2: Acute Mesenteric Ischaemia, Chronic Mesenteric Ischaemia, Abdominal Trauma Flashcards by Grace Poole

What is acute mesenteric ischaemia

Sudden decrease in blood supply to the bowl that can cause infarction

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What are the 4 types of acute mesenteric ischaemia

Acute mesenteric arterial thrombosis
Acute mesenteric arterial embolism
Venous congestion
Non-occlusive ischaemia

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If ischaemia due to thrombosis in situ what is it called

Acute mesenteric arterial thrombosis (AMAT)

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if ischaemia is due to embolism in situ what is it called

Acute mesenteric arterial embolism (AMAE)

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What is a cause of acute mesenteric arterial thrombosis

Atherosclerosis

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What are 5 causes acute mesenteric arterial embolism

AF
AAA
Thoracic AA
Mural thrombus
Prosthetic heart valve

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What are 2 causes of non-occlusive mesenteric ischaemia

Cardiogenic shock

2. Hypovolaemic shock

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What are 3 causes of venous occlusion

Coagulopathy
Thrombophilia
Malignancy

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What are risk factors for AMAT and AMAE

Cardiovascular RF:
Smoking 
Alcohol 
HTN
Hypelripidaemia

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How does acute mesenteric ischaemia present

Pain out of proportion to clinical findings
Diffuse, generalised abdominal pain
N+V

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What investigations are ordered for acute mesenteric ischaemia

ABG
CT scan with contrast
CXR

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What will be seen on ABG

High lactate

- Metabolic acidosis

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What imaging is used to definitely diagnose acute mesenteric ischaemia

CT with IV contrast

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When is a CXR performed

If perforation is suspected

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How is mesenteric ischaemia managed

IV Fluids

Broad-spec antibiotics

Surgery for re-vascularisation (with re-look 24-48h after)

Revascularisation

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What are 3 complications of mesenteric ischaemia

Bowel necrosis
Bowel perforation
Short-gut syndrome post-resection

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What is chronic mesenteric ischaemia

reduced blood supply to the bowel due to atherosclerosis

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In which individuals does chronic mesenteric ischaemia occur

Elderly patients

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What are 4 risk factors for chronic mesenteric ischaemia

Smoking
Hyperlipidaemia
HTN
DM

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How does chronic mesenteric ischaemia present

Post-prandial pain (10m-4h)

Weight loss

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Explain pathophysiology of chronic mesenteric ischaemia

Due to atherosclerosis of two blood vessels (SMA, IMA, Coeliac trunk). Due to collateral blood supply it must be 2.
Bowel receives sufficient oxygen at rest, however, struggles during increased demand: such as post-digestion.

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What is first-line investigation for chronic mesenteric ischaemia

CT angiography

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What is gold-standard for acute mesenteric ischaemia

CT with contrast

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What is used to manage chronic mesenteric ischaemia

Modify risk factors

Endovascular repair = mesenteric angioplasty

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Which sites are vulnerable to ischaemia and why

Watershed areas: Splenic flexure and rectosigmoid junction - due to switch in blood supply

Define acute mesenteric ischaemia

ischaemia of the small intestine

Define ischaemic colitis

ischaemia of the large intestine

What causes ischaemic colitis

caused by global hypo perfusion caused by: - Hypotension - Hypovolaemia - Thrombophillia

how does ischaemic colitis present

Presents in 3 phases 1. Hyperactive 2. Paralytic 3. Shock

how does the hyperactive phase of ischaemic colitis present

Colicky abdominal pain in the LIF.

how does the paralytic phase of ischaemic colitis present

- Diffuse abdominal pain - Bloating - Absent bowel sounds

how does the shock phase of ischaemic colitis present

- Acute abdomen - Guarding - Rebound tenderness

how is acute mesenteric ischaemia investigated

CT W/constrast

how is ischaemic colitis investigated

CT angiography

how is ischaemic colitis managed

IV Fluids Antiplatelets - If necrotic may require resection

What are the two types of abdominal trauma

- Blunt trauma | - Penetrating

What is blunt trauma

Blunt force to the body - does not penetrate skin.

What is penetrating trauma

Penetrates the skin.

