US Flashcards
What is one of the most common causes of the acute adbomen and one of the most frequenct indications for emergent abdominal surgery?
Appendicitis
When does appendicits most frequently occur?
20-30s, highest in those 10-19 YO.
A missed diagonsis of acute appendicits is a common reason for _______.
Litigation
Descirbe symptoms of appendicitis.
- Visceral, diffuse, visceral pain that becomes localized in the RLQ (McBurney’s point) and becomes somatic pain (sharp and localized).
- Anorexia
- N/V
- Fever
What specialty tests can we do for appendicits?
- McBurneys Point
- Rovsings sign
- Obturator sign
- Psoas sign
What diagnostic testing do you do on a patient with appendicits?
- CBC (usually high, but can be NL)
- Chemistry profile (electrolytes and LFTs)
- UA (usually NL, but can be abnormal)
- Pregnany test
Gold standard imaging in adults with Appendicitis
CT of the abdomen and pelvis with IV and oral contrast
Imaging for appendicitis in kids
-
RLQ US (less sensitive);
- if (-) => CT.
Imaging for appendicitis in pregnant patients
MRI
Initial treatment appendicitis?
- NPO
- IVF
- Antiemetic
- Pain meds
- Possible preop ABX.
Early appendicitis can mimic __________.
Viral gastroenteritis
What is important to remember about appendicitis and labs?
- CBC can be NL => still have appendicitis
- UA can be abnormal => still have appenditis
- 80% of foreign body ingestions occur in _____.
- How many need surgery?
- Children
- Most pass without intervention, but <1% need surgery.
what do kids vs adults usually ingest? and age MC
- Kids (6months- 3 yrs): coins, button batteries, toys, magnets, safety pins
- Adults (elderly): accidentally a food bolus (meat)
What is the MCC of esophageal obstruction in adults?
Food = meat
The _______ is the most frequent site of obstruction in the gastrointestinal tract
esophagus
Where do foreign bodies most often get impacted in esophagus?
- Physiological/pathological narrowing
- UES, level of aortic arch, diaphragmatic hiatus
- Structure, diverticula, rings, achalasia, tumor
It is estimated that approximately 1/2 the individuals with esophageal food impactions have underlying ______________
eosinophilic esophagitis
What symptoms of ingestion of FB requires emergent endoscopic evaluation?
What about sx that require further work-up?
- Drooling; Cant swallow liquids
- Fever, abdominal pain, repetitive vomitting after ingesting FB
Imaging and treatment for FB ingestion
- If patient has signs and symptoms of esophageal obstruction (drooling/can’t swallow liquids) => emergent EGD & NO imaging.
- In patients w/o suspected esophageal obstruction/hx of ingestion/ type of object is not known => AP/lateral plain XR from neck, chest and abdomen
When should a CT scan be done of ingestion of FB?
- Suspected perforation by a sharp/pointy object
- Ingestion of narcotics
What guides treamtment and management in a patient who ingested FB?
Majority of ingested objectes, are treated how?
- Prescense and severity of sx
- Type of object ingested (size, shape and content)
- Location of the object determined by imaging, if performed.
Expectant (watch and wait) is done for MOST ingestions.
What needs to be addressed IMMEDIATELY by ENT or GI when a patient ingests FB?
- Signs of airways compromise (choking, stridor, wheezing, difficulty breathing)
2 treatments for esophageal foreign bodies
-
Emergent endoscopy (within 6 hours);
- Complete esophageal obstruction (droolling and cant swallow liquids/ oral secretions)
- Disk batterns
- Sharp objects
-
Urgent endoscopy (within 24 hours);
- All FB must be removed within 24 hours.
Treatment of FB in the stomach of proximal duodenum?
-
Most objects that NTR stomach pass in 4-6 days are managed expectantly.
- Asymptomatic patients with small, blunt objects need weekly XR until passes/ NL diet/ monitor stool
- Urgent endoscopy (w/i 24 hours) if:
- Sharp
- >5cm
- Magnets
- Disc/cylinder batteries
- Objects with lead
Treatment of FB in the distal to L of Trietz
-
Most patients = expectant management
- Asymptomatic patients with small, blunt objects need weekly XR until passes/ NL diet/ monitor stool
- Endoscopic/surgical intervention if there are signs and symptoms = inflammation/intestinal obstrauction (fever, abdominal pain/ vomitting)
*
If a patient is complaining of a hernia, you can tell them that it is most likely what type?
