Emergencies & Trauma Flashcards
In what age group is appendicitis the highest?
10-19 yrs
How does the pain of appendicitis progress?
- begins as visceral pain (vague, non-specific aching)
- localizes to McBurney’s point in RLQ, becomes sharp
What labs would you order if you suspect appendicitis?
- CBC
- chem profile
- UA
- pregnancy test
What is the best imaging for an adult if you suspect appendicitis?
-CT abdomen and pelvis w/ IV and oral contrast
96% sensitive
What is the best imagining for a kid if you suspect appendicitis?
- ultrasound of RLQ, but lower sensitivity than CT
- -children’s hospitals do this well
-at a hospital that doesn’t work with peds, you probably need to do a CT if the U/S is negative
What is the best imaging for pregnant patients if you suspect appendicitis?
MRI
What would you order for the initial Tx of appendicitis?
- NPO
- IV fluids
- antiemetic
- analgesia
- preoperative abx (maybe)
True or False: early appendicitis can mimic gastroenteritis or viral illness
True
True or False: a normal CBC rules out appendicitis
False; a patient can have a normal CBC and still have appendicitis
True or False: an abnormal UA rules out appendicitis and points to a different cause of illness
False; a patient can have an abnormal UA and still have appendicitis
True or False: most foreign body ingestions occur in children
True; 80%
True or False: most foreign body ingestions require intervention
–False; 80-90% pass w/o the need for intervention
–Less than 1% require surgical intervention
What age range accounts for the majority of foreign body ingestion?
–6mos to 3yrs
List some common foreign bodies ingestion by children.
- coins
- button batteries
- toys
- magnets
- safety pins
What is the usual cause of esophageal obstruction in adults?
- food bolus (usually meat, occasionally pills)
- more frequent in the elderly
Where in the esophagus does obstruction normally occur?
-at strictures or sites of physiologic/pathologic narrowing
What is the most frequent site of obstruction in the GI tract?
-esophagus
Where are major locations of physiologic narrowing of the esophagus?
- upper esophageal sphincter
- at the level of the aortic arch
- at the diaphragmatic hiatus
List some structural or functional esophageal abnormalities that would increase the risk of foreign body and/or food impaction.
- diverticula
- webs
- rings
- strictures
- achalasia
True or False: it is estimated that approx. half of pt’s w/ esophageal food impactions have underlying eosinophilic esophagitis
True
What is the typical clinical presentation of foreign body ingestion?
- acute onset dysphagia
- choking
- refusal to eat
- hypersalivation
- regurgitation of undigested food
True or False: drooling and inability to swallow liquids is indicative of an esophageal obstruction and requires emergent endoscopic evaluation
True
After a foreign body ingestion, what signs would be concerning that warrant a further work-up?
- fever
- abdominal pain
- repetitive vomiting
What three things should be documented in the Hx of someone who presents w/ a foreign body ingestion?
- type of foreign body
- time of ingestion
- presence and type of ongoing symptoms
Note: only perform imaging on pt’s that don’t have signs or symptoms that suggest an esophageal obstruction
In other words: don’t delay an EGD to get imaging
What view(s) would you order on a plain radiograph for a pt who swallowed a foreign body?
- AP and lateral views of neck, chest, and abdomen
- only works if the object is radiopaque
-order for a pt only if they don’t have an esophageal obstruction associated with the foreign body
When would you order a CT for a pt who swallowed a foreign body?
- suspected perforation
- sharp or pointed foreign body
- in pts suspected of having ingested drugs/narcotics
On what factors does the management of treatment depend?
- presence and severity of symptoms
- type of object (size, shape, content)
- location of the object (past Ligament of Treitz?)
What are the signs of airway compromise, due to a foreign body, that must be addressed immediately?
- choking
- stridor
- wheezing
- difficulty breathing
What is the timeframe for an emergent endoscopy and what are examples of why one would be conducted?
- within 6hrs
- complete esophageal obstruction (drooling)
- disk batteries (cause liquid necrosis)
- sharp or pointed objects in the esophagus
What is the timeframe for an urgent endoscopy and what are examples of why one would be conducted?
- all foreign bodies in the esophagus require removal within 24 hours, because the risk of complications dramatically increases with time
- sharp, >5cm long, high power magnets, >2cm diameter
In what timeframe do most ingested foreign bodies pass out of the GI tract?
