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Emergency Medicine > CV and Abdominal Emergencies > Flashcards

CV and Abdominal Emergencies Flashcards

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1
Q

3 categories of CP?

A
  • chest wall pain
  • pleuritic or resp CP
  • visceral CP
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2
Q

Tx for SVT?

A
  • vagal maneuvers
  • start IVs
  • adenosine (blocks SA and AV conduction)
  • Cardioversion
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3
Q

Predisposing factors for Aortic Dissection?

A
  • Most impt: HTN
  • atherosclerosis
  • vasculopathies
  • marfans
  • congenital defect (aortic coarctation
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4
Q

How does aortic dissection present?

A
  • commonly w/ abrupt and severe pain in anterior chest or b/t scapula
  • ripping or tearing pain
  • HTN and tachycardia (50% present as normotensive)
  • acute aortic regurg may occur
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5
Q

intitial tx and W/U of aortic dissection?

A
  • stabilize pt
  • O2
  • IV
  • labs
  • exam: pulses in all extremities
  • EKG
  • CXR: may show widening of aorta
  • CT w/ contrast
  • TEE
  • MRI
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6
Q

Tx of aortic dissection?

A
  • HTN control: meds w/ neg inotropic effects
  • BBs: labetalol IV, metoprolol IV, esmolol IV
  • may need vasodilators: nitroprusside IV
  • stabilization and rapid referral to surgeon (***
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7
Q

Diff types of trauma to heart?

A
  • blunt: cardiac contusion
  • penetrating:
    GSWs/SWs
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8
Q

Lung traumas?

A
  • hemoptysis
  • pulmonary contusion
  • pneumos/hemo’s/chylos
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9
Q

Causes of acute pulmonary edema?

A
  • pump failure - increased hydrostatic pressure -aortic stenosis, mitral stenosis, mitral regurg, acute MI,
  • decreased oncotic pressure
  • ARDS (leaky capillaries)
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10
Q

Presentation of acute pulmonary edema?

A
  • severe resp distress
  • cool skin
  • rales
  • JVD
  • peripheral edema may or may not be present
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11
Q

W/U and initial Tx of acute pulmonary edema?

A
  • stabilize pt: maintain airway control and adequate ventilation
  • O2: guided by pulse ox
  • monitor
  • EKG
  • frequent vitals
  • labs:
    CMP
    CBC
    cardiac enzymes
    ABGs
  • Foley cath
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12
Q

CXR findings of acute pulmonary edema?

A
  • dilated upper lobe vessels
  • cardiomegaly
  • interstitial edema
  • enlarged pulmonary artery
  • pleural effusion
  • alveolar edema
  • kerley B lines
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13
Q

Further tx for pt w/ acute pulmonary edema?

A
  • IV nitro to control BP: cont infusion
  • may need nitroprusside: cont infusion
  • nesiritide: heart failure
  • critical end pt is rapidly lowering the filling pressure to prevent need for intubation
  • morphine: 2-5 mg IV
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14
Q

Diuretics used for pulmonary edema?

A

Furosemide:
diuresis can begin w/in 10-15 min
- can be repeated if adequate diuresis hasn’t begun
- need a foley

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15
Q

When should pt w/ acute pulmonary edema be admitted to ICU?

A
  • when they are really sick!
  • need close monitoring of resp status, BP, HR, urine output
  • vasodilator drips have to be monitored in ICU continously
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16
Q

Causes of pulmonary edema?

A
  • massive MI

- valve disease

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17
Q

Abdominal injury - and contents involved?

A
  • solid organs: injuries to liver, spleen, pancreas may result in bleeding into abdominal cavity or dumping contents into cavity
  • hollow organs (stomach, duodenum, intestine) may d/c chemical and bacterial contents
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18
Q

What is peritonitis?

A
  • emergent situation

- infection or rarely some other type of inflammation of the peritoneum

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19
Q

What is an acute abdomen?