-
Inguinal indirect hernia
-
75% = inguinal
- 2/3 of all inguinal are indirect
-
75% = inguinal
Hernias present as a _______________, (+/-) other symptom’s
constant/intermittant mass in the groin that gradually increases in size
How can we classify hernias?
1. Anatomic location
–Ventral (abdominal wall)
–Groin
2. Hernia contents
–Usually bowel or fat
3. Status of those contents
–Reducible
–Incarcerated
–Strangulated
Most common locations of a ventral hernia and groin hernia.
- Ventral hernia: epigastric and umbilical (other: spigelian, incisional, parastomal)
- Groin hernia: inguinal (direct vs indirect) > femoral > obtruator
Where do incisional hernias (type of ventral) occur?
what about spigelian and parastomal?
- Anywhere incision is made, but mostly midline
- Spigelian and parastomal => off midline
What is the difference between a direct vs indirect inguinal hernia?
- Direct hernias: pass through a weakness in traversaliss fascia in Hesselbach triangle
- Indirect hernia: internal ring => ER => patent process vaginalis => scrotum
Describe the 3 different status of contents of a hernia
Which is a acute surgical emergency?****
- reducible= hernia sac itself is soft and easy to replace back through the hernia neck defect.
-
incarcerated= hernia sack is firm, painful, and cannot be reduced w direct manual pressure
- no signs of systemic illness
-
strangulated*****= hernia sack firm, painful, usually with signs of
- systemic illness present (fever, N/V) means BF is impaired (arterial, venous, or both)
How do we treat hernias?
- Strangulated =>acute surgical emergency; IV ABX, fluid resus, adequate narcotic analegsia
- Incarcerated => try to reduce, if not, surgery
- Reducible => follow up at an outpatient cliic
______ is one of the top 15 causes of mortality in the United States, for those between 85 - 89YO, doesnt occur often in ppl less than 60.
AAA; causes 4-5% of sudden deaths in US
- When is a AAA diagnosed?
- Where is is most common?
- Progression and what factors influence this?
- Who has an increased risk of rupture?
- AAA is diagnosed when aortic diamter > 3cm
- Below renal arteries
- Progressively dilates overtime: diameter and smoking infiuence risk of rupture
- If rapidly dilates >5mm over 6 months or >10mm in 1 year => increased risk for rupture
What are the 3 categories of AAAs?
Which one is most common?
- Asymptomatic (majority of pts; AAA is found incidentally)
- Symptomatic but not ruptured: rapidly expanding and is compression structures/inflammation/infectious
- Sympomatic + rupture
What is the classic triad for a ruptured AAA?
- Abdominal/flank pain
- Hypotension
- Shock
Risk factors for AAA
- White M
- Old age
- Smoking
- Other large vessel aneurisms
- Atherosclerosis
What occurs 30% of the time when AAA ruptures?
Misdiagnosed as
- renal colic
- perforated viscus
- diverticulitis, GI hemorrahge, ischemic bowel
AAA Diagnostics
- Screening?
- Asymptomatic patients with known AAA
- Sympmatic patients (stable, unstable + known, unstable + unknown)
- Screen at-risk patients one time if over 65YO with US
- If asx, but have AAA: monitor by doing a US or CT abdomen/pelvis every 6months/year.
-
Syptomatic
- Stable: CT of the abdomen/pelvis with IV contrast
- Unstable + known AAA => OR
- Unstable and unknown/suspected AAA => CT adomen/pelvis with IV contrast.
Treatment for AAA.
- Conservative managment (watch and wait) if asympomatic infrarenal AAA < 5.5cm
-
AAA repair (open or endovascular****)
- Asympomatic infrarenal AAA >5.5cm
- Rapidly expaning infrarenal AAA (>0,5cm in 6months or >1cm/yr)
- Pt has arterial disease (aneurysm) or symptomatic peripheral artery disease
What is the LEADING cause of mortality globally?
What about the leading cause of death between 18-29?
- Trauma
- Road traffic injury
What are the 3 mechanisms of injury in trauma?
-
Blunt trauma => direct blow ruptures hollow organs => bleeding
- ex. Deceleration
-
Penetrating trauma =>
- Stab and low velocity GSW => damage tissue by lacerating and cutting
- High velocity GSW => more damage bc cavitation
- Explosives
How can explosives cause injury?
- Blunt + penetrating
- Blast injury to lungs and hollow viscus
- Inhalation injury
Blunt abdominal trauma (BAT) accounts for most of abdominal injuries seen in the ED.
