GI Trauma and Emergencies Flashcards
What is the H/P for acute appendicitis?
visceral periumbilical pain evolving to somatic RLQ pain
fever, n/v
McBurney’s point tenderness
What are the diagnostic tests for acute appendicitis?
CBC (elevated WBC), chem panel, UA, pregnancy test
CT abd/pelvis with IV and oral contrast in adults
US and/or CT scan in kids
MRI in pregnant women
Treatment for appendicitis?
NPO, IVF, Antiemetic and pain control, pre-op abx
Surgery
What percentage of foreign body ingestions occur in children?
80%
<1% need surgical intervention
what percentage of foreign object ingestions pass without the need for intervention?
80-90%
<1% require surgery
What FB objects do children tend to ingest?
What FB objects tend to occur in adults?
coins, button batteries, toys, magnets, etc.
food bolus (meat, bones, pills)
Where is the most frequent site of obstruction in the GI tract?
esophagus (points of pathological or physiological narrowing)
What are some physiologic narrowings of the esophagus?
upper esophageal sphincter
level of aortic arch
diaphragmatic hiatus
What esophageal pathologies can increase risk for food bolus impaction?
diverticula
webs
rings
strictures
achalasia
tumors
What percentage of individuals with esophageal food impactions have underlying eosinophilic esophagitis?
50%
what are the s/s of ingestd foreign body?
may be asymptomatic
drooling, unable to swallow (requires emergent endoscopy)
fever, abd pain, vomiting (further work up needed)
If there are s/s of esophageal obstruction (drooling, not handling secretions), what imaging study do you order?
Emergent EGD
Treatment for FB ingestion varies based on what?
What indications need emergent care by ENT or GI?
presence and severity of sx
type of object ingested
location of object
signs of airway compromise (choking, stridor, etc)
Wha types of esophageal FB injestions need emergent endoscopy (within 6hrs)
complete obstruction
disk batteries
sharp-pointed objects
What FB injestions require urgent endoscopy (within 24hrs)
all foreign bodies in esophagus
How long does it take for FBs in the stomach or proximal duodenum to pass?
4-6 days
urgent endoscopy for FB in stomach or prox. duodenum is indicated for what objects?
sharp objects
longer than 5cm
magnets
blunt objects over 2cm in diameter
disk and cylindrical batteries
lead
everything else is expectant management
What is the management of FB objects distal to Lig. of Treitz?
expectant mangement
surgery or endoscopy if signs of inflammation or obstruction
What percentage of hernias are inguinal hernias?
of that, how many are indirect?
75%
2/3
Where are ventral hernias mostly located?
epigastric and umbilical
spigelian, incisional, parastomal
Where are groin hernias typically located?
inguinal (direct and indirect)
femoral, obturator
What are the most common ventral hernia locations?
epigastric and umbilical hernias
Where do indirect inguinal hernias pass through?
pass from the internal to the external inguinal ring through the patent process vaginalis and then scrotum
Where do direct inguinal hernias pass through?
passes directly through the weakness in the transveralis fascia in the Hesselbach triangle
What is a reducible hernia?
hernia sac itself is soft and easy to repalce back through the hernia neck defect
What is an incarcerated hernia?
hernia sac is ferm, often painful, nonreducible by direct manual pressure
no signs of systemic illness
What is a strangulated hernia?
hernia sac is firm and very painful
systemic illness present
implies impaired blood flow
Which type of hernia is an acute surgical emergency?
strangulated hernia
What is the protocol for a strangulated hernia?
exquisite tenderness with toxic s/s
consult gen surg
IV abx (broad spectrum)
IVF and narcotics
pre-op labs
At what size is a AAA diagnosed?
AAA is diagnsoed when the aortic diameter exceeds 3.0cm
Most AAAs are asymptomatic, but symptoms of unruptured AAA can include:
Abd pain, flank pain, limb ischemia, fever, malaise
What is the classic triad for ruptured AAA?
Abd and/or flank pain
hypotension
shock
What are the risks of AAA?
Old, white, smoker male with fmhx and hx of vascular disease
MOSTLY ASYMPTOMATIC
AAA is misdiagnosed how often?
What is it often mistaken for?
30%
renal colic, perforated viscus, diverticulitis, GI hemorrhage, ischemic bowel
For a symptomatic AAA that is stable, what is the testing?
For unstable symptomatic AAA, what is the testing?
CT abd/pelvis with IV contrast
If known hx, go to OR without imaging
if unknown or suspected hx, CT abd/pelvis with IV contrast
Screen for AAA when?
Monitor AAA how?
one time for risky patients over 65 with US
if known AAA, monitor every 6 months or annually with US or CT abd/pelvis
What is blunt trauma?
direct blow causing rupture of hallow organs and bleeding
can be from deceleration causing sheering injuries
What is penetrating trauma?
GSW, stab, lac, etc
GSW can cause kinetic energy transfer to viscera, worsening damage
What is explosive trauma?
blunt/penetrating/lung and hollow viscus injury
inhalation injury
What are the most commonly injured abdominal organs from blunt trauma?
spleen and liver
What sort of hx do you need for MVC?
restrained?
intoxicated?
location in vehicle?
airbags?
LOC?
ejection?
roll over?
fatality at scene?
What hx do you want for penetrating injury?
time?
type of injury?
number of penetrations
What hx do you want for an explosive trauma?
enclosed space?
distance from detonation?
combo of injury types?
inhalation?
What are the ABCDEs for trauma care?
A-airway maintance by C spine control
B-breathing and ventilation
C-circulation with hemorrhage control
D-disability and neuro status
E-Exposure/environmental control
Besides normal IAPP for the abdomen during PE for trauma, what else should be assessed?
pelvic stability
urethral meatus, perinala, rectal and vaginal vaults
When to suspect diaphragm injuries?
after MVC or blunt trauma to thoracoabdominal region
most often on left
When to suspect duodenal injuries?
unrestrained driver in MVC
bicycle handlebar injury
order CT abd/pelvis with IV and oral contrast
When to suspect pancreatic injuries?
direct blow to pancreas that compresses it to vertebral column
watch amylase/lipase trends
CT abd/pelvis with IV and oral contrast
When to suspect GU injuries?
What is a clue that there might be anterior pelvic injuries present?
direct blow to back or flank
gross or microscopic hematuria
CT abd/pelvis with IV contrast
urethral dusruption
When to suspect hollow viscus injuries?
sudden decel. injury from MVC
Chance fractures
early US and CT may not ID these injuries
If liver/spleen lac and pt is hemodynamically stable, what is management?
if unstable, what is management?
close observation by gen surg in hospital
if unstable, surgery
When to suspect pelvic fracture and assx injury?
MVC, auto v. pedestrian, fall from heights
Hypotension and pelvic fx have high mortality rate
can have venous plexus damage or internal iliac artery damage
What is the main diagnostic studies for trauma in general?
CBC, chem, UA, pregnancy test, Pt/PTT/INR, type and screen
C spine, CXR, AP pelvis Xrays
FAST scan
CT abd/pelvis wiht IV contrast
DO NOT DELAY TRANSFER in order to obtain labs/images, if they need to be transfered, just send them.
Blunt abdominal trauma with hypotension with a positive fast scan or clinical evicence of intraperitoneal bleeding gets sent where?
to surgery for a laparotomy
What is the purpose of a FAST scan?
detect free intraperitoneal fluid, pericardial fluid, pleural fluid, hemothorax, pneumothorax in trauma patients
can check heart with subxiphoid view
Morrison’s pouch for kidney/liver
perisplenic view
retrovesicular view (pelvis)