A
  • spectrum of surgical, medical and gyn conditions, ranging from trivial to life-threatening, which reqr hosp admission, investigation and tx
  • intra-abdominal process causing severe pain reqring admission, hasn’t been prev. tx, may need surgical intervention
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20
Q

Tx depending on cause of acute abdomen?

A
  • pt w/ acute abdomen is emergency!! correct dx vital!
  • surgery needed: ectopic pregnancies, acute appendicitis, duodenal gastric perf ulcers
  • abx for PID
  • observation: mild ovarian cyst ruptures, pancreatitis
  • stabilization!!
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21
Q

W/U of acute abdomen?

A
  • pt condition guides urgency
  • VS: stable or unstable
  • pathology in belly can manifest itself w/ systemic signs (renal failure or shock)
  • clinical dx
  • imaging studies depend on dx
  • stabilization
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22
Q

Stabilization of acute abdomen?

A

ABCs

  • O2
  • IV fluids
  • foley
  • NG tube
  • abx
  • pain control after surgeion checks source of pain or BP is good
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23
Q

Etiology of acute abdomen in kids?

A
  • gastroenteritis
  • meckel’s diverticulitis
  • intussusception
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24
Q

Etiology of acute abdomen in adult females?

A
  • PID
  • pyelo
  • ectopic preg
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25
Q

Etiology of acute abdomen in adults?

A
  • regional enteritis
  • kidney stone
  • perf ulcer
  • testicular torsion
  • pancreatitis
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26
Q

Etiology of acute abdomen in elderly?

A
  • diverticulitis
  • intestinal obstruction
  • colon carcinoma
  • mesenteric infarction
  • aortic aneurysm
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27
Q

Sxs of acute abdomen?

A

onset:

  • sudden: bowel perf, smooth muscle colic
  • slow insidious onset: inflammation of visceral peritoneum

severity: kidney stone worst pain

character:
- burning: peptic ulcer sxs
- stabbing: kidney stone
- gripping, intermittent and crampy: intestinal obstruction worse w/ movement

progression:

  • constant: peptic ulcer
  • colicky: sec -bowel, min - kidney stone, 10 mins gallbladder
  • radiation of pain:
    back: duodenal ulcer, pancreatitis, AAA
    scapula: gall bladder
    SI region: ovary
    groin: testicular torsion
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28
Q

Hx questions for acute abdomen?

A 
- any GI sxs:
N, emesis (bilious or bloody)
last BM or flatus (obstruction)
diarrhea (bloody - IBD)
both Nausea, diarrhea usually gastroenteritis
change in sx w/ eating usually PUD
- NSAID use (duodenal ulcers)
- gyne hx
- drinking hx - pancreas - pancreatitis
- prior surgeries: adhesions SBO? still have gallbladder and appendix
- hx of hernias
- heart/lung dx
- FH of Ca or IBD
- meds: steroids,  anticoag
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29
Q

Broad categories for DDx for acute abdomen?

A
  • inflammation
  • obstruction
  • ischemia
  • perf:
    offended organ becomes distended - then lymphatic/venous obstruction due to increased pressure - and arterial pressure exceeded - leads to ischemia and prolonged ischemia leads to perf
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30
Q

inflammatory causes of acute abdomen?

A
  • stomach: gastric ulcer, duodenal ulcer
  • biliary tract: acute chole’y +/- choledocholithiasis
  • pancreas: acute, recurrent or chronic pancreatitis
  • small intestine: crohn’s, meckels diverticulum
  • large intestine: appendicitis, diverticulitis
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31
Q

Obstructive causes of acute abdomen?

A 
- SBO: 
Adhesions
Bulges
Cancer
Crohns
gallstone ileus
intussusception
volvulus
- LBO: 
malignancy
volvulus: cecal or sigmoid diverticulitis
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32
Q

PE of acute abdomen?

A 
- auscultation: 
silent = peritonitis
increased BS = obstruction
- rebound tenderness:
if +: peritoneum involved (exquisitively sensitive)
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33
Q

If you can’t localize abdominal pain - what would pt likely have?

