Extremes of age abnormal vital signs sudden onset of severe abdominal pain

X-ray obstruction series, air-fluid levels CT can determine grade

Abdominal Pain in the ED Flashcards by Addie Agboola

Belly pain in the ED should start with

ABCDE
large bore IV
cardiac monitoring
IV fluids
NPO
symptom mangament (zofran, analgesics)

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when to worry?

Extremes of age
abnormal vital signs
sudden onset of severe abdominal pain

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what are three main types of abdominal pain

Visceral peritoneal pain

inflammation/stretching of visceral peritoneum
dull, poorly localized

Parietal peritoneal pain

inflammation of the parietal peritoneum
localized and distinct

referred pain

pain felt away from the source
i.e gallbladder pain referred to the right shoulder

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Sharp = risk of perforation
larger = risk of ischemia, aspiration, tracheal encroachment
button batteries= risk of erosion/perf (thermal burn, alkaline injury, fistula formation)

Presentation

ped, cognitivie impairment, mental health hx, incarcerated
drooling/refusing P/O
dysphagia
tracheal involvement = Stridor/dyspnea

Esophageal Obstruction

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diagnosis of esophageal obstruction

plain films

button battery = “stacked sign”, flat FB shows circle in coronal plane
typically “O” on cOronal = in esOphagus

If not radio-opage

- CT soft tissue neck
- exploratory EGD
gastrograffin swallow study

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Management of Esophageal obstruction

Emergent EGD

button battery- erosioin starts in 15 min, can perf within a few hours
sharp
airway compromise
aspiration risk

Output Xray 24 hours

no emergent indication, no pain, tolerating PO

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Boerhaaves syndrome

effort rupture: ++ vomiting, abdominal trauma, defecating

Iatrogenic

Presentation

Hx of ETOHism, bulimia, recent EGD
severe retrosternal/upper abdomen pain
odynophagia

Esophageal perforation

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Diagnosis of esophageal perforation

CXR- mediastinal or free peritoneal air
CT
gastrograffin esophagram

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management of esophageal perforation?

NPO
IVF
Broad spectrum abx
surgery: primary repair, stent, diversion

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Esophageal varices

enlarged veins d/t portal hypertension
risk factors = ETOH use, liver disease

Peptic ulcer disease

gastric or duodenal
risk factors= h.pylori, NSAIDs, high dose steroids, smoking, ETOH
complications= deep ulceration causing UGIB or perforation

Presentation

hematemesis (red or coffee grounds)
melena
tachycardia, hypotension, LH/syncope, shock
PUD: abdominal rigidity

Upper GI bleed

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diagnosis of upper GI bleed?

Decreased h/h, increased BUN
- hemooccult or melena on DRE
PUD: xray= free air, if stable- CT= air, defect

Variceal bleed

clinical
EGD

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Management of Upper GI bleed?

IV x 2
type and crossmatch blood
+/- blood transfusion
prophylactic abx
bleeding/perforated ulcer: PPI, surgery cautery/omental patching
Variceal bleed: octreoctide, intubate, GI or EGD/banding

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Post op adhesion
hernias
IBD
tumors

Presentation

abdominal distention
diffuse crampy pain
n/v
inability to pass gas or stool
dehydration

Small bowel obstruction

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diagnosis of SBO?

X-ray

obstruction series, air-fluid levels

can determine grade

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management of SBO?

IVF
NPO
NG tube

Partial SBO: medical admit
high grade SBO= surgical consult
closed loop SBO= surgical emergency

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protrusion of viscous through abdominal wall defect
risk factors: increased intra-abdominal pressure (pregnancy, ascites, obesity) surgical incision sites
reducible
incarcerated
strangulated

Presentation

severely painful, tender, non-reducible mass
sbo presentation (N/V, inability to pass gas/stool)
hematochezia
if strangulated–> gangren–>perforation–> peritonitis–> septic shock

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Incarcerated and strangulated hernia

Diagnosis of hernia?

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Clinical= redness, severe tenderness at hernia
labs: Leukocytosis, elevated lactate
X-ray: SBO signs
+CT

managment of incarcerated hernia

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IV, Pain/nausea management, NPO, IVF
uncertain duration of incarceration? = don’t reduce
incarcerated = surgical consult
strangulated= IV abx, surgical emergency

median age 22, but can occur at any age
most common gen surg problem in pregnancy

Presentation

visceral pain–migrates to McBurney’s
anorexia
N/V
resisting movement

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Appendicitis

diagnosis of appendicitis?

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Rosving sign: pain to RLQ with palpation of LLQ
obturator sign: pain with internal rotation of R hip
iliospoas sign: RLQ pain with passive extension of R hip
labs: +/- leukocytosis, up 30% with normal WBC
imaging: +CTAP most sensitive, +US= children, pregnant patients, MRI= pregnancy

management of appendicitis?

