Flashcards in Cardiac/Thoracic and Abdominal Emergencies 2 Deck (41):
Always consider in a patient with atypical presenation of abdominal pain. Specifically in people with the following risk factors?
1. Older patients
2. Hx of arrhythmias or previous emboli
3. Pain out of proportion to exam
4. Evidence of visceral complaints without peritonitis
5. Systemic complications
7. They look sick
Acute mesenteric ischemia
1. Usually acute occlusion of what?
2. May need to do what?
3. Chronic mesenteric ischemia: typically which pts? 2
4. What kind of processes can progress to perforation? 3
1. Acute mesenteric ischemia
-Usually acute occlusion of the SMA from thrombus or embolism
2. May need to do embolectomy
3. Chronic mesenteric ischemia
-vasculopath with severe atherosclerotic vessel disease (low flow state)
-ischemic process can progress to perforation
Ischemic bowel disease:
(chronic mesenteric ischemia)
1. What is the most consistant sign?
2. What is intestinal agina?
1. Weight loss is the most consistent sign
2. Become afraid to eat because of postprandial pain ( intestinal angina)
3. Emergent CTA (angiography) may be in play…let the surgeon make this call
Air in Biliary System
1. usually secondary to?
2. Can be due to ?
3. Rarely due to?
1. Usually secondary to surgery on bile ducts
2. Can be due to biliary-bowel fistula from infection or neoplasm
3. Rarely, can be due to infection
1. Dx for? 6
2. Better than plain films for evaluation of what?
-intra-abdominal abscess (sigmoid diverticulitis),
-retroperitoneal bleeding (leaking abdominal aortic aneurysm) ,
-splenic pathology and even
2. solid and hollow organs.
Decision to operate (the surgeon makes the call)
1. Peritonitis- Tenderness w/ rebound, involuntary guarding
2. Severe / unrelenting pain
3. “Unstable” (hemodynamically, or septic)- Tachycardic, hypotensive, white count
4. Intestinal ischemia, including strangulation
6. Complete or “high grade” obstruction
TAKE HOME POINTS
For acute abdomen, think of these commonly (below)? 8
1. Perf DU
2. Appendicitis +/- perforation
3. Diverticulitis +/- perforation
4. Bowel obstruction
6. Ischemic or perf bowel
7. Ruptured aneurysm
8. Acute pancreatitis
Mechanisms of Blunt injury
1. Compression, crush, or sheer injury to abdominal viscera leading to?
2. Deceleration injuries are what?
1. deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus)
2. Deceleration injuries: differential movements of fixed and non-fixed structures (e.g. liver and spleen lacerations at sites of supporting ligaments)
Common injury patterns
1. In patients undergoing surgery for blunt trauma, most frequently injured organs are what? 3
-Classically injured how?
3. Signs and symptoms of duodenum injury? 3
4. Small bowel injury generally from what?
-small bowel (5-10%).
-Classically, frontal-impact MVC with unrestrained driver; or direct blow to abdomen.
-Bloody gastric aspirate,
-retroperitoneal air on XR or CT,
-series confirmed with UGI
4. Small bowel injury:
Generally from sudden deceleration with subsequent tearing near fixed points of attachment.
Common injury patterns
1. How is the pancreas commonly injured?
2. Diaphragm most commonly injured how?
3. Noted on CXR?
4. GU injuries commonly happen how?
1. Direct epigastric blow compressing pancreas against vertebral column.
-Amylase and CT not very helpful
2. Most commonly, 5-10 cm rupture involving posterolateral hemidiaphragm.
3. Noted on CXR: blurred or elevated hemidiaphragm
Patients with multisystem injuries and pelvic fractures.
Common injury patterns
1. Solid organ injury? 3
2. Pelvic fractures?
-Usually from what?
-Significant association with what?
Solid organ injury
1. Laceration to
2. Pelvic fractures:
-Suggest major force applied to patient.
-Usually auto-ped, MVC, or motorcycle
-Significant association with intra-peritoneal and retroperitoneal organs and vascular structures.
MVA trauma: questions to ask on hx? 6
2. Type of collision (frontal, lateral, sideswipe, rear, rollover)
3. Vehicle intrusion into passenger compartment
4. Types of restraints
5. Deployment of air bag
6. Patient's position in vehicle
What test is 98% sensitive for intraperitoneal bleed?
Diagnostic Peritoneal Lavage
Diagnostic Peritoneal Lavage
1. What is an indication for surgery? 3
2. If gross blood (> 10 mL) or GI contents not aspirated, perform lavage with what?
3. Has been somewhat superceded by FAST in common use; now generally performed in unstable patients with what? 2
-Free aspiration of blood,
-bile indication for surgery
2. 1000 mL warmed LR.
- intermediate FAST exams, or
-with suspicion for small bowel injury
FAST (Focused Assessment with Sonography for Trauma)
1. Used for?
2. When will the sensitivty increase?
1. For identifying hemoperitoneum in blunt abdominal trauma: way after my time for those who care
2. The larger the hemoperitoneum, the higher the sensitivity. So sensitivity increases for clinically significant hemoperitoneum.