A
  • may have general peritonitis - call surgeon
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34
Q

If pt has increased bowel sounds - what is likely dx?

A
  • intestinal obstruction
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35
Q

labs for abdominal pain?

A
  • CBC w/ diff: infection and inflammation
  • lytes, BUN, creatinine, glucose (DKA)
  • LFT (biliary tract)
  • amylase (high in acute pancreatitis)
  • UA and culture
  • preg test
  • blood gas = acidosis
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36
Q

DDx for acute abdomen?

A
  • appendicitis
  • bowel perf or obstruction
  • pancreatitis
  • diverticular disease
  • cholecystitis
  • perf gastric/duodenal ulcer
  • ruptured ectopic
  • ruptured or hemorrhagic ovarian cyst
  • PID
  • AAA
  • tubo-ovarian abscess
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37
Q

GI etiologies of acute abdomen?

A 
- Gut:
acute appendicitis
intestinal obstruction
perf peptic ulcer
diverticulitis
IBD
acute exacerbation of peptic ulcer
gastroenteritis
meckel's diverticulitis 
- liver and biliary tract:
cholecystitis
cholangitis
hepatitis
biliary colic
- pancreas:
acute pancreatitis 
- spleen:
splenic infarct and spont. rupture
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38
Q

Urinary tract etiologies of acute abdomen?

A
  • cystitis
  • acute pyelo
  • ureteric colic
  • acute retention
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39
Q

Vascular etiologies of acute abdomen?

A
  • Ruptured aortic aneurysm
  • mesenteric embolus
  • mesenteric venous thrombosis
  • ischemic colitis
  • acute aortic dissection
40
Q

Abdominal wall etiologies of acute abdomen?

Peritoneum?

A

Abdominal- rectus sheath hematoma

peritoneum - primary peritonitis, secondary peritonitis

41
Q

Retroperitoneal etiologies of acute abdomen?

A
  • hemorrhage ex: anticoagulants
42
Q

Gyn etiologies of acute abdomen?

A
  • torsion of ovarian cyst
  • ruptured ovarian cyst
  • fibroid degeneration
  • ovarian infarction
  • salpingitis
  • pelvic endometriosis
  • severe dysmenorrhea
  • endometriosis
43
Q

Extra-abdominal causes of acute abdomen?

A
  • lobar pneumonia
  • pleurisy
  • MI
  • sickle cell crisis
  • uremia
  • hypercalcemia
  • DKA
  • addison’s disease
44
Q

Acute appendicitis presentation?

A
  • periumbilical pain that migrates to RLQ
  • high risk of perf: less than 2yo or elderly, DM, immunocompromised, steroid use
  • McBurney’s pt: 1/3 the distance b/t anterosuperior iliac spine and umbilicus
45
Q

Abdominal series of XRs? what is best?

A
  • chest: upright best for free air
  • supine abdomen: best for abdominal detail - organs, bones, jts, fat and gas patterns
  • erect abdomen: air fluid levels
  • left lateral decubitus abdomen: possible substitute for erect chest and abdomen if pt can’t sit or stand
46
Q

Presentation of perf peptic ulcer?

A
  • hx: GU or DU
  • PE: rebounding tenderness, BS are quiet, muscle guarding
  • lab: elevated WBC
  • upright chest: free air
47
Q

4 cardinal features of intestinal obstruction?

A
  • abdominal pain w/ intermittent cramping
  • vomiting
  • distension
  • constipation
48
Q

colon obstruction measurements?

A
  • cecum most distensible part of colon
  • cecum of 9 cm diameter is cause for concern
  • cecum of 11 cm is impending perf
49
Q

When should you consider a pt has mesenteric infarction/ischemia?

A
  • atypical presentation of abdominal pain
  • older pts
  • hx of arrhythmias or previous emboli
  • pain out of proportion to exam
  • evidence of visceral complaints w/o peritonitis
  • systemic complications
  • acidosis
  • they look sick
50
Q

Etiology of acute mesenteric ischemia? Tx?

