Cardiac/Thoracic and Abdominal Emergencies Flashcards
1
Q
Evaluation of chest pain
Initial approach is to classify patients into three catagories?
A
- Chest wall pain
- Pleuritic or respiratory chest pain
- Visceral chest pain
2
Q
SVT
35 y/o male presents complaining of palpations that started while playing basketball 2 hours ago. He now feels like his heart is racing. He has no chest pain or shortness of breath at this time. No nausea or lightheadedness.
He is placed on a monitor and a little 02
Vitals: 110/68, 17-, 20, SA02 (98%)
- Initial tx? 2
A
- Vagal manuevers
- Start IV
- Adeonsine
3
Q
SVT
Adenosine doesn’t work and the patient is starting to feel some chest tightness and is becoming diaphoretic.
Vitals are: 82/54, 172, 20, SA02 97%
Tx now? 2
A
- Adenosine – 6mg IV push
2. Cardioversion
4
Q
Aortic dissection
- Most important predisposing factor?
- Others? 4
A
- Most important predisposing factor is HYPERTENSION
- Others
- Atherosclerosis
- Vasculopathies
- Marfans
- Congential defect
5
Q
Aortic dis
- Commonly presents how?
- Pain described as?
- symptoms? 2
- what also occur?
A
- Commonly present with abrupt and severe pain in the anterior chest or between the scapula.
- Pain is described as ripping or tearing
- Hypertension and tachycardia
- Acute aortic regurgitation may occur
6
Q
Aortic dissection tx
10
A
- Stabilize patient
- 02
- IV
- Typical labs
- EKG
- CXR – may show widening of the aorta
- CT scan – with contrast
- TEE
- MRI
- Hypertension control
Medications with negative inotropic effects
7
Q
What may the CXR show in aoritc dissection?
CT with or without contrast?
A
may show widening of the aorta
with
8
Q
Aortic dissection
HTN control meds? 2
then?
A
- Beta Blockers
- May need some vasodilators
Nitroprusside IV
Stabilization and rapid referral to surgeon
9
Q
Which beta blockers for HTN control in AD? 3
A
- Labetalol IV
- Metoprolol IV
- Esmolol IV
10
Q
Trauma to the heart
- Blunt: What will it cause?
- What is this?
- How will they dx this? 4
- Tx?
- Penetrating MC cause? 2
A
1. BLUNT
Cardiac Contusion-
2. A myocardial contusion is a term for a bruise (contusion) to the heart after an injury.
3. will also look for:
-low blood pressure
-an irregular heart rate
-a rapid heartbeat
-irregular breathing
4.
-blood drainage from the heart
-surgery to repair blood vessels
-chest tube placement to prevent fluid buildup in the chest
-placement of a pacemaker to help regulate heartbeat
- PENETRATING
GSW’s/SW’s
11
Q
Signs of Acute Pulmonary Edema?
5
A
- Severe respiratory distress
- Cool skin
- Rales
- JVD
- peripheral edema may or may not be present
12
Q
Pulmonary edema
CXR may show?
7
A
- Dilated upper lobe vessels
- Cardiomegaly
- Interstitial edema
- Enlarged pulmonary artery
- Pleural effusion
- Alveolar edema
- Kerley B lines
13
Q
Acute pulmonary edema/Heart failure
tx? 5
The critical end point for tx is what?
A
- IV nitroglycerin to control B/P -Continuous infusion
- May need nitroprusside- Continuous infusion
- Nesiritide is used with Heart failure- Continuous
- Diuretics- Furosemide
- Morphine
rapidly lowering the filling pressure to prevent the need for intubation
14
Q
Pulmonary edema
- Which diuretic?
- Diuresis can begin how quickly?
- Can this be repeated?
- Need a what always with this?
- What dose of morphine?
A
Diuretics
- Furosemide
- Diuresis can begin within 10-15 mins
- Can be repeated if adequate diuresis has not begun
- Need a foley
- Morphine
2-5 mg IV
15
Q
Pulmonary edema
- after they are stabilized do what?
- Need to closely monitor what? 5
A
- Admit to ICU
- Need close monitoring of respiratory status
- Need close monitoring of blood pressure,
- heart rate and
- urine output.
- Vasodilator drips have to be monitored in an ICU with continuous monitoring.
16
Q
Causes of Pulmonary Edema
2
A
- Massive MI
- Valve disease
Don’t forget about treating the underlying problem!!!!
17
Q
Abdominal contents
1. Solid organs. Injuries to solid organs (liver, spleen and pancreas) may result in what? 2
- Hollow organs (stomach, duodenum and intestine) may do what when injured? 2
A
- bleeding into the abdominal cavity or
- dumping their contents into the cavity.
- discharge chemical and
- bacterial contents.
