CV and Abdominal Emergencies Flashcards
(97 cards)
1
Q
3 categories of CP?
A
- chest wall pain
- pleuritic or resp CP
- visceral CP
2
Q
Tx for SVT?
A
- vagal maneuvers
- start IVs
- adenosine (blocks SA and AV conduction)
- Cardioversion
3
Q
Predisposing factors for Aortic Dissection?
A
- Most impt: HTN
- atherosclerosis
- vasculopathies
- marfans
- congenital defect (aortic coarctation
4
Q
How does aortic dissection present?
A
- commonly w/ abrupt and severe pain in anterior chest or b/t scapula
- ripping or tearing pain
- HTN and tachycardia (50% present as normotensive)
- acute aortic regurg may occur
5
Q
intitial tx and W/U of aortic dissection?
A
- stabilize pt
- O2
- IV
- labs
- exam: pulses in all extremities
- EKG
- CXR: may show widening of aorta
- CT w/ contrast
- TEE
- MRI
6
Q
Tx of aortic dissection?
A
- HTN control: meds w/ neg inotropic effects
- BBs: labetalol IV, metoprolol IV, esmolol IV
- may need vasodilators: nitroprusside IV
- stabilization and rapid referral to surgeon (***
7
Q
Diff types of trauma to heart?
A
- blunt: cardiac contusion
- penetrating:
GSWs/SWs
8
Q
Lung traumas?
A
- hemoptysis
- pulmonary contusion
- pneumos/hemo’s/chylos
9
Q
Causes of acute pulmonary edema?
A
- pump failure - increased hydrostatic pressure -aortic stenosis, mitral stenosis, mitral regurg, acute MI,
- decreased oncotic pressure
- ARDS (leaky capillaries)
10
Q
Presentation of acute pulmonary edema?
A
- severe resp distress
- cool skin
- rales
- JVD
- peripheral edema may or may not be present
11
Q
W/U and initial Tx of acute pulmonary edema?
A
- stabilize pt: maintain airway control and adequate ventilation
- O2: guided by pulse ox
- monitor
- EKG
- frequent vitals
- labs:
CMP
CBC
cardiac enzymes
ABGs - Foley cath
12
Q
CXR findings of acute pulmonary edema?
A
- dilated upper lobe vessels
- cardiomegaly
- interstitial edema
- enlarged pulmonary artery
- pleural effusion
- alveolar edema
- kerley B lines
13
Q
Further tx for pt w/ acute pulmonary edema?
A
- IV nitro to control BP: cont infusion
- may need nitroprusside: cont infusion
- nesiritide: heart failure
- critical end pt is rapidly lowering the filling pressure to prevent need for intubation
- morphine: 2-5 mg IV
14
Q
Diuretics used for pulmonary edema?
A
Furosemide:
diuresis can begin w/in 10-15 min
- can be repeated if adequate diuresis hasn’t begun
- need a foley
15
Q
When should pt w/ acute pulmonary edema be admitted to ICU?
A
- when they are really sick!
- need close monitoring of resp status, BP, HR, urine output
- vasodilator drips have to be monitored in ICU continously
16
Q
Causes of pulmonary edema?
A
- massive MI
- valve disease
17
Q
Abdominal injury - and contents involved?
A
- solid organs: injuries to liver, spleen, pancreas may result in bleeding into abdominal cavity or dumping contents into cavity
- hollow organs (stomach, duodenum, intestine) may d/c chemical and bacterial contents
18
Q
What is peritonitis?
A
- emergent situation
- infection or rarely some other type of inflammation of the peritoneum
19
Q
What is an acute abdomen?
A
- spectrum of surgical, medical and gyn conditions, ranging from trivial to life-threatening, which reqr hosp admission, investigation and tx
- intra-abdominal process causing severe pain reqring admission, hasn’t been prev. tx, may need surgical intervention
20
Q
Tx depending on cause of acute abdomen?
A
- pt w/ acute abdomen is emergency!! correct dx vital!
- surgery needed: ectopic pregnancies, acute appendicitis, duodenal gastric perf ulcers
- abx for PID
- observation: mild ovarian cyst ruptures, pancreatitis
- stabilization!!
21
Q
W/U of acute abdomen?
A
- pt condition guides urgency
- VS: stable or unstable
- pathology in belly can manifest itself w/ systemic signs (renal failure or shock)
- clinical dx
- imaging studies depend on dx
- stabilization
22
Q
Stabilization of acute abdomen?