- 75% are caused by _____
- ____ and ____ are the most commonly injured solid organs.
- MVC
- Spleen and liver
MVC historical questions?
- Restrained
- intoxicated
- Patient’s location within the vehicle?
- Vehicle type and velocity circumstances of accident (part of car involved in impact)
- Air bags were deployed?
- LOC/Amnestic to event or not?
What to ask if penetrating trauma?
- time
- type of injury
- distance
- # of stabs/shots
What to ask if explosive injury?
- enclosed space or not/ distance from detonation
According to ATLS, how do we take care of a trauma case?
which are we addressing when we look at abdominal trauma? ***
Primary Survey (ABCDE)
- Airway –maintenance with C-spine control
- Breathing and ventilation
- Circulation –with hemorrhage control *****
- Disability/neurologic status
- Exposure/Environmental control –completely undress the patient, prevent hypothermia
PE of abdomem
- Inspect
- Ausculatate and percuss = hard to do in noisy Ed
- Palpate
- Assess pelvic stability
- Assess other areas: urethral meatus, perineal, rectal, vaginal
Diaphragm Injuries
Most often on the _____ side
Result from _________
Suspect with ___________ trauma
Avoid doing what?
- L
- Blunt high impact (MVC)
- Thoracoabdominal trauma
- Do not use trochar when putting in chest tube bc stomach is in lungs
Duodenal Injuries
Seen in: __________ or ________
Dx: ____________
- Unrestrained drivers are hit from front, injury from bicycle handlebar
- Ct abd/pelvis with iv and Oral contrast **
Pancreatic Injuries
- Result from _______
- Check and trend _______
- DX: ________
- Direct blow to the pancreas, causing it to compress on vertebral column
- Amylase and lipase
- Ct of abd/pelvis with IV and oral contrast
Genitourinary Injuries
- Due to: ________
- Suspect with __________
- DX: __________
- Suspect urethral disruption with _________
- direct blow to back or flank
- gross/microscopic hematuria
- CT abdomen/pelvis with IV contrast
- anterior pelvic injuries
Hollow Viscus Injuries
- Due to: _________
- Early ____ and ___ are often not diagnostic for these injuries
- Sudden deceleration injuries (MVC
- Early US and CT = not diagnostic
If a patient has a solid organ injury, how do we treat a patient who is hemodynamically stable/unstable?
- Hemodynamically stable: manage conservatively (no operation) with close observation by general surgeon in hospital
- Hemodynamically unstable: operate (laporotomy)
Pelvic fracutes are very dangerous and most often due to what (3)?
If you have ____ + pelvic fracture = high mortality
Disruption of pelvic ring results in what?
- MVC, fall from height, auto vs peds
- Hypotension + pelvic fracture = high mortality
- => tear pelvic venous plexus and disrupt internal iliac arterial system.
Mortality in patients with pelvic fractures:
–all types of pelvic fractures = ___
–closed pelvic fractures and hypotension = ____
–open pelvic fractures = ____
- 1/6
- 1/4
- 50%
diagnostic testing for abdominal injury
- CBC, chem, UA, preg, PT/PTT,INR
- XR on ALL patients with sign trauma: lateral C spine, CXR, AP pelvis
- FAST scan
- IF stable: CT abd/pelvic with IV contrast => definitive for most intra-abdominal trauma
- If not stable => TRANSFER!!! Do not delay to get these studies
Who gets a lapartomy (surgery)
- Blunt trauma + hypotension; + FAST scan or clinical evidence of intraperitonal bleeding
- Blunt or penetrating abdominal trauma with a + DPL
What is FAST scan and purpose?
- Set of US exams to evaulate injured pt
- Purpose is to detect
- free intraperitoneal fluid/ pericardial fluid/ pleural fluid
- hemothorax/pneumothorax in trauma pts
_____ view looks at heat on FAST scan
Subxiphoid
______ view on the _______ flank looks at Morrisons pouch
Hepatorenal
R flank
______ view on the ___ flank looks at the spleen and kidney
Perisplenic
L flank
36 YO sober driver was T-boned on drivers side at high speed. What FAST scan do we do. what type of pain would they feel
FAST perisplenic view on L flank
Has LUQ pain
What view looks at bladder/pelvis and how do you hold the thing on FAST
- Retrovesicular view in suprapubic area
- Sagital/Trasnverse
