpressure, inhalation injury)
What are statistics related to trauma
leading cause of mortality globally
road traffic - leading cause death 18-29 yo
USA- leading cause of death in young adults & >50 mil get trauma related medial care annually
10% all deaths among men & women
>45 mil ppl sustain moderate-severe disability each year
30% of all ICU admissions
Most AAA have no sxs but is they do, how do they present
abd, back, flank pain
syncope
thromboembolism &/or limb ischemia
(if sxs present increased risk of rupture)
What is the Tx of FB in the stomach/proximal duodenum
most FB that enter the stomach pass in 4-6 days
urgent endoscopy (w/i 24 hours) : sharp object, blunt object >2 cm in stomach, >5 cm at or above proximal duodenum, magnets, bateries, lead
expectant management: asymp pt w/ small blunt object - weekly x-ray until object passes, resume diet and monitor stool
What is the pathophysiology of AAA
abd aorta > 3 cm in diameter (will progessively dilate over time)
MC below renal As
aortic diameter and ongoing smoking are the most imp factors that influence aortic expansion and risk of rupture
rapid diameter expansion >=5 mm over 6 months or >10 mm over a year also have increased risk for rupture
what are the 3 categories of AAA
asymp: found incidentally
symp but not ruptured: rapidly expanding and large enough to compress surrounding or is inflammmatory/infectious (abd pain, flank pian, limb ischemia, fever, malaise)
symp & ruptured: BAD, high mortality/morbidity (classic triad: abd/flank/back pain, hypotension/shock & pulsatile abd mass)
how do you Tx ingestion of FB distal to L of Trietz
most pt: expectant management - asymp pt w/ small, blunt objects - radiograph weekly, resume diet and monitor stool
endoscopic/SRG intervention - sign/sxs of inflam/intestinal obstruction (fever, abd pain, vomit)
what is Tx for esophageal FB
emergent endoscopy w/i 6 hrs: complete obstruction, drooling, disk batteries in esophagus, sharp-pointed object
urgent endoscopy w/i 24 hrs: all FB in esophagus require removal w/i 24 hours
what is apart of the initial evaluation for ingestion of FB
presence & severity of Sxs
type of object
location of object
how do you Tx appendicitis
inital Tx: NPO, IVF, Antiemetics, pain meds, possible preop Abx
surgery
what is FAST scan
standard set of US exam for evaluation of injured pt
Purpose: Detect free intraperitoneal fluid, pericardial fluid, pleural fluid, Hemothorax and pneumothorax in trauma pts
Limited sensitivity precludes the use of US = definitive test to r/o intraabd injury
who gets a laparotomy
blunt abd trauma w/ hypotension w/ (+) fast scan or clinical evidence of intraperitoneal bleeding
what is the mortality related to pelvis injuries
pt w/ hypotension & pelvic fracture - high mortality
all types of pelvic fractures = 1/6
closed pelvic fractures & hypotension = 1/4
open pelvic fracture = 1/2
(disruption of the pelvic ring tears the pelvic venous pelexus and occasionally disrupts the internal iliac arterial system)
what is the incidence for appendicitis
233 out of 100K ppl
highest in 10-19 y/o
When do diaphragm injuries occur
blunt high impact (MCV)
most often on L
suspect w/ thoraco-abd trauma
*good reason not to use a trochar when putting in chest tube
if solid organs are injured what is the best approach
liver & spleen (MC)
if hemodynamically stable - concervative w/ close observation by surgeon
if unstable or continued bleedng -operative management
what are most blunt abd trauma related to and what can they injure
75% MVC or auto vs pedestrian accidents
15% blows to the abd
6-9% falls
spleen and liver are MC injured
what are signs and Sxs of ingested FB
may be asymp
acute dysphagia, choking, refusal to eat, hypersaliva, retrosternal fullness, regurgitation of undigested food, wheezing and blood-stained saliva
drooling and inability to swallow liquid - emergent endoscopic evaluation needed
fever, abd pain, repetitive vomiting after ingestion
(be sure to record type of FB, time of ingestion and presence & type of ongoing sxs)
what are the 3 possible ways hernias can be classified
anatomic location: ventral, groin
hernia content: usually bowel/fat
(most imp) status of those contents: reducible, incarcerated, strangulated
what is the treatment for AAA
conservative (asym infrarenal AAA < 5.5mm)
elective repair (open/endocasvular)
- asymp AAA > 5.5 cm in good SRG candidates
- rapidly expanding (>0.5 cm/6 months or >1 cm/year) infrarenal AA in well-documented serial studies
- pt w/ associated arterial dz (coexisting iliac, femoeral or popliteal A aneurysm) or symp peripheral A dz undergoing revascularization
what does early appendicitis mimic
gastroenteritis
viral illness
what is the epidemiology of vental hernias
epigastric & umbilical = MC ventral hernias
1/4 ppl are either born with it or will develop one in their lifetime
incision hernias may develop anywhere an incision has been made- MC at midline (bc MC used in laparotomy), spigelian and parastromal occur off the midline
USA ->$3.4 billion spent on repair
what is the diagnositic testing for appendicitis
CBC (increase/nl)
chem profile (electrolytes & LFTs)
UA - could be abnormal
pregnancy test
imaging - adults: CT abd/pelvis w/ IV & oral contrast; kids- US, if (-) and still suspect then use CT; pregnant pt: MRI
what are history needed to assess trauma
blunt: MVC location, restraints, airbag, intoxication, impact, speed, ejection/rollover, state of passengers
penetrating: time, type of injury, distance, # stab/shots
explosive: enclosed space or not, distance from detonation, combination of blunt and penetrating, possible inhalation injury
Appendicitis is known to be one of the most..
MCC of acute abd
most freq indications for emergent abd SRG w/w
most freq in 20s-30s
what is a great way for taking care of critically ill pts
ABCDE
Airway- maintenance w/ c-spine control
Breathing/ventilation
Circulation w/ hemorrhage
Disablity/neurologic status
Exposure/environmental control (completely undress the pt and prevent hypothermia)