A
  • usually acute occlusion of SMA from thrombus or embolism

- may need embolectomy

51
Q

Chronic mesenteric ischemia - typical pt?

A
  • typically smoker, vasculopath w/ severe atherosclerotic vessel disease: low flow state
  • ischemic colitis
  • any inflammation, obstructive, or ischemic process can progress to perforation
52
Q

Signs of chronic mesenteric ischemia? What can be done?

A
  • wt loss is most consistent sign
  • become afraid to eat b/c of postprandial pain (intestinal agina)
  • emergent CTA may be needed
53
Q

Cause of air in biliary system?

A
  • usually secondary to surgery on bile ducts
  • can be due to biliary-bowel fistula from infection or neoplasm
  • rarely, can be due to infection
54
Q

US can assess what?

A
  • rapid, safe, low cost (but operator dependent)
  • fluid, inflammation, air in walls, masses
  • liver, GB, CBD, spleen, pancreas, appendix, kidney, ovaries, uterus
55
Q

abdominal CT used to dx what?

A
  • dx for intra-abdominal abscess (sigmoid diverticulitis), pancreatitis, retroperitoneal bleeding (leaking AAA), hepatic or splenic pathology and even appendicitis
  • better than plain films for eval of solid and hollow organs
56
Q

What can an elevated amylase mean?

A
  • pancreatitis
  • perf DU
  • bowel ischemia
57
Q

elevated LFTs meaning?

A
  • jaundice, hepatitis
58
Q

Why would you order a beta-hCG?

A
  • suspect preg - ectopic
59
Q

What can you see on KUB (flat and upright)?

A
  • SBO/LBO

- free air, stones

60
Q

What can you dx on US?

A
  • cholecystitis : jaundice

- GYN path

61
Q

When would you decide to operate on acute abdomen? (surgeon ult makes the call)

A
  • 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
62
Q

Common causes of acute abdomen?

A
  • perf DU
  • cholecystitis
  • appendicitis +/- perf
  • ischemic or perf bowel
  • diverticulitis +/- perf
  • ruptured aneurysm
  • bowel obstruction
  • acute pancreatitis
63
Q

mechanisms of blunt injury?

A
  • compression, crush, or sheer injury to abdominal viscera - deformation of solid or hollow organs, rupture (small bowel, graid uterus)
  • deceleration injuries: diff movements of fixed and non-fixed structures (liver, spleen lacerations at sites of supporting ligaments)
64
Q

Common injury patterns?

A
  • most freq injured organs: spleen, liver and small bowel
  • duodenum: classically, frontal impact MVC w/ untrestrained driver, or direct blow to abdomen. Bloody gastric aspirate, retroperitoneal air on XR or CT, series confirmed w/ UGI
  • small bowel injury: generally from sudden deceleration w/ subsequent tearing near fixed pts of attachment
65
Q

Common injury pattern of pancreas?

A
  • direct epigastric blow compressing pancreas against vertebral column
  • amylase and CT not very helpful
66
Q

Common injury pattern of diaphragm?

A
  • Most commonly, 5-10cm rupture involving posterolateral hemidiaphragm, noted on CXR: blurred or elevated hemidiaphragm
67
Q

Common injury pattern of GU?

A
  • pts w/ multisystem and pelvic fxs
68
Q

Common injury pattern to solid organ?

A
  • laceration to liver, spleen or kidney
69
Q

common injury pattern of pelvic fx?

A
  • suggest major force applied to pt
  • usually auto-ped, MVC, or motorcycle
  • sig assoc w/ intra-peritoneal and retroperitoneal organs and vascular structures
70
Q

Hx questions to ask about trauma?

A
  • mechanism
  • sxs, events, PMH, meds, ETOH/drugs
  • MVC:
    speed, type of collision, vehicle intrusion into passenger compartment, types of restraints, deployment of airbag, pt’s position in vehicle
71
Q

PE - assessing trauma?

