Approach to the Pt with Abd Trauma & GI emergencies

Question 1

what is the first approach to take for Tx of ingested FB

Answer 1

expectant (wait/watch) - majority of ingestions

make sure:

signs of airway compromise (choking, stridor, wheezing, difficulty breathing) must be addressed immediately (ENT or GI)

Question 2

what are the 3 ways to classify hernia by the status of contents

Answer 2

reducible: soft & easy to replace back through the hernia neck defect

incarcerated: firm, painful and nonreducible by direct manual pressure, no signs of systemic illness

strangulated: firm, very painful w/ signs of systemic illness present (fever, N/V) implies impairment of blood flow (A, V or both)

Question 3

when do genitourinary injuries occur

how do you assess these

Answer 3

direct blow to back of flank

suspect w/ gross/microscopic hematuria

CT abd/pelvis w/ IV contrast

suspect urethral disruption w/ anterior pelvic injuries

Question 4

when do hollow viscus injuries occur

how do you assess these

Answer 4

sudden deceleartion injury (MVC)

suspect w/ deceleration injuries of chance fracture

early US & CT

Question 5

what population is most likely to present w/ AAA

Answer 5

older pts

7% of > 50 yo, 4-8% M 65-80 yo

one of top 15 causes of mortality in US for 85-89

(USA- ruptured AAA = 4-5% sudden deaths)

Question 6

what diagnostic imaging is used to evaluate ingestion FB

Answer 6

only in pts w/o sign/sxs suggestive of esophageal obstruction (dont delay EGD for imaging)

X-ray: anteroposterior & lateral views from neck, chest, and abd; not all FB can be seen on radiograph (fish/chicken bones, wood, plastic, glass, thin metal objects, food)

CT: suspected perforations, sharp/pointed FB, ingestion of packet of narcotic

Question 7

which type of hernia is an acute SRG emergency

Answer 7

stragulated hernia

=severe, exquisite pain at the hernia site w/ sxs of intestinal obstruction, toxic appearance and possibly, skin changed over the hernia sac

Question 8

when do duodenal injuries occur

how do you assess these

Answer 8

unrestrainted drivers prontal impact

bike handlebar injury

CT abd/pelvis w/ IV/oral contrast

Question 9

what is the epidemiology of ingested foreign bodies

Answer 9

80% in kids

MOST pass W/O need for intervention

<1% require surgical intervention

Question 10

what is the PE for the abd

Answer 10

inspect

ausculatate/percussion

palpation

assess pelvic stabilty

assess other areas: urethral meatus, perineal rectal, vaginal

Question 11

what diagnostic tests are used for AAA

Answer 11

one time screening for at risk pt > 65

asymp (& known): 6 month or annual US/CT abd/pelvis

symp:

• stable: CT abd/pelvis w/ IV contrast
• unstable: if known Hx - straight to the OR; if unknown but suspected - CT abd/pelvis w/ IV contrast if possible

Question 12

compare direct vs indirect inguinal hernias

Answer 12

MC = indirect; pass from internal to external thru the patent process vaginalis and then to the scrotum

direct = pass thru weakness in the tranversalis fascia in the hesselback triangle

Question 13

when do pancreatic injuries occur

how do you assess these

Answer 13

direct blow to the pancreas that compress it against the vertbral column

check & trend amylase & lipase

CT of abd/pelvis w/ IV/oral contrast

Question 14

a ruptured AAA can be misdiagnosed as

Answer 14

renal colic

perforated viscus

diverticulitis

GI hemorrhage

ischemic bowel

Question 15

what is the pathophysiology of ingested FB

Answer 15

esophagus = most freq site of obstruction in GIT

often impacted at the sites of physiologic/pathologic luminal narrowing: UES, level of aortic arch and diaphragmatic hiatus

structural/fxnal esophageal abnormalities can increase risk of impaction (diverticula, webs, rings, strictures, achalasia and tumors

about 1/2 impactions - eosinophilic esophagitis

Question 16

compare ingested FB in kids vs adults

Answer 16

kids:

6 months - 3 yrs (coins, buttons, batteries, toys, magnet, safety pins, screws, marbles)

adult:

accidental (95%) - MCC esophageal obstruction by food, more freq in elderly

intentional: psychiatric dz or intoxicated, prison, drug trafficking

Question 17

what are the anatomic locations of hernias

Answer 17

ventral: epigastric, umbilical, spigelian, incisional, parastomal
groin: inguinal (direct/indirect), femoral, obturator

Question 18

what are the treatments used for the different types of hernias

Answer 18

strangulated: SRG consult immediately, broad spectrum IV Abx, fluid resuscitation and adequate narcotic analgesia, preop lab studies
incarcerated: attempt to reduce, if unsuccessful - SRG
reducible: outpt SRG

Question 19

what will be the historical and physical findings for appendicitis

Answer 19

RLQ abd pain (starts w/ visceral pain and then localizes)

anorexia, N/V, (+/-) fever

(+) McBurney’s point tenderness, Rovsing’s sign, Obturator sign and Psoas sign

Question 20

what are RFs for AAA

Answer 20

old

male

white

Fhx

smoking

presence of other large vessel aneurysm

artherosclerosis

Question 21

what are hernias

Answer 21

a protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contain it

75% = inguinal; 2/3 of these = indirect

constant/intermittent mass in groin, gradually increasing in size

Question 22

What are the mechanisms of trauma

Answer 22

blunt trauma: direct blow causes rupture of hollow organs and bleeding; deceleration cause shearing injuries

penetrating trauma: stab wound and low velocity GSW - lacerating and cutting damage; high velocity -increased damage by cavitation

explosive: injuries by several mechanisms (blunt/pentrating, blast injury to lung & hollow viscus from blast overpressure, inhalation injury)

Question 23

What are statistics related to trauma

Answer 23

leading cause of mortality globally

road traffic - leading cause death 18-29 yo

USA- leading cause of death in young adults & >50 mil get trauma related medial care annually

10% all deaths among men & women

>45 mil ppl sustain moderate-severe disability each year

30% of all ICU admissions

Question 24

Most AAA have no sxs but is they do, how do they present

Answer 24

abd, back, flank pain

syncope

thromboembolism &/or limb ischemia

(if sxs present increased risk of rupture)

Question 25

What is the Tx of FB in the stomach/proximal duodenum

Answer 25

**most FB that enter the stomach pass in 4-6 days** urgent endoscopy (w/i 24 hours) : sharp object, blunt object \>2 cm in stomach, \>5 cm at or above proximal duodenum, magnets, bateries, lead expectant management: asymp pt w/ small blunt object - weekly x-ray until object passes, resume diet and monitor stool

Question 26

What is the pathophysiology of AAA

Answer 26

**abd aorta \> 3 cm in diameter** (will progessively dilate over time) MC below renal As aortic diameter and ongoing smoking are the most imp factors that influence aortic expansion and risk of rupture rapid diameter expansion \>=5 mm over 6 months or \>10 mm over a year also have increased risk for rupture

Question 27

what are the 3 categories of AAA

Answer 27

_asymp:_ found incidentally _symp but not ruptured_: rapidly expanding and large enough to compress surrounding or is inflammmatory/infectious (abd pain, flank pian, limb ischemia, fever, malaise) _symp & ruptured:_ BAD, high mortality/morbidity (**classic triad**: abd/flank/back pain, hypotension/shock & pulsatile abd mass)

Question 28

how do you Tx ingestion of FB distal to L of Trietz

Answer 28

most pt: expectant management - asymp pt w/ small, blunt objects - radiograph weekly, resume diet and monitor stool endoscopic/SRG intervention - sign/sxs of inflam/intestinal obstruction (fever, abd pain, vomit)

Question 29

what is Tx for esophageal FB

Answer 29

**emergent endoscopy w/i 6 hrs:** complete obstruction, drooling, disk batteries in esophagus, sharp-pointed object ## Footnote **urgent endoscopy w/i 24 hrs: all FB in esophagus require removal w/i 24 hours**

Question 30

what is apart of the initial evaluation for ingestion of FB

Answer 30

**presence & severity of Sxs** **type of object** **location of object**

Question 31

how do you Tx appendicitis

Answer 31

inital Tx: NPO, IVF, Antiemetics, pain meds, possible preop Abx surgery

Question 32

what is FAST scan

Answer 32

standard set of US exam for evaluation of injured pt Purpose: Detect free intraperitoneal fluid, pericardial fluid, pleural fluid, Hemothorax and pneumothorax in trauma pts Limited sensitivity precludes the use of US = definitive test to r/o intraabd injury

