EM Block II Flashcards
Describe visceral pain
Obstruction, ischemia, or inflammation can cause stretching of unmyelinated fibers that innervate the walls or capsules of organs, resulting in visceral pain
Visceral pain is often described as “crampy, dull, or achy,” and it can be either steady or intermittent (colicky)
(Think obstruction).
Describe parietal pain
Parietal (somatic) abdominal pain is caused by irritation of myelinated fibers that innervate the parietal peritoneum, usually the portion covering the anterior abdominal wall.
This may be caused by continued inflammation from an obstructed organ or chemical irritants
Parietal afferent signals: specific area of peritoneum! Parietal pain can be localized to the dermatome superficial to the site of the painful stimulus.
If you think you need blood later on then what should you order
Type and Screen
If you need blood now, what should you order
Type and Cross
Who is it most common to have appendicitis
Acute appendicitis is most common in patients age 10 to 19 years, remains the most frequent cause of atraumatic abdominal pain in children >1 year old, and is the most common non-obstetric surgical emergency in pregnancy, complicating up to 1 in 1500 pregnancies.
What is the traditional cause of appendicitis
Luminal obstruction of the vermiform appendix, typically by a fecalith,(poop stone) is considered the traditional cause of appendicitis.
What is the location of McBurney’s point
located one third of the distance from the anterior superior iliac spine to the umbilicus.
What is the initial pain sensation of appendicitis
unenervated visceral pain fibers
What is rovsings sign
Rebound referred pain from contra lateral compression of the abdomen that is a sign of appendicitis
What kind of pyuria is present is appendicitis
Sterile pyuria
In appendicitis in pregnant or child pts
What is the imaging modality of choice
US ! First
What is the imaging for Appendicitis in the majority of pts
Non con ct
What is the tx for appendicitis
Immediate surg consult
NPO immediately
Maintenance fluids and pain meds
ABX as appropriate
Ampicillin/Sulbactam
Pipercillin/ Tazobactam
Cefetoxin
What is the flow of ducts through the pancreas
Bile flows out of the liver through the left and right hepatic ducts, which come together to form the common hepatic duct. This duct then joins with a duct connected to the gallbladder, called the cystic duct, to form the common bile duct. The common bile duct enters the small intestine at the sphincter of Oddi (a ring-shaped muscle), located a few inches below the stomach.
How does pancreatitis general resolve
Generally resolves with only supportive care
IV Fluids, pain control, bowel rest etc etc..
What are the common pancreatitis presentation in men vs women
Alcohol is more common in men
Gall stones more common in women
What surgery has a 5% incidence rate for pancreatitis
ERCP ( gall stone removal)
What enzyme is responsible for auto digestion of the pancreas
Trypsin
What is the criteria to Dz pancreatitis
(1) clinical presentation consistent with acute pancreatitis
(2) serum lipase or amylase elevated above the upper limit of normal (X3)
(3) imaging findings characteristic of acute pancreatitis
(IV contrast CT, MRI, or transabdominal US)
How elevated with the amylase or lipase be in pancreatitis
3x ULN
ALT elevated above 150 means..
An alanine aminotransferase of >150 U/L within the first 48 hours of symptoms predicts gallstone pancreatitis
When does pancreatitis show up on CT
72 hours of onset
What is the SIRS criteria for severe acute pancreatitis
Patient characteristics:
>55 years, obesity, AMS, comorbidities
Labs:
BUN >20 or rising; hematocrit >44% or rising; ↑creatinine- DEHYDRATION!