What are 3 causes of blunt trauma

- RTA - Falls - Deceleration injuries or external crushing

What are 2 causes of penetrating trauma

- Gunshot wounds | - Stabbing

What is the most common injury following blunt trauma

Splenic rupture (40%)

What are 5 other injuries that can occur due to abdominal trauma

- Liver haematoma - Pancreatic contusion - Intra-abdominal bleeding due to fracture ribs causing injury - Traumatic injury to bladder and kidney - Duodenal injury and haematoma - Pelvic fracture

Why may blunt trauma cause intra-abdominal bleeds

Due to causing fracture of ribs - which are able to penetrate intra-abdominal organs

What type of injury pancreatic contusion

Handlebar - trauma to epigastric region

How will pancreatic contusion present clinically

Epigastric pain N+V Anorexia Fever

What is a common injury in children who suffer blunt abdominal trauma

Duodenal haematoma

How will splenic rupture present

Hypotension - dizziness, syncope Left hypogastric pain Left shoulder irritation

How will liver haematoma present clinically

Ecchymosis of the right chest - pain referred to right shoulder

What is the most common site for gunshot wound to injure

Small bowel

What is the most common site for stab wound to injure

Liver

Explain signs of intra-abdominal bleeding

- Hypotension - Tachycardia - Discolouration flanks - Shock - Rigid abdomen - Abdominal distention

For blunt trauma, what is used pre-hospital to manage patients

ATLS | : any resuscitation required is undertaken

What imaging is used for blunt trauma

FAST scan | Focused assessment with sonography for trauma

What is FAST scan used to detect

Haemoperitoneum (intra-abdominal bleeding)

If FAST scan is unavailable, what should happen to blunt abdominal trauma patients

Taken immediately to theatres

If patient is stable and FAST scan is inconclusive what imaging is used

CT scan

If patient is unstable and FAST scan inconclusive, what imaging is used

Diagnostic peritoneal lavage

Explain diagnostic peritoneal lavage

Surgical investigation: - Incision made into abdomen - Catheter inserted and fluid aspirate - If blood aspirated, Hartmann's solution is inserted and left for 5 minutes - then removed and sent for analysis

What is second-line to FAST scan for investigaitng abdominal trauma

Laparotomy

What are 3 indications of laparotomy

- Haemodynamic instability - Clinical peritonitis - Intra-abdominal bleed detected on imaging

What does management of abdominal trauma depend on

Site of injury

How is pancreatic injury managed

Percutaneous drainage

How is duodenal injury managed

NG tube and parental nutrition

How are individuals with penetrating trauma managed in pre-hospital enviorment

ATLS

What is important for penetrating trauma

- Tetanus prophylaxis | - Antibiotics

How is penetrating trauma managed

- Tetanus prophylaxis - Antibiotics - Emergency exploratory laparotomy

What are 6 indications for emergency exploratory laparotomy

1. Extraviscation (organ outside) 2. Peritonitis 3. Haemodynamic instability 4. Penetrating object in-situ 5. PR bleed 6. Free air under diraphragm

How is ATLS approach to trauma divided

- Primary survey | - Secondary survey

What is the primary survey approach

Used to look for injuries that will require immediate resuscitation

What is secondary survey

Used to scan for all other injuries

what may be looked for on secondary surgery in abdominal trauma

- Grey-turner's sign - Cullen's sign - Seatbelt sign

What is the seat belt sign

Presence of bruising in mark resembling lap portion of seatbelt

What is looked for on palpation in the secondary survey

Crepitus over lower ribs indicating splenic or liver damage

When is FAST imaging indicated for abdominal trauma

Immediate imaging as part of secondary survey for haemodynamically unstable patients

What is the problem with FAST scans

Poor at identifying retroperitoneal haemorrhage

When is diagnostic peritoneal lavage used for diagnosis

Haemodynamically unstable patients

What is the problem with diagnostic peritoneal lavage

May miss retroperitoneal haemorrhage and diaphragm injury

When is abdominal CT ordered

Stable patient

What is the advantage of abdominal CT

Good method for localising injury

What is fluid resuscitation

Individual is given 500mL crystalloid fluid challenge. Then given up to 2L fluid

How can individuals response to fluid be categorised

1. Responder 2. Transient responder 3. Non-responder

What is a responder

Demonstrates physiological improvement on fluid

How much blood loss has a responder to fluid had

<20%

What is a transient responder

Someone who initially demonstrates an improvement on fluid and then deteriorates

How much blood loss has a transient responder had

20-40%

What will a transient responder require

Blood products

What is a non-responder

Someone who continues to deteriorate on fluid

How much blood loss has a non-responder had

>40%

2: Acute Mesenteric Ischaemia, Chronic Mesenteric Ischaemia, Abdominal Trauma Flashcards

(88 cards)