How much fluid can FAST detect?
As little as 100 cc’s
Does FAST replace CT?
Only at the extremes. such as? 2
1. Unstable patient, (+) FAST → OR
2. Stable patient, low force injury, (-) FAST → consider observing patient.
1. The gold standard for characterizing intra-parenchymal injury is what?
2. What if the pt is unstable?
1. CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma
2. Never send an unstable patient to CT. FAST, however, can be performed during resuscitation.
1. CT is recommended for evaluation of hemodynamically stable patients with equivocal findings on what?
2. CT is the diagnostic modality of choice for?
1. physical examination, associated neurologic injury, or multiple extra-abdominal injuries.
2. non-operative management of solid visceral injuries.
Penetrating Trauma Evaluation
1. Inspect wound to determine if there is violation of the fascia
2. Difficult to assess stab wound trajectory
3. Determine if gunshot traversed the peritoneal cavity (I’m not buying it)
Penetrating Trauma Management? 4
2. Fluid resuscitate
3. To lap or not to lap is the issue
4. Many splenic/liver lacs managed non-operatively
Penetrating trauma: when to not go lap? 3
1. Unstable (with no other reason)
2. Free air/peritonitis (antibiotics)
3. Unexplained free fluid
1. What is the superior imaging modality for GU injuries?
2. Careful with what?
1. CT is the superior imaging modality
GU injuries: the kidneys
1. Kidneys are well protected
Most commonly injured how?
2. Pts with a shattered kidney: prognosis?
3. Renal vascular injuries may result in what?
2. become rapidly unstable
3. thrombosed vessels
GU Injuries: The Bladder
1. Extraperitoneal presents with what? 3
-inability to void
1. Hematemesis source?
2. Melena source?
3. Hematochezia source?
4. Occult source?
1. Hematemesis-UGI source
2. Melena-UGI source usually but 5% can be from LGI source
3. Hematochezia (BRBPR)-LGI source usually but 15% from UGI source
4. Occult-UGI or LGI source
1. UGI vs LGI location determined by the what?
2. UGI – proximal to LT: which structrues? 4
3. LGI- distal to LT? which structures? 2
1. Ligament of Treitz
2 UGI – proximal to LT
*2nd/3rd portion of duodenum
3. LGI – distal to LT
Determine the urgency of the clinical situation:
1. two questions to ask?
-Is the patient in shock?
-Is the pt orthostatic?
2. ABC’s and order some blood
1. What is considered shock?
2. Symptoms? 4
1. 40% loss of circulating blood volume
Initial management of GI bleeding:
1. History/physical exam
2. Replace intravascular volume
3. Nasogastric intubation (…maybe…be careful with varices)
4. Supplemental nasal oxygen
5. Laboratory evaluation:
Initial management of GI bleed: initial labs? 4
the status of UGI bleeding and gives indirect information in LGI bleeding
What do the following indicate?
1. Bright red/clots?
2. Coffee grounds?
1. Bright red/clots – active UGI bleed
2. Coffee-grounds – slow bleeding, oozing, stopped
3. Clear – indeterminate (16% still bleeding)
4. Bilious – UGI bleeding has stopped
GI CONSULT: Imaging? 3
Never use what in acute GI???
1. Endoscopy – upper/lower
2. Radionuclide scanning
NEVER EVER USE BARIUM IN ACUTE GI BLEEDING
UGI bleeding (2225 patients):
Diagnoses: Top 4?
1. DU 24.3
2. Gastric erosion, “itis” 23.4
3. GU 21.3
4. Varices 10.3
Major LGI bleeding:
Diagnosis: Top 4?
1. Diverticulosis 43
2. Angiodysplasia (avm’s) 30
3. Neoplasia 9
4. Colitis 9
2. Usual site?
3. Dx? 2
1. Acute, painless bleeding presenting with bright red blood/maroon stool
2. Right colon usual site 20% episodes are recurrent/persistent
-Colonoscopy after bowel prep
-Tagged RBC scans/angiography
1. MC cause?
3. How should you proceed with management?
2. Minor, intermittent bleeding with defecation
3. Always a diagnosis of exclusion after more serious lesions in the GI tract have been ruled out (CRC/polyps/colitis) but make sure you look.
Role of endoscopy in triage of UGI bleeders Accurate identification of the urgency of the clinical situation?
hemodynamic compromise/signs of on-going bleeding/coagulopathy/co-morbidities
Diagnosing the cause of UGI bleeding:
1. Is the bleeding on-going(rapid vs slow)/intermittent/chronic
2. Cautious consideration of NG lavage
3. Cautious evaluation of initial laboratory
4. Close attention to vital signs and response to resuscitation effort
5. URGENT endoscopy must be considered for pts with on-going bleeding/coagulopathy/significant co-morbidities
6. EARLY for all other UGI bleeders