What is the treatment appraoch to biliary pancreatitis
Early surgical consult! ERCP
In a female, fat, fertile over 40
Think of what d/o
Cholecystitis
What is the most common complication of gallstone dz
Biliary colic
Define emphysemic cholecystitis
inflamed gallbladder becomes infected with gas-producing organisms
Define choleodocolithiasis
gallstones within the common bile duct
Define Cholangitis
Infection of the biliary tree
What is billary sludge
Biliary sludge is microlithiasis composed of cholesterol crystals, calcium bilirubinate pigment, and other calcium salts
Define acute acalculus cholesytisis
Occurs in the setting of critical illness such as septic shock, burns, & major trauma or surgery
Old age, DM, and immunosuppression are also risk factors
A pt that presents with N/V and back pain that happens around midnight
Think
Cholecystitis and biliary colic
Jaundice in the setting of biliary tract stone disease implies:
Obstruction of the CBD from choledocholithiasis
What is the Dx criteria for Acute cholecystitis
+ Murphys
RUQ pain
Fever, Elevated CRP And WBC
What is Charcots triad
Fever
RUQ abdominal pain
Jaundice
Dx cholangitis
What is Reynolds pentad
Fever
RUQ abdominal pain
Jaundice
+ AMS and Shock
For cholangitis
What is the most sensitive serum marker for choledocholithiasis
GGT
What is the normal measurement for the common bile duct
Less than 5cm
If youre looking for choledocholithiasis
What should you order
ERCP
What is the perferred initial imaging for cholecystitis
US
How do we tx biliary colic
Elective cholecystectomy is occasionally recommended for those at high risk for gallstone complications
- Sickle cell disease
- Planned organ transplantation
- Ethnic groups at high risk for GB cancer
ED managment of biliary colic:
NSAIDs 1st line, Antiemetics, analgesics
Referal to outpt or to general surgery
What is the tx approach to acute cholecytsis
Laparotomy/ scopy
Analgesics Antiemits NPA Fluids And ABX
What is a gallstone ileus
Gallstone ileus —>mechanical SBO caused by an ectopic gallstone that has reached the intestinal lumen via a biliary-enteric fistula
What is riglers triad
Diagnosed on plain films or with CT (usually) for gallstone ileus
Rigler’s triad: small bowel obstruction, pneumobilia, and an ectopic gallstone.
What separates upper and lower GI bleed
Ligament of tritz
What is the most common cause of GI bleeding
PUD
What is responsible for maintingin the gastric mucosal barrier
Prostaglandins
What is the major cause of varicela bleeding
Cirrhotics
What are the S/s of an underlying GI bleed
Hypotension, tachycardia, angina, syncope, weakness, confusion, or cardiac arrest
What is the most reliable way to Dx Upper GI bleed
Visual inspection of the vomitus
Spider angiomas, palmar erythema, jaundice, and gynecomastia suggest
Liver Dz
What is the single most important lab test for a signifigant bleed
Cross and match
What is the BUN level be in an upper GI bleed
Elevated
An elevated lactate level is a sentinel sign of…
Severe illness
Can pts with GI bleeds get barium studies
Barium contrast studies are contraindicated because barium may hinder subsequent endoscopy or angiography- don’t do them
When should you order tagged red blood cells
In babies or in pts with C/i for endoscopy
What procedure is both Dx and Tx for a GI bleed
NG placement and aspiration are diagnostic and therapeutic
What is the threshold for blood transfusion in a GI bleed
Transfusion is less than 7 or less than 9 in older pts
What is the ABX for prophylaxis in Upper GI bleed
Ciprofloxacin 400 mg
Or Ceftriaxone 1 gram IV
Only really need for pts with cirrhosis
What is a concerning INR in a pt with a GI bleed
INR ≥1.5 is a significant predictor of mortality in UGIB pts who are receiving anticoagulants! They are thin!!!
What is octreotide used for in an Upper GI Bleed
Octreotide is a long-acting analog of somatostatin that elicits several actions in patients with UGIB
Inhibits the secretion of gastric acid- good
Reduces blood flow to the gastroduodenal mucosa- also good
Causes splanchnic vasoconstriction- Mixed..