A
  • inspection: abrasion, contusions, lacerations, deformity
  • subtle signs of peritonitis
    (+ rebound tenderness)
  • difficult if intoxicated
72
Q

Dx tests for trauma?

A
  • labs: BMP, CBC, coags, b-HCG, amy/lip, UA, tox screen, TandC
  • plain films: CXR, pelvis, abdominal films not really helpful
  • DPL
  • FAST
  • CT
73
Q

Use of dx peritoneal lavage?

A
  • 98% sensitive for intraperitoneal bleeding
  • free aspiration of blood, GI contents, or bile indicaiton for surgery
  • if gross blood (over 10 mL) or GI contents not aspirated perform lavage w/ 1000 mL warmed LR
  • has been somewhat superceded by FAST in common use, now generally performed in unstable pts w/ intermediate FAST exams, or w/ suspicion for small bowel injury
74
Q

Use of FAST? Comparison to CT?

A
  • focused assessment w/ sonography for trauma
  • for ID hemoperitoneum in blunt abdominal trauma
  • larger hemoperitoneum the higher the sensitivity, so sensitivity increases for clinically significant hemoperitoneum
  • FAST can detect as little as 100 cc
  • FAST replaces CT only at extremes:
    unstable pt - if + FAST - go to OR
  • if stable pt, low force injury and - FAST - consider observation
  • CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma, god std for characterizing intra-parenchymal injury
  • never send unstable pt to CT though - FAST can be used during resuscitation
75
Q

When is CT recommended?

A
  • for eval of hemodynamically stable pts w/ equivocal findings for PE, assoc neuro injury, or mult extra abdominal injuries
  • CT is dx modality of choice for non-operative management of solid visceral injuries
76
Q

Eval for penetrating trauma?

A
  • mandatory exploration abandoned (old school) - roll the pt
  • no digital exploration or contrast studies
  • inspect wound to determine if there is violation of fascia
  • difficult to assess stab wound trajectory
  • determine if gunshot transversed peritoneal cavity
77
Q

Management of penetrating trauma to abdomen?

A
  • ABCs
  • fluid resuscitate
  • to OP or not OP is issue:
    unstable w/ no other reason
    free air/peritonitis (abx)
    unexplained free fluid
  • many splenic/liver lacs managed non-op
78
Q

Penetrating flank and buttock injuries - assessment?

A
  • potential for peritoneal and or retroperitoneal injury
  • similar eval and management to abdominal
  • buttock injuries may also reach peritoneal and or retroperitoneal structures
79
Q

GU trauma - what is MC injured?

A
  • 2-5% of adult traumas
  • vast majority blunt mechanisms
  • 80% renal
  • 10% bladder
  • rarely reqr immediate intervention
80
Q

Eval of GU trauma?

A
  • rectal: high riding prostate
  • perineum: ecchymosis, lacs
  • genitals: meatal/vaginal blood
  • difficult cath placement - don’t force may have urethral tear!
  • UA: hematuria - poor correlation w/ injury
  • US and plain films of little use
  • CT superior imaging modality but be careful w/ contrast
  • IVP/cystoscopy less useful in ED
81
Q

Kidney injuries?

A
  • they are well protected
  • MC bruised
  • pts w/ shattered kidneys become rapidly unstable
  • renal vascular injuries may result in thrombosed vessels
82
Q

Bladder injuries?

A
  • contusion
  • rupture: intra vs extraperitoneal
  • extraperitoneal: presents w/ pain, hematuria, inability to void
  • urethral injuries: anterior vs posterior
  • no foley for urethral injuries
83
Q

How common is GI bleeding? Mortality?

A
  • GI bleeding is common disorder that troubles all medical/surgical specialities
  • UGI bleeding more common than LGI
  • 6-8% mortality (hasn’t changed since 1945)
  • usually w/o belly pain
84
Q

Presentation of GI bleeding and source?