A
ABCs
- O2
- IV fluids
- foley
- NG tube
- abx
- pain control after surgeion checks source of pain or BP is good
23
Q
Etiology of acute abdomen in kids?
A
- gastroenteritis
- meckel’s diverticulitis
- intussusception
24
Q
Etiology of acute abdomen in adult females?
A
- PID
- pyelo
- ectopic preg
25
Etiology of acute abdomen in adults?
- regional enteritis
- kidney stone
- perf ulcer
- testicular torsion
- pancreatitis
26
Etiology of acute abdomen in elderly?
- diverticulitis
- intestinal obstruction
- colon carcinoma
- mesenteric infarction
- aortic aneurysm
27
Sxs of acute abdomen?
onset:
- sudden: bowel perf, smooth muscle colic
- slow insidious onset: inflammation of visceral peritoneum
severity: kidney stone worst pain
character:
- burning: peptic ulcer sxs
- stabbing: kidney stone
- gripping, intermittent and crampy: intestinal obstruction worse w/ movement
progression:
- constant: peptic ulcer
- colicky: sec -bowel, min - kidney stone, 10 mins gallbladder
- radiation of pain:
back: duodenal ulcer, pancreatitis, AAA
scapula: gall bladder
SI region: ovary
groin: testicular torsion
28
Hx questions for acute abdomen?
```
- any GI sxs:
N, emesis (bilious or bloody)
last BM or flatus (obstruction)
diarrhea (bloody - IBD)
both Nausea, diarrhea usually gastroenteritis
change in sx w/ eating usually PUD
- NSAID use (duodenal ulcers)
- gyne hx
- drinking hx - pancreas - pancreatitis
- prior surgeries: adhesions SBO? still have gallbladder and appendix
- hx of hernias
- heart/lung dx
- FH of Ca or IBD
- meds: steroids, anticoag
```
29
Broad categories for DDx for acute abdomen?
- inflammation
- obstruction
- ischemia
- perf:
offended organ becomes distended - then lymphatic/venous obstruction due to increased pressure - and arterial pressure exceeded - leads to ischemia and prolonged ischemia leads to perf
30
inflammatory causes of acute abdomen?
- stomach: gastric ulcer, duodenal ulcer
- biliary tract: acute chole'y +/- choledocholithiasis
- pancreas: acute, recurrent or chronic pancreatitis
- small intestine: crohn's, meckels diverticulum
- large intestine: appendicitis, diverticulitis
31
Obstructive causes of acute abdomen?
```
- SBO:
Adhesions
Bulges
Cancer
Crohns
gallstone ileus
intussusception
volvulus
- LBO:
malignancy
volvulus: cecal or sigmoid diverticulitis
```
32
PE of acute abdomen?
```
- auscultation:
silent = peritonitis
increased BS = obstruction
- rebound tenderness:
if +: peritoneum involved (exquisitively sensitive)
```
33
If you can't localize abdominal pain - what would pt likely have?
- may have general peritonitis - call surgeon
34
If pt has increased bowel sounds - what is likely dx?
- intestinal obstruction
35
labs for abdominal pain?
- CBC w/ diff: infection and inflammation
- lytes, BUN, creatinine, glucose (DKA)
- LFT (biliary tract)
- amylase (high in acute pancreatitis)
- UA and culture
- preg test
- blood gas = acidosis
36
DDx for acute abdomen?
- appendicitis
- bowel perf or obstruction
- pancreatitis
- diverticular disease
- cholecystitis
- perf gastric/duodenal ulcer
- ruptured ectopic
- ruptured or hemorrhagic ovarian cyst
- PID
- AAA
- tubo-ovarian abscess
37
GI etiologies of acute abdomen?
```
- Gut:
acute appendicitis
intestinal obstruction
perf peptic ulcer
diverticulitis
IBD
acute exacerbation of peptic ulcer
gastroenteritis
meckel's diverticulitis
- liver and biliary tract:
cholecystitis
cholangitis
hepatitis
biliary colic
- pancreas:
acute pancreatitis
- spleen:
splenic infarct and spont. rupture
```
38
Urinary tract etiologies of acute abdomen?
- cystitis
- acute pyelo
- ureteric colic
- acute retention
39
Vascular etiologies of acute abdomen?