If a pt has an allergy to ciprofloxacin what is the ABX to be used
Ceftriaxone
When should we use ABX in a Upper GI Bleed
Patients with cirrhosis have an impaired immune system and have an increased risk of gut bacterial translocation during an acute bleeding episode
Prophylactic antibiotics
- Reduce infectious complications
- May decrease mortality
- Start ASAP
- Ciprofloxacin 400 mg IV or ceftriaxone 1 gram IV
What is the Dx study of choice in a Uppe GI bleed
UGI endoscopy is the diagnostic study of choice for bleeding- Why?
Allows visualization of bleeding source (in most cases) & administration of hemostatic therapy- two in one!
What is the most common cause of Lower GI bleed
diverticular disease
Define hematochezia
bright red or maroon-colored rectal bleeding
Originating from a UGI source—> brisk UGIB
May be accompanied by hematemesis & hemodynamic instability
~10% of hematochezia episodes may be associated with UGIB
Define Melena
Melena—> dark or black-colored stools
Usually represents bleeding from a UGI source
May also represent slow bleeding from an LGI source along with slow colonic transit or constipation..
Is bleeding from diverticulosis painful?
Usually painless
Describe Vascular ectasia
Incl. arteriovenous malformations & angiodysplasias of the colon
Can also be present in the small bowel
Development in the large bowel —> chronic process & increases with age
Valvular heart disease is a risk factor for developing bleeding vascular ectasias
What is the most common cause of intestinal ischemia
Ischemic colitis
What are the pts for high index for ischemia and Mesenteric ischemia
> 60 years old
Atrial fibrillation
Congestive heart failure
Recent myocardial infarction
Postprandial abdominal pain
Unexplained weight loss
What is the Dx study of choice for Ischemic and Mesenteric ischemia
Angiography
Describe meckels diverticulum
Consists of embryonic tissue
Most commonly found in the terminal ileum
More than half of lesions contain ectopic gastric tissue
Can secrete gastric enzymes, eroding the mucosal wall & cause bleeding
Rare but important condition, esp in the younger population!
Bleeding and a non tender abdomen is a sign of..
Nontender abdomen (predictive of severe bleeding)
LGIB, a lack of abdominal tenderness suggests bleeding from disorders involving the vasculature (diverticulosis or angiodysplasia)
What is the BUN in a upper or lower GI bleed
Bleeding from a source higher in the GI tract may elevate blood urea nitrogen levels through digestion & absorption of hemoglobin
Which is more sensitive for a bleed in the GI
Scintigraphy or angiography
Scintigraphy appears more sensitive than angiography and can localize the site of bleeding at as low a rate as 0.1 mL/min
What is the role of multi detector CT angiography
Multidetector CT angiography has a sensitivity up to 100% and specificity of up to 99% for detecting active or recent GI bleeding
~93% accurate in determining the site of bleeding
Useful tool prior to treatment with conventional angiography
What is the tole or flexible sig
Can evaluate possible distal colonic & rectal sources of bleeding
Cannot identify more proximal sources of bleeding
If colonoscopy fails to determine the source of bleeding—>consider…
onsider upper endoscopy to evaluate for a UGI source
Describe diverticulitis
Incidental finding
small herniations at sites where the vasculature (vasa recta) penetrates the circular muscle layer of the colon
True diverticula involve all layers of the colon wall
What are the common bacterial pathogens in diverticulitis
Bacteroides Peptostreptococcus Clostridium Fusobacterium Gram-negative rods, such as Escherichia coli
What causes diverticula formation
Altered bowel motility —>high intraluminal colonic pressures lead to diverticula formation
Smoking & obesity increase risk for diverticulitis
Is diverticula on the left or right abdomen?
