US Flashcards
(67 cards)
1
Q
What is one of the most common causes of the acute adbomen and one of the most frequenct indications for emergent abdominal surgery?
A
Appendicitis
2
Q
When does appendicits most frequently occur?
A
20-30s, highest in those 10-19 YO.
3
Q
A missed diagonsis of acute appendicits is a common reason for _______.
A
Litigation
4
Q
Descirbe symptoms of appendicitis.
A
- Visceral, diffuse, visceral pain that becomes localized in the RLQ (McBurney’s point) and becomes somatic pain (sharp and localized).
- Anorexia
- N/V
- Fever
5
Q
What specialty tests can we do for appendicits?
A
- McBurneys Point
- Rovsings sign
- Obturator sign
- Psoas sign
6
Q
What diagnostic testing do you do on a patient with appendicits?
A
- CBC (usually high, but can be NL)
- Chemistry profile (electrolytes and LFTs)
- UA (usually NL, but can be abnormal)
- Pregnany test
7
Q
Gold standard imaging in adults with Appendicitis
A
CT of the abdomen and pelvis with IV and oral contrast
8
Q
Imaging for appendicitis in kids
A
-
RLQ US (less sensitive);
- if (-) => CT.
9
Q
Imaging for appendicitis in pregnant patients
A
MRI
10
Q
Initial treatment appendicitis?
A
- NPO
- IVF
- Antiemetic
- Pain meds
- Possible preop ABX.
11
Q
Early appendicitis can mimic __________.
A
Viral gastroenteritis
12
Q
What is important to remember about appendicitis and labs?
A
- CBC can be NL => still have appendicitis
- UA can be abnormal => still have appenditis
13
Q
- 80% of foreign body ingestions occur in _____.
- How many need surgery?
A
- Children
- Most pass without intervention, but <1% need surgery.
14
Q
what do kids vs adults usually ingest? and age MC
A
- Kids (6months- 3 yrs): coins, button batteries, toys, magnets, safety pins
- Adults (elderly): accidentally a food bolus (meat)
15
Q
What is the MCC of esophageal obstruction in adults?
A
Food = meat
16
Q
The _______ is the most frequent site of obstruction in the gastrointestinal tract
A
esophagus
17
Q
Where do foreign bodies most often get impacted in esophagus?
A
- Physiological/pathological narrowing
- UES, level of aortic arch, diaphragmatic hiatus
- Structure, diverticula, rings, achalasia, tumor
18
Q
It is estimated that approximately 1/2 the individuals with esophageal food impactions have underlying ______________
A
eosinophilic esophagitis
19
Q
What symptoms of ingestion of FB requires emergent endoscopic evaluation?
What about sx that require further work-up?
A
- Drooling; Cant swallow liquids
- Fever, abdominal pain, repetitive vomitting after ingesting FB
20
Q
Imaging and treatment for FB ingestion
A
- If patient has signs and symptoms of esophageal obstruction (drooling/can’t swallow liquids) => emergent EGD & NO imaging.
- In patients w/o suspected esophageal obstruction/hx of ingestion/ type of object is not known => AP/lateral plain XR from neck, chest and abdomen
21
Q
When should a CT scan be done of ingestion of FB?
A
- Suspected perforation by a sharp/pointy object
- Ingestion of narcotics
22
Q
What guides treamtment and management in a patient who ingested FB?
Majority of ingested objectes, are treated how?
A
- Prescense and severity of sx
- Type of object ingested (size, shape and content)
- Location of the object determined by imaging, if performed.
Expectant (watch and wait) is done for MOST ingestions.
23
Q
What needs to be addressed IMMEDIATELY by ENT or GI when a patient ingests FB?
A
- Signs of airways compromise (choking, stridor, wheezing, difficulty breathing)
24
Q
2 treatments for esophageal foreign bodies
A
-
Emergent endoscopy (within 6 hours);
- Complete esophageal obstruction (droolling and cant swallow liquids/ oral secretions)
- Disk batterns
- Sharp objects
-
Urgent endoscopy (within 24 hours);
- All FB must be removed within 24 hours.