- Ruptured aortic aneurysm
- mesenteric embolus
- mesenteric venous thrombosis
- ischemic colitis
- acute aortic dissection
40
Abdominal wall etiologies of acute abdomen?
| Peritoneum?
Abdominal- rectus sheath hematoma
peritoneum - primary peritonitis, secondary peritonitis
41
Retroperitoneal etiologies of acute abdomen?
- hemorrhage ex: anticoagulants
42
Gyn etiologies of acute abdomen?
- torsion of ovarian cyst
- ruptured ovarian cyst
- fibroid degeneration
- ovarian infarction
- salpingitis
- pelvic endometriosis
- severe dysmenorrhea
- endometriosis
43
Extra-abdominal causes of acute abdomen?
- lobar pneumonia
- pleurisy
- MI
- sickle cell crisis
- uremia
- hypercalcemia
- DKA
- addison's disease
44
Acute appendicitis presentation?
- periumbilical pain that migrates to RLQ
- high risk of perf: less than 2yo or elderly, DM, immunocompromised, steroid use
- McBurney's pt: 1/3 the distance b/t anterosuperior iliac spine and umbilicus
45
Abdominal series of XRs? what is best?
- chest: upright best for free air
- supine abdomen: best for abdominal detail - organs, bones, jts, fat and gas patterns
- erect abdomen: air fluid levels
- left lateral decubitus abdomen: possible substitute for erect chest and abdomen if pt can't sit or stand
46
Presentation of perf peptic ulcer?
- hx: GU or DU
- PE: rebounding tenderness, BS are quiet, muscle guarding
- lab: elevated WBC
- upright chest: free air
47
4 cardinal features of intestinal obstruction?
- abdominal pain w/ intermittent cramping
- vomiting
- distension
- constipation
48
colon obstruction measurements?
- cecum most distensible part of colon
- cecum of 9 cm diameter is cause for concern
- cecum of 11 cm is impending perf
49
When should you consider a pt has mesenteric infarction/ischemia?
- atypical presentation of abdominal pain
- older pts
- hx of arrhythmias or previous emboli
- pain out of proportion to exam
- evidence of visceral complaints w/o peritonitis
- systemic complications
- acidosis
- they look sick
50
Etiology of acute mesenteric ischemia? Tx?
- usually acute occlusion of SMA from thrombus or embolism
| - may need embolectomy
51
Chronic mesenteric ischemia - typical pt?
- typically smoker, vasculopath w/ severe atherosclerotic vessel disease: low flow state
- ischemic colitis
- any inflammation, obstructive, or ischemic process can progress to perforation
52
Signs of chronic mesenteric ischemia? What can be done?
- wt loss is most consistent sign
- become afraid to eat b/c of postprandial pain (intestinal agina)
- emergent CTA may be needed
53
Cause of air in biliary system?
- usually secondary to surgery on bile ducts
- can be due to biliary-bowel fistula from infection or neoplasm
- rarely, can be due to infection
54
US can assess what?
- rapid, safe, low cost (but operator dependent)
- fluid, inflammation, air in walls, masses
- liver, GB, CBD, spleen, pancreas, appendix, kidney, ovaries, uterus
55
abdominal CT used to dx what?
- dx for intra-abdominal abscess (sigmoid diverticulitis), pancreatitis, retroperitoneal bleeding (leaking AAA), hepatic or splenic pathology and even appendicitis
- better than plain films for eval of solid and hollow organs
56
What can an elevated amylase mean?
- pancreatitis
- perf DU
- bowel ischemia
57
elevated LFTs meaning?
- jaundice, hepatitis
58
Why would you order a beta-hCG?
- suspect preg - ectopic
59
What can you see on KUB (flat and upright)?
- SBO/LBO
| - free air, stones
60
What can you dx on US?
- cholecystitis : jaundice
| - GYN path
61
When would you decide to operate on acute abdomen? (surgeon ult makes the call)
- peritonitis: tenderness w/ rebound, involuntary guarding
- severe/unrelenting pain
- unstable (hemodynamically, or septic): tachycardic, hypotensive, white count
- intestinal ischemia, including strangulation
- pneumoperitoneum
- complete or high grade obstruction
62
Common causes of acute abdomen?
- perf DU
- cholecystitis
- appendicitis +/- perf
- ischemic or perf bowel
- diverticulitis +/- perf
- ruptured aneurysm
- bowel obstruction
- acute pancreatitis
63
mechanisms of blunt injury?