A
  • hematemesis: UGI source
  • melena: UGI source usually but 5% can be from LGI
  • hematochezia - LGI source usually but 15% form UGI source
  • occult: UGI or LGI source
85
Q

How is UGI and LGI location determined?

A
  • by ligament of Trietz
  • UGI: prox to LT: esophagus, stomach, duodenal bulb, 2nd/3rd portion of duodenum
  • LGI: distal to LT: small bowel, colon
86
Q

How do you determine urgency of GI bleed?

A
  • is pt in shock?
    40% loss of circulating blood vol, agititation, pallor, tachycardia, hypotension
  • is pt orthostatic?
    20% loss of circ blood vol, postural hypotension
  • never rely on initial H/H values to assess amount of blood loss (hemoconcentration)
  • ABCs and order some blood
87
Q

Initial management of GI bleeding?

A
  • H and P
  • replace intravascular volume
  • NG intubation (careful w/ varices)
  • supp nasal O2
  • lab eval: CBC/platelets/INR/PTT/BUN/creatinine
  • admit
88
Q

Use of NG aspirate in GI bleeding?

A
  • determines status of UGI bleeding and gives indirect info in LGI bleeding:
  • bright red/clots: active UGI bleed
  • coffee grounds: slow bleeding, oozing, stopped
  • clear: indeterminate (16% still bleeding)
  • bilious: UGI bleeding has stopped
89
Q

Dx/therapeutic modalities for GI bleed?

A
  • GI consult!!
  • endoscopy: upper/lower
  • radionuclide scanning
  • angiography
  • never ever use barium in acute GI bleeding!!
90
Q

MC sites for GI bleeds in UGI?

A
  • DU
  • gastric erosion, itis
  • GU
  • varices
  • M-W tear
  • esophagitis
91
Q

MC sites for GI bleeds in LGI?

A
  • diverticulitis
  • angiodysplasia (AVMs)
  • neoplasia
  • colitis
92
Q

GI bleeding in diverticulosis?

A
  • occurs in 3% of pts w/ diverticulosis
  • acute, painless bleeding presenting w/ bright red blood/maroon stool
  • right colon usual site 20% episodes are recurrent/persistent
  • colonoscopy after bowel prep
  • tagged RBC scans/angiography
93
Q

Anorectal/perianal disease - cause of GI bleeding?

A
  • common cause of BRBPR: hemorrhoids
  • minor, intermittent bleeding w/ defecation
  • always a dx of exclusion after more serious lesions in GI tract have been r/o (CRC, polyps, colitis) but make sure you look
94
Q

Role of endoscopy in triage of UGI bleeders?

A
  • accurate ID of urgency of clinical situation: hemodynamic compromise/signs of on-going bleeding/coag/co-morbidities
  • helps determine who should be hosp, admitted
  • dx cause
95
Q

Assessing cause of UGI bleeding?

A
  • is bleeding ongoing (rapid vs slow), intermittent or chronic?
  • cautious consideration of NG lavage
  • cautious eval of initial lab
  • close attention to vital signs and response to resuscitation effort
  • URGENT endoscopy must be considered for pts w/ on-going bleeding/coag/sig co-morbidities
  • early for all other UGI bleeders
96
Q

What pts presenting w/ GI bleeding should be hosp?

A
  • UGI bleeders usually admitted to host even if endoscopy performed b/f admission showed low risk lesion
  • ER/PCP freq. makes admission decision and error is on side of safety
  • mandatory admission: proven or susp. variceal hemorrhage/hemodynamic instability/co-morbidity (CP)/mental impairment or non-compliance/coag/anemia rqring transfusion
97
Q

Where should you admit pt w/ GI bleeding?

A
  • ICUs offer close observation/monitoring of clinical status/immediate resuscitative effort if needed
  • no study shows improvement in outcome in GI bleeding from ICU care
  • restrict ICU admission to pts w/: high risk or re-bleeding or unstable pt
  • advanced age alone doesn’t rqr ICU admission

Emergency Medicine (22 decks)

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