Clinical Apporach to the Patient Presenting with Abdominal Trauma and GI Emergencies

Question 1

What age group is the highest incidence for acute appendicitis seen?

Answer 1

10-to-19-year-old age group

Question 2

What type of pain does an appendicitis usually start with before migrating to the RLQ?

Answer 2

Vague visceral pain

Question 3

What are some specialty tests for acute appendicitis in order of specificity and sensitivity?

Answer 3

1) McBurney’s Point
2) Rovsing’s sign
3) Obturator sign
4) Psoas Sign

Question 4

What is the gold standard for diagnosing appendicitis in adults?

What should be performed first in kids before moving on to the gold standard?

What should be used for pregnant patients?

Answer 4

1) Ct Abdomen and Pelvis with IV and Oral Contrast
2) Ultrasound of RLQ
3) MRI

Question 5

What can early appendicitis mimic?

Answer 5

Gastroenteritis or viral illness

Question 6

80 percent of all foreign body ingestions occur in?

How do most (80 to 90 percent) of these cases progress?

Only 10 to 20 percent require?

Less than 1 percent require?

Answer 6

1) Children
2) Pass without the need for intervention
3) Endoscopic removal
4) Surgical intervention

Question 7

What is a common ingested FB seen in kids?

What about in adults (more frequently in elderly)?

Answer 7

1) Coins

2) Food bolus

Question 8

Where is the most frequent site of obstruction in the

gastrointestinal tract?

Answer 8

The esophagus

Question 9

Esophageal foreign bodies are often impacted at sites of?

It is estimated that approximately half the individuals with esophageal food impactions have underlying?

Answer 9

1) Physiologic or pathologic luminal narrowing

2) Eosinophilic esophagitis

Question 10

What is indicative of an esophageal obstruction and requires emergent endoscopic evaluation?

What symptoms after FB ingestion are concerning and warrant further workup?

Answer 10

1) Drooling and inability to swallow liquids

2) Fever, abdominal pain, repetitive vomiting

Question 11

What should be done for a patient that presents with signs and symptoms of esophageal obstruction?

Answer 11

Emergent EGD (within 6 hrs)

Question 12

The approach to management of esophageal obstruction is guided by the initial evaluation and depends upon?

Answer 12

1) Presence and severity of symptoms
2) Type of object ingested (size, shape, content)
3) Location of the object

Question 13

All foreign bodies in the esophagus require removal within?

Answer 13

24 hours

Question 14

Most foreign bodies that enter the stomach will pass in?

Answer 14

Four to six days

Question 15

75% of all hernias are?

Answer 15

Inguinal hernias

Question 16

2/3 of all inguinal hernias are?

Answer 16

Indirect

Question 17

What are the most common ventral (abdominal wall) hernias?

What are the most common groin hernias?

Answer 17

1) Epigastric and Umbilical

2) Inguinal

Question 18

Direct inguinal hernias pass directly through a weakness in?

Indirect inguinal hernias passes through?

Answer 18

1) Transversalis fascia in the Hesselbach triangle

2) The internal and external inguinal ring

Question 19

How is the hernia described if the hernia sac itself is soft and easy to replace back through the hernia neck defect?

What if the hernia sac is firm, often painful, and nonreducible by direct manual pressure with no signs of systemic illness?

What if the hernia sac is firm, very painful, and usually with signs of systemic illness (fever, nausea, vomiting) due to an impairment of blood flow (arterial, venous,
or both)?

Answer 19

1) Reducible
2) Incarcerated
3) Strangulated

Question 20

How is a strangulated hernia treated?

Answer 20

Acute surgical emergency

Question 21

What is one of the top 15 causes of mortality in the

United States, for those between 85 and 89 years?

Answer 21

Abdominal Aortic Aneurysm

Question 22

An AAA is diagnosed when the aortic diameter exceeds?

Where does it most commonly occur in the abdomnen?

Answer 22

1) 3.0 cm

2) Below renal arteries

Question 23

What is the classic triad for a ruptured AAA?

Answer 23

1) Abdominal and/or flank pain
2) Hypotension
3) Shock

Question 24

Why is a ruptured AA misdiagnosed 30% of the time?

Answer 24

Mistaken for other conditions because its symptoms (if they are even present) are vague

Question 25

What should the general screening be for an at risk patient over 65?

What should be done for an asymptomatic AAA patient?

What should be done for a stable symptomatic patient?

What should be done for an unstable symptomatic patient?

Answer 25

1) US
2) Monitor every 6 months or annual US or CT Abd/pelvis
3) CT Abd/pelvis with IV contrast
4) Emergency surgery

Question 26

What are the most commonly injured solid organs?

Answer 26

Spleen and liver

Question 27

What process adopted by ACLS and PALS is used for taking care of critically ill patients?

Which is most important in terms of abdominal trauma assessment?

Answer 27

1) Airway maintenance with C-spine control
2) Breathing and ventilation
3) Circulation with hemorrhage control (Important for abdominal trauma)
4) Disability/neuro status
5) Exposure/Environmental control

Question 28

Where are diaphragm injuries most common?

What are they a common result of?

What should not be used when putting in a chest tube?

Answer 28

1) On the left
2) Blunt high impact (MVC)
3) Trochar

Question 29

Patients that have trauma due to being in an unrestrained MVC with frontal impact or from a bicycle handlebar result in what injuries?

What imaging should be done?

Answer 29

1) Duodenal injuries

2) Ct abd/pelvis with iv and Oral contrast

Question 30

Pancreatic injuries result from direct blow to the
pancreas that compresses it against?

What lab values should you check?

What imaging should be done?

Answer 30

1) The vertebral column
2) Amylase and lipase
3) Ct abd/pelvis with iv and Oral contrast

Question 31

What type of injury can direct blows to the back or flank cause?

Answer 31

Urethral disruption with anterior pelvic injury

Question 32

What injuries are seen with sudden deceleration injuries from MVC and Chance fractures?

Answer 32

Hollow viscus injuries

Question 33

Why must patients with pelvic fractures be attended to emergently?

Answer 33

They have high mortality rates due to massive hemorrhage

Question 34

What should be done on all patients with significant trauma?

Answer 34

1) Lateral C spine
2) CXR
3) AP pelvis

Question 35

Why should you delay transfer of a trauma patient to definitive care in order to obtain diagnostic studies?

Answer 35

You should NOT do this

Question 36

When should laparotomy be performed?

Answer 36

Patient presents with blunt abdominal trauma with hypotension with a positive fast scan or clinical evidence of intraperitoneal bleeding

Question 37

What does a Focused Assessment with Sonography for Trauma (FAST) Scan detect?

Answer 37

1) Free intraperitoneal fluid
2) Pericardial fluid
3) Pleural fluid
4) Hemothorax and pneumothorax

Question 38

A FAST scan on the right flank is used to view?

On the left flank?

On the pelvis?

Answer 38

1) Hepatorenal space (Morrison’s Pouch)
2) Perisplenic
3) Bladder and retrovesical structures