LEFT ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
A pt presents with LLQ pain, +/- fever, and leukocytosis
Think
Diverticular Dz
Can present with a change in bowel (diarrhea or constipation)
When is imaging required in diverticular dz
If a prior diagnosis has not been confirmed
or
the current episode differs from the past episode:
Diagnostic imaging is required to exclude other intra-abdominal pathology and to evaluate for complications
What is the preferred imaging modality for Diverticular Dz
Contrast abd/pelvis CT
What is the treatment for uncomplicated diverticulitis
bowel rest (liquid diet) and oral antibiotics
Dietary restriction/modification (efficacy is not clear)
No advantage of IV antibiotics over oral antibiotics
Admission is not necessary unless there are serious comorbidities or obstacles to outpatient care
Confirmed with CT—>success rate of ambulatory treatment is about 98%
What is the tx for complicated diverticulitis
diverticulitis generally requires admission
Bowel rest and IV antibiotics
Specific treatments are directed to complications
What is stage 1 hínchey classification
Stage 1 is small, confined pericolic or mesenteric abscesses
Stage II hínchey classification
Stage 2 is larger abscesses, extending to the pelvis
Stage III hínchey classification
Stage 3 is perforated diverticulitis and purulent peritonitis
What is stage IV hínchey classification
Stage 4 is free perforation with fecal contamination of the peritoneal cavity
What is a phlegmon
Phlegmon is inflammation and infection of tissue without abscess- but causes pus, so not walled off.
What is the ED D/c approach for uncomplicated diverticulitis
F/u in 2-3 days
Or go to the ER if worsening
What is defined as failure of Tx in diverticulitis
Failure of outpatient therapy= symptoms or worsening radiographic imaging within 6 weeks of the initial episode
What are the most common sites for kidney stone obstruction
The most common sites of obstruction include:
-Ureteropelvic junction, where the 1-cm pelvis constricts into the 2- to 3-mm ureter
- Pelvic brim, where the ureter courses over both the pelvis and the iliac vessels
- Ureterovesical junction, because this is the most constricted site of the ureter due to the muscular coat of the bladder.
Where do distal ureter stones usually present
Distal ureter stone, which is where 75% of stones are diagnosed, refers pain to the groin.
What is the Rx most commonly used for medical expulsion therapy
tamsulosin
Pregnancy in a patient with prior tubal surgery for sterilization is assumed to be
Ectopic pregnancy UPO
Define the discriminatory zone for a trans vaginal vs trans abdominal US in pregnancy pts
With transvaginal scanning, the discriminatory zone is often considered to be 1500 mIU/mL.
For transabdominal scanning, an IUP should be detectable when the β-hCG level reaches about 6000 mIU/mL.
Slide 20 Ectopic Pregnancy
What is the most common Rx for Ectopic pregnancy
Methotrexate
What are the managment options for stable pts with a HCG below that ediscrimanatoy zone
Management options for stable patients with a β-hCG level below the discriminatory zone and indeterminate US include consultation in the ED or discharge for follow-up in 2 days for reexamination and repeat β-hCG levels.
What does AEIOU TIPS stand for
Alcohol/ Acidosis/ Alkalosis Endocrine. Electrolytes. Insulin Opiates Uremia
Trauma
ICP/ Infection
Poisoning/ Psych
SZR. Syncope
What is the threshold for dialysis
Acidosis <7.1
Electrolytes: K >6.5
Intoxications: SLIME
- salicylates
- lithium
- isopropanol
- ethylene glycol
Overload: volume
uremia: uremic syndrome
If a child has an unexpected postive Tox screen
What should you do
Notify CPS
Drugs that widen the QRS
Diphenhydramine
Antipsychotics:
- Risperidone
- Quetiapine
TCAs;
- amitryptyline
- imipramine
- nortriptyline
What does the acronym sludge mean
S-alivation L-acrimation U-rination D-iaphoresis G-astrointestinal E-mesis
What is the only poising that you get the antidote before you do ABCs
Cyanide
What is the treatment for Hypogl in OD
IV dextrose
If a pt has an IV lipid emulsion
What is the tx
management of cardiac arrest in bupivacaine toxicity.