–4 to 6 days
What is the treatment process for ingestion of foreign bodies, such as small blunt objects, that are managed expectantly?
- -weekly X-ray until object passes
- resume a normal diet
- -monitor stools for evidence of the object
What is “ a protrusion, bulge, or projection of an organ or a part of an organ through the body wall that normally contains it”?
-hernia
What is the most common type (and subtype) of hernia?
- 75% are inguinal hernias
- -2/3rds of inguinal hernias are INdirect
What is the general presentation of a hernia?
-constant or intermittent mass in the groin that is gradually increasing in size
What are three ways that hernias are categorized?
- location (ventral or groin)
- contents (bowel or fat)
-status of contents (reducible, incarcerated, strangulated)
What are the two most common locations of ventral hernias?
- epigastric (more common in obese men)
- umbilical (more common in kids)
What is the most common location of groin hernias?
indirect inguinal
What is the most common location of an incisional hernia?
-midline, b/c midline incisions are the most common used during laparotomies
Where do spigelian and parastomal hernias occur?
off midline
What is the path of a direct hernia?
-passes directly through a weakness in the transversalis fascia in the Hesselbach Triangle
What is the path of an indirect hernia?
-passes from the internal to the external inguinal ring through the patent process vaginalis then to the scrotum
Definition: hernia sack itself is soft and easy to replace back through the hernia neck defect
Reducible
Definition: hernia sack is firm, often painful, and nonreducible by direct manual pressure, no signs of systemic illness
Incarcerated
Definition: hernia sack firm and very painful, usually with signs of systemic illness present (fever, nausea, vomiting), implies impairment of blood flow (arterial, venous, or both)
Strangulated
What is the clinical presentation of a strangulated hernia?
- sever, exquisite pain
- signs and symptoms of intestinal obstruction
- toxic appearance
- skin changes over hernia sack (maybe)
- ACUTE SURGICAL EMERGENCY
What is the Tx of a strangulated hernia?
- -consult general surgery immediately
- -broad-spectrum abx
- -fluid resuscitation
- -adequate narcotic analgesia
- -preoperative lab studies
What is the Tx of an incarcerated hernia?
- attempt to reduce
- -if unsuccessful, consult surgery
What is the Tx of a reducible hernia?
–outpatient surgery with follow-up
True or False: AAA is usually a disease of older persons
True; occurs in 7% of individuals over the age of 50
Note: In the US, AAA is estimated to cause 4-5% of sudden deaths
approx 7000 deaths per year in the US are attributed to ruptured AAA
What is the normal diameter of the abdominal aorta and at what diameter is a AAA diagnosed?
normal = 2 cm
AAA > 3 cm
Where is the most common location of a AAA?
-below the renal arteries (infrarenal aneurysm)
What are the most important factors for the risk of rupture of a AAA?
- aortic diameter
- ongoing smoking
Which size of AAA expands faster, small/medium or large?
Large AAA’s (>5.5 cm) expand faster (3-4mm per yr)
What growth rate of a AAA has an increased risk of rupture?
> 5mm over 6 months
>10mm over 1 yr
How are the majority of AAA’s found in patients?
- incidentally
- most are asymptomatic
What are the symptoms of a AAA (if they’re symptomatic)?
- abdominal pain
- flank pain
- limb ischemia
- fever
- malaise
What is the classic triad for a pt with a ruptured AAA?
- abdominal or flank pain
- hypotension
- shock
-look bad … high morbidity and mortality if ruptured
List some risk factors for developing a AAA?
- advanced age
- male sex
- Caucasian race
- family Hx
- presence of other large vessel aneurysms
If a ruptured AAA is misdiagnosed 30% of the time, what other conditions might it be mistaken for?
- renal colic
- perforated viscus
- diverticulitis
- GI hemorrhage
- ischemic bowel
What is the screening protocol for AAA?
–one-time screening for at-risk patients over 65, using an ultrasound
What is the monitoring protocol for an asymptomatic AAA?
-U/S or CT of the abdomen and pelvis every 6 months to a year
What is the testing for a symptomatic AAA in a stable patient versus an unstable patient?
stable = CT abdomen/pelvis with IV contrast
unstable = if they have a known Hx of AAA, they go straight to the OR w/o imaging
What is the leading cause of mortality globally?
trauma
What is the leading cause of death worldwide for ages 18-29?
road traffic injuries
What is the leading cause of death in the US for young adults?
trauma
True or False: trauma accounts for 30% of all ICU admissions
True
What are the three main categories of trauma injury?