18
Q
The acute abdomen may be defined generally as what?
A
an intra-abdominal process causing severe pain requiring admission to hospital, and which has not been previously investigated or treated and may need surgical intervention.
19
Q
KEY: A patient with an acute abdomen is an EMERGENCY, and it is IMPERATIVE to get a correct diagnosis
Treatment depends entirely on the cause
For example:
1. Surgery for? 4
2. PID tx?
3. Mild ovarian cyst ruptures or pancreatitis tx?
A
- Surgery indicated for:
- ectopic pregnancies,
- acute appendicitis,
- duodenal and
- gastric perforating ulcers - Antibiotics for PID
- Observation for mild
20
Q
Stabilization (ABC’s)
of acute abdomen? 6
A
- Oxygen
- IV fluids
- Foley
- NG tube (maybe)
- Abx
- Pain control after surgeon checks the patient or ……….
21
Q
Classification with age: Acute ab:
- Children? 3
- Adult? 5
- Adult female? 3
- Elderly? 5
A
- Children
- Gastroenteritis
- Meckel’s diverticulitis
- Intussusception - Adult
- Regional enteritis
- kidney stone
- Perforated ulcer
- Testicular torsion
- Pancreatitis - Adult female
- PID
- Pyelonephritis
- Ectopic pregnancy - Elderly
- Diverticulitis
- Intestinal obstruction
- Colon carcinoma
- Mesentric infarction
- Aortic aneurysm
22
Q
Symptoms--Pain Which correlate with these pain characteristics. 1. Sudden? 2. Slow onset? 3. Severity? 4. Burning? 5. Stabbing? 6. Gripping, intermittent and crampy?
A
Onset
- sudden
- perforation of bowel,
- smooth muscle colic - slow insidious onset-
- inflammation of visceral peritoneum - Severity
- Patient asked to rate pain from 1-10
- kidney stone is one of worst pains
Character
- Burning- peptic ulcer symptoms
- Stabbing-kidney stone
- Gripping, intermittent and crampy
- intestinal obstruction worse by movement
23
Q
Symptoms-Pain Progression
- Constant?
- Colicky?
- seconds?
- minutes?
- tens of minutes? - May change character completely from dull poorly localized pain to sharp pain indicates involvement of parietal peritoneum?
Radiation of the pain
- Back? 3
- Scapula?
- Sacroiliac?
- Groin?
A
Progression
- Constant e.g. peptic ulcer
- Colicky e.g.
- seconds (bowel),
- minutes (kidney stone) or
- tens of minutes (gallbladder) - (appendicitis)
Radiation of the pain
- Back:
- duodenal ulcer,
- pancreatitis,
- aortic aneurysm - Scapula: gall bladder
- Sacroiliac region: ovary
- Groin: testicular torsion
24
Q
Think Broad categories for DDx as you start to put it together? 4
A
- Inflammation
- Obstruction
- Ischemia
- Perforation (you pathophysiologists)
25
Perforation (you pathophysiologists)
1. Offened organs become?
2. What is obstructed due to increased pressure?
3. Arterial pressure exceeded leads to?
4. Prolonged ischemia leads to?
1. Offended organ becomes distended
2. Lymphatic/venous obstrux due to ↑pressure
3. Arterial pressure exceeded → ischemia
4. Prolonged ischemia → perforation
26
Organ- inflammation:
1. Stomach?2
2. Biliary Tract? 2
3. Pancreas? 1
4. Small Intestine? 2
5. Large Intestine? 2
Location of obstruction- lesion?
1. Small Bowel obstruction? 7
2. Large bowel obstruction? 3
Lesion
1.
- Gastric Ulcer
- Duodenal Ulcer
2.
- Acute chol’y
- +/choledocholithiasis
3. Acute, recurrent, or chronic pancreatitis
4.
- Crohn’s disease
- Meckel’s diverticulum
5.
- Appendicitis
- Diverticulitis
1. Small Bowel Obstruction
- Adhesions
- Bulges
- Cancer
- Crohn’s disease
- Gallstone ileus
- Intussusception
- Volvulus
```
2. Large Bowel
Obstruction
-Malignancy
-Volvulus: cecal or sigmoid
-Diverticulitis
```
27
Physical Examination and BS
Auscultation
1. Silent abdomen?
2. Increased bowel sounds?
Auscultation
1 -silent abdomen: peritonitis
2 -increase bowel sounds: intestinal obstruction
28
PE: rebound tenderness
1. The peritoneum: describe how its innervated and its sensitivity?
2. What does a positive rebound tenderness show?
- managment?
1. The peritoneum is well innervated and exquisitely sensitive
2. You most likely are dealing with peritonitis and they need surgery
29
If you cant localize or reproduce the pain then do what??