What is a DONT cocktail
Dextrose
O2
Naloxone
Thiamine
For Coma
How do you decon someone’s eyes
Eyes: Copious Irrigation w/ NS or LR 1-2L per eye followed by ph testing
How do you decon the GI system
GI Decon: NG Lavage w/ Charcoal & Cathartic
What anesthetic is used in eye washouts
Tetracaine
If alkaline gets in the eye what should you do
Wash out maybe 1-2 hours
And refer to ophthalmology
Ten minutes after irrigation (allowing equilibration of crystalloid and conjunctival sac pH), conjunctival sac pH is tested.
Irrigation continues until pH is between 7.2 and 7.4.
What is the role of polyethylene glycol (Mira lax)
Whole bowel irrigation
How do we alkalinize the urine
Bicarb
(Used for aspirin OD)
Infused over 1 hr
Urine goal 7.5-8.5
If an OD doesn’t respond to Tx
What should you do
Hemodialysis or Hemoperfusion
What is the Admission length for an OD
Admission -persistent and/or severe toxic effects or will require a prolonged course of treatment.
Typically 6-hour observation period is sufficient to exclude the development of serious toxicity and change in condition of the patient.
In the developed world, toxicity will resolve within 24 hours in most poisoned patients requiring noncritical care inpatient management unless unstable or requires intensivists care.
What are the toxins that can be removed with dialysis
Remember SLIME
Salicylates Lithium Isopropanolol Methanol Ethylene Gylcol
A pt presents with an volume overload status and a ph less than 7.1 with unexplained decline in mental status..
What is the treatment approach
Indications for dialysis
What are the drugs that can be picked up on Tox Screen
Benzo Cocaine PCP Barbituates Opiods Amphetamines
What are the drugs that can not be found with a Tox Screen
Rohypnol
Methadone or Meperidine
MDMA
What can the Toxicologist handshake tell you
absence of palpated axillary sweat-anticholinergic
or presence- sympathomimetic or cholinergic.
Define a wide QRS
Any duration greater than 100 ms is abnormal
A pt presents wtih mydriasis, dry flushed skin, urinary retention, decreased bowel sounds, hyperthermia, dry mucos membranes, SZR, and possible Rhabo
Think?
Mad as a hatter
Atropine, antihistamines, antipsychotics
ANTICHOLINERGICS
A pt presents with salivation, lacrimation, diaphoresis, vomiting, urination, defecation, bronchorrhea, muscle fasiculations, weakness, miosis/ mydriasis, Brady cardia and SZR
Think
SLUDGE
Cholinergic
Organophosphate poison
Sarin
Insecticides
A pt presents with AMS, diaphoresis, tachycardia, HTN , dysarthria, behavioral changes, and SZR
Think
HOgl
Sulfonylreas or Insulin
A pt presents with miosis, rr depression, CNS depression, Hypothermia, bradycardia
Think
Opiod!
Cocaine, heroin, morphine
A pt has AMS, resp Alky met acid, and tinnitus
Think
Aspirin! (Salicylates)
A pt presents wtih CNS depression, Ataqxia, dysarthria, Bradycardia, and RR depression
Think
Sedative/ Hyponotic
Benzos and barbituates
sodium channel blocker toxicity with cardiovascular complications, such as wide QRS complex tachydysrhythmias
Is treated with…
Sodium Bicarb
How do you treat agitation in the ED
Benzos
What is in a cyanide rescue kit
Amyl nitrate
Sodium Nitrate
Sodium Thiosulfate
Can also use hydroxocobalamin
What is the antidote to Beta Blockers
Glucagon
What is the antidote to CCB
Calcium chloride/ gluconate
+/- glucagon
What do you use methylene blue for
Nitrates, benzocaine, Sulfonamides
over doses
Antidote for Isonazid
Pyridoxine
What is the antidote for a pt in wernickes syndrome
Thiamine
How do you decon the blood or urine
Urine alkalization or hemodialysis/ perfusion
During eye irrigation when is the conjunctival sac ph tested
Ten minutes after irrigation
(allowing equilibration of crystalloid and conjunctival sac pH), conjunctival sac pH is tested.