25
Treatment of FB in the **stomach** of **proximal duodenum?**
* **Most** objects that NTR stomach pass in 4-6 days are **managed expectantly.**
* Asymptomatic patients with small, blunt objects need weekly XR until passes/ NL diet/ monitor stool
* Urgent endoscopy (w/i 24 hours) if:
1. Sharp
2. \>5cm
3. Magnets
4. Disc/cylinder batteries
5. Objects with lead
26
Treatment of FB in the **distal to L of Trietz**
1. **Most patients = expectant management**
1. Asymptomatic patients with small, blunt objects need **weekly XR** until passes/ **NL diet**/ **monitor stool**
2. **Endoscopic/surgical intervention** if there are signs and symptoms = inflammation/intestinal obstrauction (fever, abdominal pain/ vomitting)
****
*
27
If a patient is complaining of a **hernia**, you can tell them that it is most likely what type?
* **Inguinal indirect hernia**
* **75% = inguinal**
* 2/3 of all inguinal are **indirect**
28
**Hernias** present as a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, (+/-) other symptom’s
**constant/intermittan**t mass in the groin that **gradually** **increases** in size
29
How can we classify **hernias**?
**1. Anatomic location**
–Ventral (abdominal wall)
–Groin
**2. Hernia contents**
–Usually bowel or fat
**3. Status of those contents**
–Reducible
–Incarcerated
–Strangulated
30
Most common locations of a **ventral hernia** and **groin hernia.**
* **Ventral hernia:** _epigastric_ and _umbilical_ (other: spigelian, incisional, parastomal)
* **Groin hernia:** _inguinal_ (direct vs indirect) \> femoral \> obtruator
31
Where do i**ncisional hernias (type of ventral)** occur?
what about spigelian and parastomal?
* Anywhere incision is made, but mostly midline
* Spigelian and parastomal =\> off midline
32
What is the difference between a **direct** vs **indirect inguinal hernia?**
* **Direct hernias:** pass through a weakness in traversaliss fascia in Hesselbach triangle
* **Indirect hernia:** internal ring =\> ER =\> patent process vaginalis =\> scrotum
33
Describe the 3 different **status of contents** of a hernia
Which is a acute surgical emergency?\*\*\*\*
1. **reducible**= hernia sac itself is soft and easy to replace back through the hernia neck defect.
2. **incarcerated**= hernia sack is firm, painful, and cannot be reduced w direct manual pressure
1. no signs of systemic illness
3. **strangulated\*\*\*\*\***= hernia sack firm, painful, usually with signs of
1. systemic illness present (fever, N/V) means BF is impaired (arterial, venous, or both)
34
How do we treat **hernias**?
1. **Strangulated** =\>acute surgical emergency; IV ABX, fluid resus, adequate narcotic analegsia
2. **Incarcerated** =\> try to reduce, if not, surgery
3. **Reducible** =\> follow up at an outpatient cliic
35
\_\_\_\_\_\_ is one of the **top 15 causes** of mortality in the United States, for those between **85 - 89YO, doesnt occur often in ppl less than 60.**
**AAA**; causes 4-5% of sudden deaths in US
36
1. When is a AAA diagnosed?
2. Where is is most common?
3. Progression and what factors influence this?
4. Who has an increased risk of rupture?
1. AAA is diagnosed when **aortic diamter \> 3cm**
2. **Below renal arteries**
3. Progressively dilates overtime: **diameter** and **smoking** infiuence risk of rupture
4. If rapidly dilate**s \>5mm over 6 months** or **\>10mm in 1 year** =\> increased risk for rupture
37
What are the 3 categories of AAAs?
Which one is most common?