- compression, crush, or sheer injury to abdominal viscera - deformation of solid or hollow organs, rupture (small bowel, graid uterus)
- deceleration injuries: diff movements of fixed and non-fixed structures (liver, spleen lacerations at sites of supporting ligaments)
64
Common injury patterns?
- most freq injured organs: spleen, liver and small bowel
- duodenum: classically, frontal impact MVC w/ untrestrained driver, or direct blow to abdomen. Bloody gastric aspirate, retroperitoneal air on XR or CT, series confirmed w/ UGI
- small bowel injury: generally from sudden deceleration w/ subsequent tearing near fixed pts of attachment
65
Common injury pattern of pancreas?
- direct epigastric blow compressing pancreas against vertebral column
- amylase and CT not very helpful
66
Common injury pattern of diaphragm?
- Most commonly, 5-10cm rupture involving posterolateral hemidiaphragm, noted on CXR: blurred or elevated hemidiaphragm
67
Common injury pattern of GU?
- pts w/ multisystem and pelvic fxs
68
Common injury pattern to solid organ?
- laceration to liver, spleen or kidney
69
common injury pattern of pelvic fx?
- suggest major force applied to pt
- usually auto-ped, MVC, or motorcycle
- sig assoc w/ intra-peritoneal and retroperitoneal organs and vascular structures
70
Hx questions to ask about trauma?
- mechanism
- sxs, events, PMH, meds, ETOH/drugs
- MVC:
speed, type of collision, vehicle intrusion into passenger compartment, types of restraints, deployment of airbag, pt's position in vehicle
71
PE - assessing trauma?
- inspection: abrasion, contusions, lacerations, deformity
- subtle signs of peritonitis
(+ rebound tenderness)
- difficult if intoxicated
72
Dx tests for trauma?
- labs: BMP, CBC, coags, b-HCG, amy/lip, UA, tox screen, TandC
- plain films: CXR, pelvis, abdominal films not really helpful
- DPL
- FAST
- CT
73
Use of dx peritoneal lavage?
- 98% sensitive for intraperitoneal bleeding
- free aspiration of blood, GI contents, or bile indicaiton for surgery
- if gross blood (over 10 mL) or GI contents not aspirated perform lavage w/ 1000 mL warmed LR
- has been somewhat superceded by FAST in common use, now generally performed in unstable pts w/ intermediate FAST exams, or w/ suspicion for small bowel injury
74
Use of FAST? Comparison to CT?
- focused assessment w/ sonography for trauma
- for ID hemoperitoneum in blunt abdominal trauma
- larger hemoperitoneum the higher the sensitivity, so sensitivity increases for clinically significant hemoperitoneum
- FAST can detect as little as 100 cc
- FAST replaces CT only at extremes:
unstable pt - if + FAST - go to OR
- if stable pt, low force injury and - FAST - consider observation
- CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma, god std for characterizing intra-parenchymal injury
- never send unstable pt to CT though - FAST can be used during resuscitation
75
When is CT recommended?
- for eval of hemodynamically stable pts w/ equivocal findings for PE, assoc neuro injury, or mult extra abdominal injuries
- CT is dx modality of choice for non-operative management of solid visceral injuries
76
Eval for penetrating trauma?
- mandatory exploration abandoned (old school) - roll the pt
- no digital exploration or contrast studies
- inspect wound to determine if there is violation of fascia
- difficult to assess stab wound trajectory
- determine if gunshot transversed peritoneal cavity
77
Management of penetrating trauma to abdomen?
- ABCs
- fluid resuscitate
- to OP or not OP is issue:
unstable w/ no other reason
free air/peritonitis (abx)
unexplained free fluid
- many splenic/liver lacs managed non-op
78
Penetrating flank and buttock injuries - assessment?
- potential for peritoneal and or retroperitoneal injury
- similar eval and management to abdominal
- buttock injuries may also reach peritoneal and or retroperitoneal structures
79
GU trauma - what is MC injured?
- 2-5% of adult traumas
- vast majority blunt mechanisms
- 80% renal
- 10% bladder
- rarely reqr immediate intervention
80
Eval of GU trauma?
- rectal: high riding prostate
- perineum: ecchymosis, lacs
- genitals: meatal/vaginal blood
- difficult cath placement - don't force may have urethral tear!
- UA: hematuria - poor correlation w/ injury
- US and plain films of little use
- CT superior imaging modality but be careful w/ contrast
- IVP/cystoscopy less useful in ED
81
Kidney injuries?
