division external: ant. abdomen. post abdomen. flank internal true abdomen thoracic part pelvic...
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ACUTE ABDOMEN
DivisionExternal:
Ant. Abdomen.Post abdomen.Flank
InternalTrue abdomenThoracic partPelvic part.
Retroperitoneal
When to admit patientPain less than 48 hours.
Followed by vomiting.
History of: trauma, operation or hemorrhage.
History of loss of consciousness: because even in acute
pain abdomen is lax.
Extreme of age: they don’t have enough omentum to
protect from infection.
Abnormal physical sign:Tenderness. Distension.Rigidity. Guarding.Bowl sound: absent, hyperactive or
tingling.
Investigation:CBC.Urea.Lytes.PtPTT.Urine analysis.LFT.Serum amylase.Lipase.
Radiology.Plain abdominal x-ray.Erect: airUnder diaphragm.Air fluid level.Psoas shadow.Supine: To detect Distention and caliper of
bowlContrast study: Contraindicated in perforated
gut. Because it may cause granuloma.Gastrographine.IVP.
Endoscope:Upper GIT endoscope.Sigmoidoscope.Colonoscopy.
Emergency US: For renal, billiary or peritoneal dis.
Emergency CT: don’t pay unstable pt outside ER.
Abdominal lavage: It is rapid and sensitive.
Emergency laparoscopy: But you must have the facility.
Causes of acute abdomenMedical:
MILobar pneumonia.Diabetic ketoacidosis.Acute hepatitis.Congenital spherocytosis.Henoch-schonlen purpura.Congenital erythropoietin hepatic porphyriasis.Herpes zoster.Lead poisoning.Campylobacter infection.
Peritonitis:Acute peritonitis:
Bacterial:Primary: In immunocompromise patient. like:
pediatrics, female, chronic liver diseases, chronic renal failure.
Secondary: Chloecystitis, appendicitis and diverticulitis.
Non-bacterial: Rupture or leakage of bile. Chronic peritonitis:
Bacterial: Like TB and bovine.Non bacterial: Granuloma
Surgical:
Pneumoperitonium:Causes:
After laporotomy, abdominal pacentesis and peritoneal dialysis.
Gyn causes.After GIT endoscope.Escape of air from trachiobronchial tree.Pneumotosis cystoids intestinalis. (v-rare).
It will lead to peritonitis.Haemoperitonium:
Clinically, patient present with shock.Causes: Trauma, surgery, pelvic fracture, ectopic pregnancy,
2ry peritoneal carcinomatosis, abdominal aneurysm and hemorrhage or clotting disorders.
Ascitis:Fluid in abdomen clinically detected if reaches 1 liter.Causes:
Lymph obstruction.Liver dis.Inflammatory dis.Malignant dis.
Color of fluid: Serous. Chylous milky lymph obstruction malignancy. Pseudochylous turbid malignancy. Blood stain. Myxomatous mucous tumor of mexomatous cells.
Intractable ascitis:Massive and not respond to treatment.Causes: budd-chiary syndrome, advanced chronic liver disease and
peritoneal carcinomatosis.Lab: US and aspiration.
Mesenteric ischemia:Types:
Occlusive:Vein Artery 90%
Non-occlusive.FATAL GANGRENE.
Clinically: Sever pain, without any physical sign.
Intestinal obstruction:Mechanical:
Acute: pain and vomiting. Subacute off\on adhesive most commonly post-op. Chronic: something grows in the abdomen. Acute on chronic serius Dx.
Paralytic: 2ry to:
Late stage of mechanical obstruction. Anti-cholinergic drugs. Metabolic disturbance hypokalemia. Mesenteric ischemia. Peritonitis.
Management: Supportive: IV fluid, urinary catheter and NG tube. Surgery.
CPR
CARDIO-PULMONARY
RESUSCITATION
Candidates for CPR:
Compromised vital signs including oxygen
saturation.
Compromised conciousness.
ill appearance of patient.
Now you know this patient is critical!!
what to do?
Talk to the patent and look for his
response
Start ABC
If you come to the circulation and there is
no carotid pulse (don't compress for more
than 10 sec on the carotid pulse) start CPR
What is CPR?
Cardio pulmonary resuscitation
It is a cycles of compression and
artificial breathing.
How to do it?Hand position: Palm of the hands two fingers above
the xyphoid process .
Lock the elbows and press by your shoulders.
Shoulder should be vertical to your hands.
In infants compression by thumbs.
In children 1-8 years by the heal of one hand.
Depth of compression 1/3 of the AP diameter of the
chest (in adults 3cm).
In the hospital:
Give 5 compressions and one breath by ambu bag
In public:
If there is any assistance let him give two breaths
If you’re alone give 15 compressions then give one
breath for four cycles and then check the pulse
If there is no pulse repeat cycle. If you gain pulse
STOP CPR.
Aim: 100 compressions / min
1-Airway management
It's the first thing to do in ABCDE (A; airway
management and c-spine stabilization, B: breathing, C;
circulation, D ; disability, E: exposure)
We stabilize the c-spine by cervical collar and by
putting the patient on hard backboard.
Assessment of air way before assessing the airway we ask the patient are you ok. and
we look for his response
if the patient is talking this mean his airway is patent
if he is woning or unresponsive we do gaga reflex and look
If gaga reflex is present this mean the patient can protect his
airway only if you maintain it.
if no gaga this patient can't protect his airway so you have to
intubate him.
if the patient is wheezing or snoring this mean his airway is
obstructed.
A - Techniques :
head-tilt/chin left maneuver; It's contraindicated in head or
neck trauma where injury to c-spines if suspected
jaw thrust; suitable for trauma patient.
B- Instrument :
Oropharyngeal airway: It`s used to maintain the airway
and to prevent tongue fall. And also for aspiration of
secretion.
2-Airway management
Q ; how you check for it's fitness?
A; if it's length is equal to the distance between the
angel of mouth and the angel of mandible this mean its
appropriate and it can fit.
it is contraindicated in conscious patient
Endotracheal tubeIt's definitive airway because it protect and maintain the
airway.
● indication :
Orofacial trauma .
To prevent aspiration .
Apanic patient .
Sever shock and hypoxia with need to ventilator.
If you failed to secure the airways after all of that go for
other definitive airway which is cricothyrodectomy
[surgical airway]
This done by inserting a needle in hyoid membrane
between the cricoid cartilage and hyoid bone.
If you failed ask for trachestomy
other instruments are ventory mask and non-rebreathing
facial mask (it gives up to 85% of oxygen ) ,oxygen nasal
canula (it gives low concentration of oxygen about 40%).
Q : what is the diff. Between child and adult
laryngeoscope ?
The bald is strait and short in children
larygeoscope.
You have to oxygenated every patient by ambu or by
facial mask.
Q : How you do intubation? A : by 5 steps
1- Prepare equipment and patient
Equipments are ETT,syringe to inflate ETT cuff, laryngeoscope ,k/y gel.
2- preoxygenate the patient. By ambuo baging for 5min. It can gives 100% oxg. Saturation.
3- premedicate .Sedation by propafol.Analgesia by morphin.Muscle relaxant by succinyl choline.In comatose patient give only muscle relaxant.
4- passing the tube.
5- post intubation assessment.
Auscultate first in the epigastrium (if there is no
air entry it is mean your tube is not in the
esophagus).
Auscultate all over the chest and listen for equal
air entry to make sure that your tube is in the
trachea.
visualization ; Look if the tube is going through the vocal
cords.
X-ray .