1. Asymptomatic (majority of pts; AAA is found incidentally)
2. Symptomatic but not ruptured: rapidly expanding and is compression structures/inflammation/infectious
3. **Sympomatic + rupture**
38
What is the classic triad for a **ruptured AAA?**
1. **Abdominal/flank pain**
2. **Hypotension**
3. **Shock**
39
Risk factors for **AAA**
1. **White M**
2. **Old age**
3. **Smoking**
4. **Other large vessel aneurisms**
5. **Atherosclerosis**
40
What occurs **30%** of the time when **AAA** ruptures?
**Misdiagnosed** as
* renal colic
* perforated viscus
* diverticulitis, GI hemorrahge, ischemic bowel
41
**AAA Diagnostics**
1. Screening?
2. Asymptomatic patients with known AAA
3. Sympmatic patients (stable, unstable + known, unstable + unknown)
1. **Screen** at-risk patients one time if over 65YO with US
2. **If asx, but have AAA**: monitor by doing a US or CT abdomen/pelvis every 6months/year.
3. **Syptomatic**
1. _Stable_: CT of the abdomen/pelvis with IV contrast
2. _Unstable + known AAA_ =\> OR
3. _Unstable and unknown/suspected AAA_ =\> CT adomen/pelvis with IV contrast.
42
**Treatment for AAA.**
1. **Conservative managment (watch and wait)** if asympomatic infrarenal AAA \< 5.5cm
2. **AAA repair (open or endovascular\*\*\*\*)**
1. Asympomatic infrarenal AAA \>5.5cm
2. Rapidly expaning infrarenal AAA (\>0,5cm in 6months or \>1cm/yr)
3. Pt has arterial disease (aneurysm) or symptomatic peripheral artery disease
43
What is the **LEADING** cause of **mortality** globally?
What about the leading cause of death between **18-29?**
* **Trauma**
* **Road traffic injury**
44
What are the 3 mechanisms of injury in trauma?
1. **Blunt trauma** =\> direct blow ruptures hollow organs =\> bleeding
1. **ex. Deceleration**
2. **Penetrating trauma** =\>
1. Stab and low velocity GSW =\> damage tissue by lacerating and cutting
2. High velocity GSW =\> more damage bc cavitation
3. **Explosives**
45
How can **explosives** cause injury?
1. **Blunt + penetrating**
2. **Blast injury to lungs and hollow viscus**
3. **Inhalation injury**
46
**Blunt abdominal trauma (BAT)** accounts for most of abdominal injuries seen in the ED.
* **75%** are caused by \_\_\_\_\_
* ____ and ____ are the most commonly injured solid organs.
* MVC
* Spleen and liver
47
**MVC** historical questions?
1. Restrained
2. intoxicated
3. Patient's location within the vehicle?
4. Vehicle type and velocity circumstances of accident (part of car involved in impact)
5. Air bags were deployed?
6. LOC/Amnestic to event or not?
48
What to ask if **penetrating** trauma?
* **time**
* **type of injury**
* **distance**
* **# of stabs/shots**
49
What to ask if explosive injury?
1. enclosed space or not/ distance from detonation
50
According to ATLS, how do we take care of a trauma case?
which are we addressing when we look at abdominal trauma? \*\*\*
Primary Survey (**ABCDE**)
1. **Airway** –maintenance with C-spine control
2. **Breathing** and ventilation
3. **Circulation** –with hemorrhage control \*\*\*\*\*
4. **Disability/neurologic status**
5. **Exposure/Environmental control** –completely undress the patient, prevent hypothermia
51
PE of abdomem
1. **Inspect**
2. **Ausculatate and percuss =** hard to do in noisy Ed
3. Palpate
4. **Assess pelvic stability**
5. **Assess other areas**: urethral meatus, perineal, rectal, vaginal
52
**_Diaphragm Injuries_**
Most often on the _____ side
Result from \_\_\_\_\_\_\_\_\_
Suspect with ___________ trauma
Avoid doing what?