Irrigation continues until pH is between 7.2 and 7.4.
What drugs can multi dose active char be used for
Theophylline (Theo-Dur) Carbamazepine (Tegretol) Phenobarbital Quinine Dapsone
What are the indications to use míralax in the ED
Indications for WBI:
Sustained or delayed-release pills
-Iron, lithium, lead, and drugs in body: stuffers/packers
Contraindications: Substances causing diarrhea, bowel obstruction
Pts that intentionally intox themselves need what Referal before D/c
Psych
A pt presents with a possible ectopic
The B-hCG level is 500
The qualitative and Quanitative test is pos
Think?
Ectopic preg
Consult with OBGYN
Where is hCG made
hCG is a hormone produced by the trophoblast. Intact hCG consists of the α and β subunits.
Where is the common site for an ectopic preg
In the ampullary segment of the Fallopian tubes
What is the most often pathology that leads to ectopic pregs
The underlying cause is most often damage to the tubal mucosa from previous infection, preventing transport of the ovum to the uterus.
Is amenorrhea common in ectopic pregnancy
Amenorrhea from 4 to 12 weeks after the last normal period is reported in 70% of ectopic pregnancy cases.. Meaning it was missed or late…
A woman presents with sudden sharp and severe lateralized abdominal pain
Think
Ectopic preg
What is a corpus luteum cyst
a 3- to 11-cm, thin-walled, unilocular cyst seen after ovulation that can cause pain and tenderness on exam as well as menstrual irregularities, mimicking an ectopic pregnancy. (differential diagnosis.. Image that!)
What is Chadwicks sign
Chadwick sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow.
It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy.
What is the primary goal of US in early pregnancy
The primary goal of US in early pregnancy is determination of a viable IUP and exclusion of ectopic pregnancy
What is a Dx and Tx for suspected ectopic preg with a non Dx US
Laparoscopy
What is the tx approach to u ruptured ectopic pregnancy
Either srgical laparoscopy or methotrexate
What is the MOA of methotrexate
Methotrexate is a folic acid antagonist that inhibits dihydrofolate reductase, causing depletion of cofactors needed for DNA and RNA synthesis.
What is the HIV drug that can lead to increased kidney stone formation
The protease inhibitor indinavir sulfate, used to treat the human immunodeficiency virus, is associated with a 4% to 10% incidence of symptomatic urolithiasis.
Why do kidneys stones cause pain
Pain associated with kidney stones is due to obstruction of a hollow viscus organ (ureter) and subsequent hydronephrosis creating pressure against Gerota’s fascia, causing flank pain.
What is the most constricted site of the ureter
Ureterovesical junction, because this is the most constricted site of the ureter due to the muscular coat of the bladder.
Ureterovesical junction can mimic a urinary tract infection by causing frequency, urgency, and dysuria.
Just know that
What are the 2 DDx to consider in renal stone/ flank pain
Abdominal aortic aneurysm
Renal artery infarction
How many layers does diverticulitis effect?
True diverticula involve all layers of the colon wall
Most acquired diverticula are considered false diverticula
Involves only the mucosal and submucosal layers
What measurement of abscess requires drainage in diverticulitis
Greater than 3 cm or Hínchey stage greater than 1
When should you admit a pt with diverticulitis
If immuno comped or taking chronic steroids
Or if failed outpt tx
A pt presents with a crunching sound upon auscultation of the heart due to pneumomediastium
With coughing up blood
Think
Boerhaves syndrome
If bright red blood or clots are found in the NG aspirate, perform…
gentle gastric lavage with room temp water
What is the one label Rx for ulcer bleeds
Omeprazole
Octreotide is unlabeled use for what type of bleeding
Varices
What must the pH be for clot formation
Has to be higher than 6
What is the role of PPI in PUD
In patients with peptic ulcer bleeding, PPIs reduce the need for surgery, the length of stay in the hospital, and signs of bleeding
What are the three things octreotide does for a pt with PUD
Inhibits the secretion of gastric acid- good
Reduces blood flow to the gastroduodenal mucosa- also good
Causes splanchnic vasoconstriction- Mixed..
