DSA: Approach to Pt. Presenting with Abdominal Trauma and GI Emergencies

Question 1

Appendicitis

What age range does it most commonly affect and how does it present clinically?

What 4 specialty tests can be used?

Answer 1

Age: usually 2nd-3rd decades of life
- highest in 10-19 yo age range

Clinical: starts as nonspecific visceral pain that becomes localized to the RLQ (sharp and localized)

Tests: McBurneys Point, Rovsing’s Sign, Obturator and Psoas Signs

Question 2

What imaging would you order for adult, child, and pregnant patients suspected of Appendicitis?

How would you treat appendicitis?

Answer 2

Adult: Ct abdomen/pelvis w/IV or Oral contast
- gold standard (96% sensitive)

Child: Ultrasound of RLQ (use CT if negative)

Pregnant: MRI

Treat: NPO, IV fluids, antiemetic/pain meds, SURGERY (laproscopic or open surgery)

Question 3

What does Early Appendicitis mimic clinically?

Answer 3

gastroenteritis or viral illness

treat the patient, NOT the lab

Question 4

What group do Ingested Foreign Bodies commonly affect and what is the difference in materials ingested by kids vs adults?

Answer 4

• MC (80%) occur in children with most passing WITHOUT need for intervention

Kids (6 mo-3 yrs): COINS, buttons, marbles, toys
Adult: food bolus (MEAT) –> frequently elderly
- 95% accidental
- 5% intentional - Psychiatric diseases/intoxication

Question 5

What is the most common site of obstruction in the GI Tract?

What are the 3 points of physiological narrowing in the esophagus?

What condition do 1/2 of all pts. with esophageal food impactions have?

Answer 5

• MC obstruction site = ESOPHAGUS
• Strictures occur at UES, Aortic Arch lvl, Diaphragmatic Hiatus

50% of esophageal food impactions occur in pts with underlying eosinophilic esophagitis

Question 6

Drooling and inability to swallow liquids are common symptoms of what clinical issue?

Answer 6

Foreign Body Ingestion

• requires emergent endoscopic evaluation

fever, abdominal pain, repetitive vomiting require further work-up

Question 7

What imaging would you do for a patient suspected of Foreign Body Ingestion?

What 3 considerations would make you pick a CT Scan instead?

Answer 7

• use Plain Radiographs (unless pt has signs/symptoms of obstruction –> EGD immediately)
  
  • NEVER delay EGD for imaging

CT Scan: suspected perforation, sharp/pointed material ingestion, or packets of narcotics

Question 8

What is the difference between Emergent Endoscopy (3 serious things) and Urgent Endoscopy treatments for Esophageal Foreign Bodies?

Answer 8

EE: done within 6 HOURS
- complete obstruction, disk batteries, sharp objects

UE: done within 24 HOURS

• all foreign bodies require removal within 24 hours
• complication risk inc. with time

most foreign bodies that enter stomach will pass within 4-6 days

Question 9

What are the 2 most common forms of Ventral Hernias and what populations are they frequently seen in?

What is the most common type of Groin Hernia?

Answer 9

VH: Epigastric and Umbilical
- most common in kids and obese males

GH: Inguinal Hernia (75% of ALL hernias)

• 2/3 of all Inguinal Hernias are INDIRECT
• Indirect: passes internal to external inguinal ring

Direct Inguinal Hernia passes directly through transversalis fascia weakness in Hesselbach Triangle

Question 10

What is the difference between a Reducible, Incarcerated, or Strangulated Hernia?

How is each stage of hernia treated?

Answer 10

R: sac soft and easily replaceable through defect
- outpatient surgery w/follow-up

I: sac firm, painful, nonreducible
- attempt reduction, consult surgery if no affect

S: sac firm, very painful w/signs of systemic illness

• IMPAIRMENT OF BLOOD FLOW
• ACUTE SURGICAL EMERGENCY (do surgery ASAP)
• IV Abx, fluid resuscitation, pain meds, pre-op labs

Question 11

Abdominal Aortic Aneurysm

Who does it most commonly affect, when is it diagnosed, where does it occur, and what are the two most important factors associated with risk of rupture? (AD/S)

Answer 11

• disease of OLDER PERSONS (between 85-89 years)
  
  • non significant in populations < 60 yo

D: AAA when aortic diameter > 3.0 cm

• commonly occurs in abdomen BELOW renal arteries

RF: aortic diameter and ongoing smoking

Question 12

How does Abdominal Aortic Aneurysm typically present?