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IV, NPO, IVF, pain/nausea control, abx if per
surgical consult- appendectomy, drain/wash out if complicated (abscess or perf)

inflammation/infection of out-pocketing of the colon
risk factors= constipation/low fiber diets, increased intraluminal pressures
complications: abscess, perforation

Presentation

LLQ pain/ tenderness
diarrhea
N/V
+/- fever
hematochezia
hx of diverticulosis on colonoscopy

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Acute diverticulitis

diagnosis of acute diverticulitis?

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labs (+/- leukocytosis)
imaging: CTAP, shared decision making if forego CTP, prior episode with exact same sxs, not sick

management of acute diverticulitis?

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IV, NPO, IVF, pain/nausea control
Uncomplicated = discharge home (bowel rest- clear liquid diet) abx (cipro and flagyl or augmentin)
complicated= IV abx, admit/OR (perforation= surgery, abscess = IR drainage)

* Perforation through the wall of hollow organs (small intestine, colon) * PUD * Complicated apendectomy * complicated diverticu * complicated SBO Presentation * sick * abdominal distention * septic shock

Rupture hollow viscus

diagnosis of rupture hollow viscus?

labs * leukocytosis * elevated lactate (sepsis) Xray * pneumoperitoneum (air cresent- under diaphragm on upright, rigler sign- double wall sign) * + CT

Managment of rupture hollow viscus

IV, NPO, IVF, pain/nausea control, IV abx sugery

* average size < 2 cm diameter * aneruysmal = >3 diameter * higher rupture risk > 5cm diameter * risk factors: age, atherosclerosis, HTN, connective tissue disorders, family hx Presentation * Classic triad: abdominal or flank pain, hypotension, pulsatile abd mass * LH/ syncope * tachycardia and hypotension * hemorrhagic shock * pain is severe, ripping or tearing * retroperitoneal hemorrhage (cullen sing, grey-turner sign)

Ruptured abdominal aortic aneurysm

diagnosis of Ruptured abdominal aortic aneurysm

* POCUS esp in the setting of known AAA * aorta > 5.5cm diameter with shock * CT if stable * labs: decreased h/h, elevated lactate

management of AAA?

ABCDE * emergency surgery, vascular

septic ureteral stones

* dont miss AAA * typically 20s to 50s * 75% calcium- increased intake, immobilization, hyperparathyroidism * 10-15% magnesium phosphate, "struvite" * staghorn calculi- very prone to infection, abx penetration poor * 10% uric acid

presentation of * colicky pain, follows trajectory of ureter * if septic + sick sxs * pacing, vomiting, extremely painful * hang up uteropelvic and uterovesicular junctions

Septic ureteral stones

diagnosis of septal ureteral stones?

* clinical clues * UA: blood, infection * CBC/cmpt * CT Renal stone protocol (no contrast) * US- pregnancy, may miss smaller stones

management of Ureteral stones?

* IV, NPO, IVF, pain/nausea control (septic stone = urine culture, blood cultures, IV abx) * emergency urologic surgery (obstructing stone+ infection, staghorn infection+) * urology consult (renal dysfunction on labs, obstructing stone or staghorn, > 6mm) * admit (intractable pain or vomiting) * home (no infection, baseline renal function, pain and nausea managed PO)

* severe hepatocellular injury in pt with normal liver or well-compensated liver disease * + toxin induced (acetaminophen) or viral (Hep B) * Presentation: AMS, abdominal pain, generalized weakness, anorexia, jaundice, N/V/D, RUQ tenderness * dx: Elevated LFTs (very high AST and ALT), prolonged INR, +/- elevated ammonia, APAP level

fulminant hepatic failure/ acetaminophen OD

management of acetaminophen OD?

* +/- activated charcoal if within 4 hours * N=aceytlcysteine (NAC = antidote) prevents APAP metabolites from futher damaging liver cells (**almost 100% effective if given within 8 hours post ingestion)** Rumack matthew nomogram * acute, single ingestion * known time of ingestion * above the nomogram line= treat with NAC to decrease hepatotoxicity * ICU, +/- care at liver transplant facility

* ascites fluid infection without apparent intra-abdominal treatable source * associated with large volume ascies * up to 30% cirrhotic pts * **presentation: large volume ascites, fever, diffuse abdominal pain/ttp/ peritoneal signs, AMS**

Spontaneous bacterial peritonitis

diagnosis of spontaneous bacterial peritonitis?

* basic labs * paracentesis with fluid analysis * 60% of patients will be culture negative, abx still indicated

management of spontaneous bacterial peritonitis

* abx for typical enteric flora * consider albumin infusion * large volume paracentesis => 5 L fluid taken off * ICU admission

Abdominal Pain in the ED Flashcards

(39 cards)