Cardiac/Thoracic and Abdominal Emergencies 2 Flashcards
Mesenteric Infarction/Ischemia
Always consider in a patient with atypical presenation of abdominal pain. Specifically in people with the following risk factors?
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- Older patients
- Hx of arrhythmias or previous emboli
- Pain out of proportion to exam
- Evidence of visceral complaints without peritonitis
- Systemic complications
- Acidosis
- They look sick
Acute mesenteric ischemia
- Usually acute occlusion of what?
- May need to do what?
- Chronic mesenteric ischemia: typically which pts? 2
- What kind of processes can progress to perforation? 3
- Acute mesenteric ischemia
- Usually acute occlusion of the SMA from thrombus or embolism - May need to do embolectomy
- Chronic mesenteric ischemia
- Typically smoker,
- vasculopath with severe atherosclerotic vessel disease (low flow state) - Any
- inflammation,
- obstructive
- ischemic process can progress to perforation
Ischemic bowel disease: (chronic mesenteric ischemia) 1. What is the most consistant sign? 2. What is intestinal agina? 3. Dx?
- Weight loss is the most consistent sign
- Become afraid to eat because of postprandial pain ( intestinal angina)
- Emergent CTA (angiography) may be in play…let the surgeon make this call
Air in Biliary System
- usually secondary to?
- Can be due to ?
- Rarely due to?
- Usually secondary to surgery on bile ducts
- Can be due to biliary-bowel fistula from infection or neoplasm
- Rarely, can be due to infection
Abdominal CT:
1. Dx for? 6
- Better than plain films for evaluation of what?
- intra-abdominal abscess (sigmoid diverticulitis),
- pancreatitis ,
- retroperitoneal bleeding (leaking abdominal aortic aneurysm) ,
- hepatic or
- splenic pathology and even
- appendicitis.
- solid and hollow organs.
Decision to operate (the surgeon makes the call)
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- Peritonitis- Tenderness w/ rebound, involuntary guarding
- Severe / unrelenting pain
- “Unstable” (hemodynamically, or septic)- Tachycardic, hypotensive, white count
- Intestinal ischemia, including strangulation
- Pneumoperitoneum
- Complete or “high grade” obstruction
TAKE HOME POINTS
For acute abdomen, think of these commonly (below)? 8
- Perf DU
- Appendicitis +/- perforation
- Diverticulitis +/- perforation
- Bowel obstruction
- Cholecystitis
- Ischemic or perf bowel
- Ruptured aneurysm
- Acute pancreatitis
Mechanisms of Blunt injury
1. Compression, crush, or sheer injury to abdominal viscera leading to?
- Deceleration injuries are what?
- deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus)
- Deceleration injuries: differential movements of fixed and non-fixed structures (e.g. liver and spleen lacerations at sites of supporting ligaments)
Common injury patterns
1. In patients undergoing surgery for blunt trauma, most frequently injured organs are what? 3
- Duodenum:
- Classically injured how? - Signs and symptoms of duodenum injury? 3
- Small bowel injury generally from what?
- spleen (40-55%),
- liver (35-45%)
- small bowel (5-10%).
- Duodenum:
- Classically, frontal-impact MVC with unrestrained driver; or direct blow to abdomen. - Bloody gastric aspirate,
- retroperitoneal air on XR or CT,
- series confirmed with UGI
- Small bowel injury:
Generally from sudden deceleration with subsequent tearing near fixed points of attachment.
Common injury patterns
1. How is the pancreas commonly injured?
- Diaphragm most commonly injured how?
- Noted on CXR?
- GU injuries commonly happen how?
Pancreas:
- Direct epigastric blow compressing pancreas against vertebral column.
- Amylase and CT not very helpful
Diaphragm:
- Most commonly, 5-10 cm rupture involving posterolateral hemidiaphragm.
- Noted on CXR: blurred or elevated hemidiaphragm
- Genitourinary:
Patients with multisystem injuries and pelvic fractures.
Common injury patterns
- Solid organ injury? 3
- Pelvic fractures?
- suggest what?
- Usually from what?
- Significant association with what?
Solid organ injury
- Laceration to
- liver,
- spleen
- kidney - Pelvic fractures:
- Suggest major force applied to patient.
- Usually auto-ped, MVC, or motorcycle
- Significant association with intra-peritoneal and retroperitoneal organs and vascular structures.
MVA trauma: questions to ask on hx? 6
- Speed
- Type of collision (frontal, lateral, sideswipe, rear, rollover)
- Vehicle intrusion into passenger compartment
- Types of restraints
- Deployment of air bag
- Patient’s position in vehicle
What test is 98% sensitive for intraperitoneal bleed?
Diagnostic Peritoneal Lavage
Diagnostic Peritoneal Lavage
- What is an indication for surgery? 3
- If gross blood (> 10 mL) or GI contents not aspirated, perform lavage with what?
- Has been somewhat superceded by FAST in common use; now generally performed in unstable patients with what? 2
- Free aspiration of blood,
- GI contents
- bile indication for surgery
- 1000 mL warmed LR.
- intermediate FAST exams, or
- with suspicion for small bowel injury
FAST (Focused Assessment with Sonography for Trauma)
1. Used for?
- When will the sensitivty increase?
- For identifying hemoperitoneum in blunt abdominal trauma: way after my time for those who care
- The larger the hemoperitoneum, the higher the sensitivity. So sensitivity increases for clinically significant hemoperitoneum.
How much fluid can FAST detect?
As little as 100 cc’s