What is the Classic Triad seen in patients with rupture?

Answer 12

• majority of pts. ASYMPTOMATIC, but can be symptomatic without rupture
  
  • can compress structures = pain, fever, limb ischemia
• patients WITH rupture present with: Abdominal/Flank pain, hypotension, and shock
  
  • occurs in 50% of patients with ruptured AAA
  • 30% misdiagnosed due to MIMICRY of problems

Question 13

What screening should be done for Abdominal Aortic Aneurysm? (Stable vs Unstable)

Answer 13

• one time for at risk pts. > 65 yo with ultrasound
• if known AAA –> 6 month or annual ultrasound or CT
• Stable pts: CT with IV contrast
• Unstable pts: OR without imaging (w/AAA history)

Question 14

What is the difference between Blunt Trauma, Penetrating Trauma, and Explosive Trauma?

Answer 14

BT: direct blow causes rupture of organs/bleeding
- deceleration = SHEARING

PT: stab wounds/low velocity GSWs lacerate/cut
- high velocity GSWs cause inc. damage by cavitation

ET: blunt and penetrating trauma, blast injury to lungs and viscus by blast overpressure, and inhalation injury

Question 15

What are the two most commonly injured organs from Blunt Abdominal Trauma (BAT)?

Answer 15

SPLEEN and LIVER

• account for majority of abdominal injuries seen in the ER, with 75% being related to motor vehicle collisions (MVC)

Question 16

What are the ABCDE’s of Trauma patient surveys?

Answer 16

A - airway (maintenance of C-spine control)
B - breathing and ventilation
C - circulation (WITH HEMMORRHAGE CONTROL)
D - disability/neurologic control
E - exposure/environmental control
- completely undress pt, prevent hypothermia

Question 17

Diaphragm Injuries

What side of the body do they commonly occur on, what are they caused by, and what do we NOT use when putting in a chest tube?

Answer 17

• commonly seen on LEFT side of body due to BLUNT HIGH IMPACT (MVC)
• do NOT use trochar for putting in chest tube (could aspirate stomach contents)

Question 18

Duodenal Injuries

What patient population do these typically occur in and how are they visualized?

Answer 18

• commonly occur to unrestrained drivers with FRONTAL impact (bicycle handlebar injury)
• use CT with IV/Oral contrast

Question 19

Pancreatic Injuries

What do they result from, what labs should you check, and how are they visualized?

Answer 19

• from direct blows to pancreas that COMPRESS against the vertebral column
• check AMYLASE and LIPASE
• use CT with IV/Oral contast

Question 20

Genitourinary Injuries

What causes them and how are they visualized?

Answer 20

• from direct blows to back or flank (suspect with gross or microscopic hematuria)
• use CT with IV contrast

suspect urethral disruption with anterior pelvic injuries

Question 21

Hollow Viscus Injures

What causes them and how are they visualized?

Answer 21

• from sudden deceleration injuries (MVC)
• early ultrasound and CT not often diagnostic for these injuries

suspect with deceleration injuries or Chance fracture

Question 22

Solid Organ Injuries

What two organs are most commonly affected, and how should a hemodynamically stable pt be treated compared to a hemodynamically unstable pt?

Answer 22

• commonly affects LIVER and SPLEEN

Stable: conservatively managed with close observation by general surgeon

Unstable: requires operative management

Question 23

What is the difference in mortality between patients with any type of pelvic fracture, closed pelvic fracture w/hypotension, and open pelvic fracture?

Answer 23

Any = 1:6, Closed = 1:4, Open = 1:2

disruption of pelvic ring tears pelvic venous plexus and can disrupt internal iliac arterial system

Question 24

What patients would get a laparotomy?

Answer 24

• pts with blunt abdominal trauma with HYPOTENSION and positive FAST scan, or with clinical evidence of intraperitoneal bleeding

Question 25

What is a FAST Scan?

What 4 areas are commonly visualized? (S/M/P/P)

Answer 25

• ultrasound examinations for evaluation of injured pts that can detect free intraperitoneal, pericardial, pleural fluids or hemo/pneumothorax in trauma pts.
• limited sensitivity precludes ultrasound as a definitive test
• check Subxiphoid, Morrison’s Pouch (right flank, hepatorenal), Perisplenic, and Pelvic (retrovesicular)