- they are well protected
- MC bruised
- pts w/ shattered kidneys become rapidly unstable
- renal vascular injuries may result in thrombosed vessels
82
Bladder injuries?
- contusion
- rupture: intra vs extraperitoneal
- extraperitoneal: presents w/ pain, hematuria, inability to void
- urethral injuries: anterior vs posterior
- no foley for urethral injuries
83
How common is GI bleeding? Mortality?
- GI bleeding is common disorder that troubles all medical/surgical specialities
- UGI bleeding more common than LGI
- 6-8% mortality (hasn't changed since 1945)
- usually w/o belly pain
84
Presentation of GI bleeding and source?
- hematemesis: UGI source
- melena: UGI source usually but 5% can be from LGI
- hematochezia - LGI source usually but 15% form UGI source
- occult: UGI or LGI source
85
How is UGI and LGI location determined?
- by ligament of Trietz
- UGI: prox to LT: esophagus, stomach, duodenal bulb, 2nd/3rd portion of duodenum
- LGI: distal to LT: small bowel, colon
86
How do you determine urgency of GI bleed?
- is pt in shock?
40% loss of circulating blood vol, agititation, pallor, tachycardia, hypotension
- is pt orthostatic?
20% loss of circ blood vol, postural hypotension
- never rely on initial H/H values to assess amount of blood loss (hemoconcentration)
- ABCs and order some blood
87
Initial management of GI bleeding?
- H and P
- replace intravascular volume
- NG intubation (careful w/ varices)
- supp nasal O2
- lab eval: CBC/platelets/INR/PTT/BUN/creatinine
- admit
88
Use of NG aspirate in GI bleeding?
- determines status of UGI bleeding and gives indirect info in LGI bleeding:
- bright red/clots: active UGI bleed
- coffee grounds: slow bleeding, oozing, stopped
- clear: indeterminate (16% still bleeding)
- bilious: UGI bleeding has stopped
89
Dx/therapeutic modalities for GI bleed?
- GI consult!!
- endoscopy: upper/lower
- radionuclide scanning
- angiography
- never ever use barium in acute GI bleeding!!
90
MC sites for GI bleeds in UGI?
- DU
- gastric erosion, itis
- GU
- varices
- M-W tear
- esophagitis
91
MC sites for GI bleeds in LGI?
- diverticulitis
- angiodysplasia (AVMs)
- neoplasia
- colitis
92
GI bleeding in diverticulosis?
- occurs in 3% of pts w/ diverticulosis
- acute, painless bleeding presenting w/ bright red blood/maroon stool
- right colon usual site 20% episodes are recurrent/persistent
- colonoscopy after bowel prep
- tagged RBC scans/angiography
93
Anorectal/perianal disease - cause of GI bleeding?
- common cause of BRBPR: hemorrhoids
- minor, intermittent bleeding w/ defecation
- always a dx of exclusion after more serious lesions in GI tract have been r/o (CRC, polyps, colitis) but make sure you look
94
Role of endoscopy in triage of UGI bleeders?
- accurate ID of urgency of clinical situation: hemodynamic compromise/signs of on-going bleeding/coag/co-morbidities
- helps determine who should be hosp, admitted
- dx cause
95
Assessing cause of UGI bleeding?
- is bleeding ongoing (rapid vs slow), intermittent or chronic?
- cautious consideration of NG lavage
- cautious eval of initial lab
- close attention to vital signs and response to resuscitation effort
- URGENT endoscopy must be considered for pts w/ on-going bleeding/coag/sig co-morbidities
- early for all other UGI bleeders
96
What pts presenting w/ GI bleeding should be hosp?
- UGI bleeders usually admitted to host even if endoscopy performed b/f admission showed low risk lesion
- ER/PCP freq. makes admission decision and error is on side of safety
- mandatory admission: proven or susp. variceal hemorrhage/hemodynamic instability/co-morbidity (CP)/mental impairment or non-compliance/coag/anemia rqring transfusion
97
Where should you admit pt w/ GI bleeding?
- ICUs offer close observation/monitoring of clinical status/immediate resuscitative effort if needed
- no study shows improvement in outcome in GI bleeding from ICU care
- restrict ICU admission to pts w/: high risk or re-bleeding or unstable pt
- advanced age alone doesn't rqr ICU admission