If you can’t localize it, they may have general peritonitis and the cat is out of the bag and you may never know what the deal is until the surgeon calls you after exploration. That’s ok!
30
LABS
| for acute abdomen?
1. CBC with differential
2. Electrolytes, BUN, creatinine, glucose
3. LFT
4. Amylase
5. Urinalysis and culture
6. Pregnancy test
7. Blood gas…
31
What do the following indicate for acute abdomen:
1. CBC with differential? 2
2. Electrolytes, BUN, creatinine, glucose? 1
3. LFT? 1
4. Amylase? 1
5. Blood gas? 1
1.
- infection
- inflammation
2. (DKA)
3. (the biliary tract)
4. ( high in acute pancreatitis)
5. acidosis
32
Abx that may be used in acute abdomen (coverage for?) 2
Antibiotics-
1. Gram Neg
2. Anaerobic
33
Causes of Acute Abdomen (DDx)
| 11
1. Appendicitis
2. Bowel Perforation or obstruction
3. Pancreatitis
4. Diverticular disease
5. Cholecystitis
6. Perforating Gastric/Duodenal ulcer
7. Ruptured Ectopic Pregnancy
8. Ruptured or hemorrhagic ovarian cyst
9. Pelvic Inflammatory Disease
10. Abdominal Aortic Aneurysm
11. Tubo-ovarian abscess
34
```
A. Gastrointestinal-
1-Gut? 8
2-Liver and biliary tract? 4
3-Pancreas? 1
4-Spleen? 2
```
1-Gut
- Acute appendicitis
- Intestinal obstruction
- Perforated peptic ulcer
- Diverticulitis
- Inflammatory bowel disease
- Acute exacerbation of peptic ulcer
- Gastroenteritis
- Meckel’s diverticulitis
2-Liver and biliary tract
- cholecystitis
- cholangitis
- Hepatitis
- biliary colic
3-Pancreas
-Acute pancreatitis
4-Spleen
- Splenic infarct and
- spontaneous rupture
35
Etiologies
1. Urinary tract? 4
2. Vascular? 5
3. Abdominal wall conditions? 1
4. Peritoneum? 2
1.
- Cystitis
- Acute pyelonephritis
- Ureteric colic
- Acute retention
2.
- Ruptured aortic aneurysm
- Mesenteric embolus
- Mesenteric venous thrombosis
- Ischemic colitis
- Acute aortic dissection
3.
- Rectus sheath hematoma
4.
- Primary peritonitis
- Secondary peritonitis
36
1. Retroperitoneal? 1
| 2. Gynecological? 8
1. Retroperitoneal
- Hemorrhage e.g. anticoagulants
2. Gynecological
- Torsion of ovarian cyst
- Ruptured ovarian cyst
- Fibroid denegeration
- Ovarian infarction
- Salpingitis
- Pelvic endometriosis
- Severe dysmenorrhea
- Endometriosis
37
Extra-abdominal causes? 8
Extra-abdominal causes
- Lobar pneumonia
- Pleurisy
- MI
- Sickle cell crisis
- Uremia
- Hypercalcemia
- DKA
- Addison’s disease
38
Acute appendicitis
1. Typical presentation?
2. High risk of perforation? 5
3. What is McBurney's point?
1. Typical presentation: -periumbilical pain that migrates to RLQ
2. High risk of perforation:
- less 2 years old;
- elderly ;
- DM ;
- immunocompromised ;
- steroid use
3. McBurney’s point: 1/3 the distance between anterosuperior iliac spine and umbilicus
39
The Abdominal Series X-rays?
1. Chest best for?
2. Supine abdomen (best for abdominal detail? 5
3. Erect abdomen?
4. Left lateral decubitus?
1. Chest
- upright best for free air
2. Supine abdomen (best for abdominal detail…
- organs,
- bones,
- joints,
- fat
- gas patterns
3. Erect abdomen (air-fluid levels)
4. Left lateral decubitus abdomen
- possible substitute for erect chest and abdomen if patient can’t sit or stand
40
Perforated peptic ulcer
1. Hx question?
2. PE? 3
3. Lab? 1
4. Upright chest XR?
1. History: GU or DU
2. PE:
- rebounding tenderness,
- BS are quiet ,
- muscle guarding
3. Lab: elevated WBC
4. Upright chest : free air
41
The four cardinal features of intestinal obstruction:
- abdominal pain with intermittent cramping
- vomiting
- distension
- constipation
42
Colon Obstruction: Measurements
1. WHat is the most distensible part of the colon?
2. A cecum of what size is cause for concern?
3. A cecum of what size is impending perforation?
1. The cecum is the most distensible part of the colon
2. A cecum of 9 cm diameter is cause for concern
3. A cecum of 11 cm is impending perforation