What are two examples of promotility agents in the tx of GI bleeds
Erythromycin and metoclopramide are examples of promotility agents used to enhance endoscopic visualization
Not recommended for routine use
May consider if the patient is undergoing endoscopy in the ED and suspect large amounts of blood in the UGI tract
How id endoscopy used in treating GI bleeds
Variceal Ligation and sclerotherappy
Can allow access for clips, thermoregulation, and injections
PRETREAT WITH ANTIEMETIC!
(Ondansetron)
Use Fentanyl and Versed/ Propofol
What should be considered for unstable pts prior to endoscopy for a UGIB
Unstable patients—> consider using cardiovascular stable agents such as etomidate or ketamine
What is an effective short term tx for GI bleeds
Balloon Tamp
Strongly consider intubation prior to Balloon Tamp
What is the SRGY options for a UGIB
If a pt is non responsive to meds or endoscopy then send for emergent SRGY
For a shunt (TIPS) or for junction devasc
If a pt has uncontrolled bleeding what is the approach
Airway>Stabilize>Emergent surgical consultation
What is the most common cause of anorectal bleeding
Hemorrhoids
A pt with a hx of aortic graft, and a GI bleed think..
possibility of an aortoenteric fistula
What are the imaging procedures of choice for a LGIB
Initial diagnostic procedure of choice—angiography, scintigraphy, or endoscopy—depends upon resource ability and consultant preference
What is a useful tool with 100% sensitivity for detecting a GI bleed prior to angiography
Multidetector CT angiography
Can flexible sigmoidoscopy detect proximal sources of bleeding
NO!
What should be done If colonoscopy fails to locate a source of bleeding
consider upper endoscopy to evaluate for a UGI source
A pt presents with acute severe abdominal pain
With N/V and anorexia and decreased oral intake
With pain in both the R and L Upper quads
Think
Acute pancreatitis
What is the palpation/ provocation for pancreatitis
Pain may worsen with oral intake or laying supine
Pain may improve with sitting up with the knees flexed
What is the most common cause of pancreatitis
Gallstones
If you are unsure of if a pt has acute pancreatitis,… what image should you order
Abd ct with IV CON
What is ranson criteria at admission
Age over 55
WBC elevated
BG above 200
Serum LDH above 350
AST above 250
Ranson criteria at 48 hours
Decreased HCT
Increased BUN
Calcium less than 8
PaO2 less than 60
Base Def greater than 4
Fluid sequestered 6,000
A ranson score above 6 means
Mortality 40%
What time of day does biliary colic present
Midnight
What are the definitive Dx for Choledocolithisis
magnetic resonance cholangiopancreatography
endoscopic US
endoscopic retrograde cholangiopancreatography (ERCP)
When should elective cholecystectomy recommend
Elective cholecystectomy is occasionally recommended for those at high risk for gallstone complications
- Sickle cell disease
- Planned organ transplantation
- Ethnic groups at high risk for GB cancer
What Dz is emphysema cholecystisis associated with
DM and the elderly
From gas producing bacteria like C Diff, e. Coli, Klebsiella
What is the Tx for emphysema cholecystisis
ABX
SRGY
REFER
When should you think acalc cholecysitis
Most often occurs as inpatients with critical illness
May be seen in the ED (immunocompromised)
Diagnostic challenge - variable clinical presentation and no test result is pathognomonic
What is the common cause of post cholecystectomy pain
Choledocholithiasis
Where do visceral fibers of the appendix enter the spinal cord
T10
What is the most important measure of immune competency in pts with HIV/ AIDs
CD4 count
If you measure an aorta greater than 2.5 cm what should you do
Addition testing for AAA
Acute appendicitis is most common in what age group
10-19