* L
* Blunt high impact (MVC)
* Thoracoabdominal trauma
* **Do not use trochar when putting in chest tube** bc stomach is in lungs
53
**_Duodenal Injuries_**
Seen in: __________ or \_\_\_\_\_\_\_\_
Dx: \_\_\_\_\_\_\_\_\_\_\_\_
* Unrestrained drivers are hit from front, injury from bicycle handlebar
* Ct abd/pelvis with iv and **Oral contrast \*\***
54
**_Pancreatic Injuries_**
* Result from \_\_\_\_\_\_\_
* Check and trend \_\_\_\_\_\_\_
* DX: \_\_\_\_\_\_\_\_
* Direct blow to the pancreas, causing it to compress on vertebral column
* **Amylase** and **lipase**
* **Ct of abd/pelvis with IV and oral contrast**
55
**_Genitourinary Injuries_**
* Due to: \_\_\_\_\_\_\_\_
* Suspect with \_\_\_\_\_\_\_\_\_\_
* DX: \_\_\_\_\_\_\_\_\_\_
* Suspect urethral disruption with \_\_\_\_\_\_\_\_\_
* direct blow to back or flank
* gross/microscopic hematuria
* CT abdomen/pelvis with IV contrast
* anterior pelvic injuries
56
**_Hollow Viscus Injuries_**
* Due to: \_\_\_\_\_\_\_\_\_
* Early ____ and ___ are often **not** diagnostic for these injuries
* Sudden deceleration injuries (MVC
* Early US and CT = not diagnostic
57
If a patient has a **solid organ injury,** how do we treat a patient who is hemodynamically stable/unstable?
* **Hemodynamically stable:** manage conservatively (no operation) with close observation by general surgeon in hospital
* **Hemodynamically unstable:** operate (laporotomy)
58
**Pelvic fracutes** are very dangerous and most often due to what (3)?
If you have ____ + pelvic fracture = high mortality
Disruption of pelvic ring results in what?
* **MVC, fall from height, auto vs peds**
* **Hypotension** + pelvic fracture = high mortality
* =\> tear **pelvic venous plexus** and d**isrupt internal iliac arterial system.**
59
**Mortality** in patients with pelvic fractures:
–all types of pelvic fractures = \_\_\_
–closed pelvic fractures and hypotension = \_\_\_\_
–open pelvic fractures = \_\_\_\_
* 1/6
* 1/4
* 50%
60
diagnostic testing for **abdominal injury**
* CBC, chem, UA, preg, PT/PTT,INR
* **XR on ALL patients with sign trauma:** lateral C spine, CXR, AP pelvis
* **FAST scan**
* **IF stable:** CT abd/pelvic with IV contrast =\> definitive for most intra-abdominal trauma
* If not stable =\> TRANSFER!!! Do not delay to get these studies
61
Who gets a **lapartomy (surgery)**
1. Blunt trauma + hypotension; + FAST scan or clinical evidence of intraperitonal bleeding
2. Blunt or penetrating abdominal trauma with a + DPL
62
What is FAST scan and purpose?
* Set of US exams to evaulate injured pt
* Purpose is to detect
* free intraperitoneal fluid/ pericardial fluid/ pleural fluid
* hemothorax/pneumothorax in trauma pts
63
\_\_\_\_\_ view looks at heat on FAST scan
Subxiphoid
64
\_\_\_\_\_\_ view on the _______ flank looks at **Morrisons pouch**
Hepatorenal
R flank
65
\_\_\_\_\_\_ view on the ___ flank looks at the **spleen** and **kidney**
Perisplenic
L flank
66
36 YO sober driver was T-boned on drivers side at high speed. What FAST scan do we do. what type of pain would they feel
FAST perisplenic view on L flank
Has LUQ pain
67
What view looks at bladder/pelvis and how do you hold the thing on **FAST**
* Retrovesicular view in suprapubic area
* **Sagital/Trasnverse**