- blunt
- penetrating
- explosive
What are the characteristics of blunt trauma?
- direct blow causes rupture of hollow organs
- internal bleeding
- deceleration causes shearing injuries
What are the characteristics of penetrating trauma?
- stab wounds and low velocity GSW’s cause tissue damage by lacerating and cutting
- high velocity GSW’s transfer more kinetic energy to the abd viscera… increased damage by cavitation
What are the characteristics of explosive trauma?
- blunt, penetrating, and inhalation injuries
- blast injury to lung and hollow viscera from overpressure
What type of injury accounts for the majority of abdominal injuries in the ED?
- blunt
- 75% are related to MVC’s
- spleen and liver are the most common organs injured
What are some questions that should be asked when taking history of an MVC?
- restrained or not?
- intoxicated or not?
- location within the vehicle?
- vehicle type and velocity?
- were the air bags deployed?
What are some factors of an MVC that cause increased risk of serious injury?
- unrestrained
- ejected
- vehicle rolled over
- another fatality at the scene
What are some questions that should be asked when taking history of a penetrating injury?
- time
- type of injury
- distance
- number of stabs or shots
What are some questions that should be asked when taking history of an explosive injury?
- enclosed space or not?
- distance of pt from detonation
- possible inhalation injury?
- combo of blunt and penetrating?
What are the ABCDE’s of caring for a critically ill patient?
- Airway (maintenance with Cspine control)
- Breathing and ventilation
- Circulation w/ hemorrhage control
- Disability or neurological status
- Exposure/Environmental control
Which side of the diaphragm is injured most often?
left
What are characteristics of a duodenal injury?
- unrestrained drivers with frontal impact
- bicycle handlebar injury
- get a CT abd/pelvis with IV and oral contrast
What are characteristics of pancreatic injury?
-result from direct blow to pancreas where it gets compressed against the vertebral column
- check and trend amylase and lipase
- CT of abd/pelvis with IV and oral contrast
What are characteristics of genitourinary injury?
- direct blows to back or flank
- suspect with gross or microscopic hematuria
- CT abd/pelvis with IV contrast
- suspect urethral disruption with anterior pelvic injury
What are characteristics of hollow viscus injuries?
- sudden deceleration injury (MVC)
- suspect with Chance Fx
- early U/S and CT are often not diagnostic
What are characteristics of solid organ injuries (LIVER, SPLEEN, and kidneys)?
- may be managed conservatively with close monitoring in the hospital if pt is hemodynamically stable
- requires operative mgmt if hemodynamically unstable or cnt’d bleeding
What are characteristics of pelvic fractures and associated injuries?
- mechanisms: MVC’s, and falls from heights
- pts with hypotension and pelvic Fx have high mortality
- -closed pelvic Fx’s w/ hypotension mortality is 25%
- disruption of pelvic ring tears pelvic venous plexus
- mortality of open pelvic Fx’s is 50%
What diagnostic testing do you order for a trauma patient?
- CBC, chem profile, UA, pregnancy test, PT/PTT/INR
- Type and Screen
- Lateral Cspine, CXR, and AP pelvis
- FAST scan
- CT scan if pt is stable
True or False: transfer of the patient should wait until the diagnostic studies are obtained
False; do NOT delay transfer to definitive care in order to obtain diagnostic studies. If you can’t do anything for the patient there, just get them to wherever they’re going to be treated!
List examples of patient scenarios that go to surgery?
- blunt abd trauma w/ hypotension w/ +FAST scan
- evidence of intraperitoneal bleeding
- hypotension w/ penetrating abd wound
- GSW traversing the perineal cavity
- free air, retroperitoneal air, or ruptured hemidiaphragm
What is the purpose of a FAST (Focused Assessment w/ Sonography for Trauma) scan?
-detect free intraperitoneal fluid, pericardial fluid, pleural fluid, hemothorax, or pneumothorax in trauma patients
True or False: an U/S can be used as a definitive test to R/O intra-abdominal injury
False; it has limited sensitivity
What areas can be assessed by a FAST scan?
- R and L thorax
- cardiac
- RUQ and LUQ
- Bladder
