Cardiothoracic Emergency Flashcards
Chest Pain Evaluation - three categories
Chest wall pain
Pleuritic/respiratory chest pain
Visceral chest pain
Identifying a High Lateral AMI
Look in leads 1 and AVL for ST elevation
May be very subtle
SVT Treatment
Vagal maneuvers (only if stable)
Adenosine (6 mg, then 12 mg IV w/ 20 ml NS bolus)
Cardioversion (50-100 J)
Aortic Dissection Presentation
HTN is MC predisposing factor
- But they may be normotensive
- Also atherosclerosis, vasculopathy, Marfan’s, congenital defect
Commonly present w/ abrupt and severe pain in anterior chest or between scapula - ripping/tearing pain
May cause acute aortic regurgitation
-never use a balloon pump with aortic regurgitation
Aortic Dissection Treatment
Control HTN - negative inotropic medications
IV BB: Labetalol, Metoprolol, Esmolol
Vasodilation: Nitroprusside IV
Stabilize and rapid referral to surgeon
Always assess all extremity pulses
Abdominal Injuries to Solid and Hollow Organs
Solid organs: may result in bleeding into abdominal cavity or dumping their contents into the cavity
- liver, spleen, pancreas
Hollow organs: may discharge chemical and bacterial contents
- stomach, duodenum, intestine
Peritonitis
Emergent
Infection, or rarely inflammation of the peritoneum
Peritoneum is the membrane that covers the surface of the organs within the abdominal cavity
Silent abdomen with rebound tenderness
Acute Abdomen
Generally intra-abdominal process causing severe pain which requires specialized investigation and intervention
An emergency
Treatment depends on cause
Determine whether patient is stable or unstable - belly pathology may manifest w/ systemic signs (renal failure or shock)
Morphine Effect with Angina
Pain control
Decreases BP and heart workload by dilating splenic vessels and decreasing peripheral vascular disease
Common Abdominal Pathologies in Children
Gastroenteritis
Meckel’s diverticulitis
Intussusception
Common Abdominal Pathologies in Adults and in Adult Women
Adults:
Regional enteritis
Kidney stone
Perforated ulcer
Testicular/Ovarian torsion
Pancreatitis
Women: PID, Pyelonephritis, Ectopic pregnancy
Common Abdominal Pathologies in Elderly
Diverticulitis
Intestinal Obstruction
Colon carcinoma
Mesentric infarction
Aortiv aneurysm
Pain Symptoms and Indications
Onset - slow or sudden
Severity
Character - burning, stabbing, gripping/intermittent/crampy
Slow insidious onset: inflammation of visceral peritoneum
Sudden onset: perforation of bowel, smooth muscle colic
Severity: Kidney stones is one of the worst pains
Burning: Peptic ulcer symptoms
Stabbing: kidney stone
Gripping, intermittent, crampy: intestinal obstruction that gets worse w/ movement
Pain Symptoms and Indications
Progression - constant, colicky, character change
Radiation - back, scapula, sacroiliac, groin
Constant pain: peptic ulcer
Colicky pain: bowel in seconds, kidney stone in minutes, gallbladder is tens of minutes
Character change: dull poorly localized pain to sharp pain indicates parietal peritoneum involvement (appendicitis)
Radiation to back: duodenal ulcer, pancreatitis, aortic aneurysm
Radiation to scapula: gall bladder
Radiation to sacroiliac region: ovary
Radiation to groin: testicular torsion
McBurney’s point
1/3 the distance between the anterosuperior iliac spine and umbilicus
Acute appendicitis
Four Cardinal Features of Intestinal Obstruction
Abdominal pain with intermittent cramping
Vomiting
Distension
Constipation
Colon Obstruction - MC part affected and size measurements
Cecum is the most distensible part
Cecum = 9cm - cause for concern about perforation
Cecum = 11 cm - impending perforation
Mesenteric Infarction/Ischemia
Older patients with history of arrhythmias or previous emboli
Pain out of proportion to exam
Visceral complaints without peritonitis
Systemic complications with acidosis - they look sick
Acute Mesenteric Ischemia
Usually acute occlusion of SMA from thrombus or embolism
May need to do embolectomy
Chronic Mesenteric Ischemia
Typically smoker, vasculopath with severe atherosclerotic vessels disease
Weight loss is most consistent sign
Severe post-prandial pain
Reasons to call the surgeon
Peritonitis - rebound tenderness w/ involuntary guarding
Severe/unrelenting pain
Unstable - hemodynamically or septic
Intestinal ischemia
Pneumoperitoneum
Complete or high-grade obstruction
Common Blunt Injury Patterns for Duodenum and Small Bowel
Duodenum: frontal-impact MVC with unrestrained driver, direct blow to abdomen
-Get bloody gastric aspirate, retroperitoneal air
Small Bowel Injury: Sudden Deceleration with subsequent tearing near fixed points of attachment
Common Blunt Injury Patterns for Pancreas, Diaphragm, and Genitourinary
Pancreas: Direct epigastric blow compressing pancreas against vertebral column
Diaphragm: MC rupture on posterolateral hemidiaphragm noted on CXR
Genitourinary: Patients with multisystem injuries and pelvis fractures
Common Blunt Injury Patterns for Solid Organ Injury or Pelvic Fracture
Solid Organ Injury: laceration to liver, spleen, or kidney
Pelvic Fractures: usually auto-pedestrian, MVC, or motorcycle
-significant association with intraperitoneal and retroperitoneal organs and vascular structures
FAST
Focused Assessment with Sonography for Trauma
Used to identify hemoperitoneum in blunt abdominal trauma
Larger the hemoperitoneum, the higher the sensitivity
-Sensitivity increases clinically significant hemoperitoneum
Gold Standard for characterizing intraparenchymal injury
CT is gold-standard
FAST is useful for a resuscitation
Kidney Trauma
MC bruised
Shattered kidneys become rapidly unstable
Renal vascular injuries may result in thrombosed vessels
Bladder Rupture
Extraperitoneal
Intraperitoneal
Extraperitoneal rupture presents with pain, hematuria, and inability to void - MC
- May be managed by catheterization alone
Intraperitoneal ruptures always require surgical exploration and repair
Urethral Injuries
Posterior
Anterior
Posterior: located in the membranous and prostatic urethra
- related to massive blunt trauma with massive deceleration
- often have pelvic fractures to anterior pelvis with shearing injuries
Anterior: anterior to membranous urethra and result of blunt trauma to perineum
- delayed presentation, stricture like
GI Bleed
UGI bleeds MC than LGI bleed
UGI proximal to Ligament of Treitz (LT), LGI distal to LT
- UGI esophagus to 2nd/3rd duodenum
Usually presents w/o belly pain
Presents w/ hematemesis, hematochezia, melena
Never use barium in acute GI bleed
Diverticulosis and GI Bleed
Acute, painless bleeding presenting with bright red blood/maroon stool
Right colon 20% recurrent/persistent episode sites
Colonoscopy after bowel prep
Tagged rbc scans/angiography
Anorectal/Perianal Disease and GI Bleeds
Common cause of hemorrhoids
Minor, intermittent bleeding with defecation
Dx of exclusion - r/o more serious lesions of GI tract like CRC/polyps/colitis first
GI Bleed and Hospitalization
UGI bleeds usually admitted even before endoscopy
Mandatory admission w/ proven or suspected variceal hemorrhage/hemodynamic instability/co-morbidity/mental impairment