Question 33

who gets a laparotomy

Answer 33

**blunt abd trauma w/ hypotension w/ (+) fast scan or clinical evidence of intraperitoneal bleeding**

Question 34

what is the mortality related to pelvis injuries

Answer 34

pt w/ hypotension & pelvic fracture - high mortality all types of pelvic fractures = 1/6 closed pelvic fractures & hypotension = 1/4 open pelvic fracture = 1/2 (disruption of the pelvic ring tears the pelvic venous pelexus and occasionally disrupts the internal iliac arterial system)

Question 35

what is the incidence for appendicitis

Answer 35

233 out of 100K ppl ## Footnote **highest in 10-19 y/o**

Question 36

When do diaphragm injuries occur

Answer 36

blunt high impact (MCV) most often on L suspect w/ thoraco-abd trauma \*good reason not to use a trochar when putting in chest tube

Question 37

if solid organs are injured what is the best approach

Answer 37

liver & spleen (MC) if hemodynamically stable - concervative w/ close observation by surgeon if unstable or continued bleedng -operative management

Question 38

what are most blunt abd trauma related to and what can they injure

Answer 38

75% MVC or auto vs pedestrian accidents 15% blows to the abd 6-9% falls **spleen and liver are MC injured**

Question 39

what are signs and Sxs of ingested FB

Answer 39

may be asymp acute dysphagia, choking, refusal to eat, hypersaliva, retrosternal fullness, regurgitation of undigested food, wheezing and blood-stained saliva **drooling and inability to swallow liquid - emergent endoscopic evaluation needed** **fever, abd pain, repetitive vomiting after ingestion** (be sure to record type of FB, time of ingestion and presence & type of ongoing sxs)

Question 40

what are the 3 possible ways hernias can be classified

Answer 40

anatomic location: ventral, groin hernia content: usually bowel/fat (most imp) status of those contents: reducible, incarcerated, strangulated

Question 41

what is the treatment for AAA

Answer 41

conservative (asym infrarenal AAA \< 5.5mm) elective repair (open/endocasvular) * asymp AAA \> 5.5 cm in good SRG candidates * rapidly expanding (\>0.5 cm/6 months or \>1 cm/year) infrarenal AA in well-documented serial studies * pt w/ associated arterial dz (coexisting iliac, femoeral or popliteal A aneurysm) or symp peripheral A dz undergoing revascularization

Question 42

what does early appendicitis mimic

Answer 42

gastroenteritis viral illness

Question 43

what is the epidemiology of vental hernias

Answer 43

**epigastric & umbilical = MC ventral hernias** 1/4 ppl are either born with it or will develop one in their lifetime incision hernias may develop anywhere an incision has been made- _MC at midline_ (bc MC used in laparotomy), spigelian and parastromal occur off the midline USA -\>$3.4 billion spent on repair

Question 44

what is the diagnositic testing for appendicitis

Answer 44

CBC (increase/nl) chem profile (electrolytes & LFTs) UA - could be abnormal **pregnancy test** imaging - adults: _CT abd/pelvis w/ IV & oral contrast_; kids- US, if (-) and still suspect then use CT; pregnant pt: MRI

Question 45

what are history needed to assess trauma

Answer 45

**blunt:** MVC location, restraints, airbag, intoxication, impact, speed, ejection/rollover, state of passengers **penetrating:** time, type of injury, distance, # stab/shots **explosive:** enclosed space or not, distance from detonation, combination of blunt and penetrating, possible inhalation injury

Question 46

Appendicitis is known to be one of the most..

Answer 46

MCC of acute abd most freq indications for emergent abd SRG w/w most freq in 20s-30s

Question 47

**what is a great way for taking care of critically ill pts**

Answer 47

ABCDE Airway- maintenance w/ c-spine control Breathing/ventilation Circulation w/ hemorrhage Disablity/neurologic status Exposure/environmental control (completely undress the pt and prevent hypothermia)