pp acute abdome
TRANSCRIPT
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CUTEBDOMEN
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• Treat any acute abdominal
pain as life-threatening
until prove otherwise.
• Associated hypotension,
syncope or pale, cool, and
clammy skin – bad!. Painfor > 6 hours – bad!!!
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Acute Abdomen
• i. Focused History:
– Fever, nausea & vomiting, distended,
bloated, bowel movement, diarrhea,constipation, last period, change in body
weight, current medication(JAMU).
– Pain, anxiety & fear, guarded position,
rapid/shallow breathing, rapid pulse,hypotension
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• ii. Physical Exam:
– Inspection: expose abdomen, flatsunken or distended, Cullen’s sign
– Auscultate the Abdomen: normal
bowel sounds every 5-10 sec,
blood or irritans inside
hyperactive, blood or irritans
outside diminished
– Palpate the Abdomen: can use pt’s
hand or a stethoscope. Check for
rigidity, guarding, bulges,
subcutaneous emphysema
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• Mechanical Obstruction
• Internal Bleeding
• Generalize Peritonitis
3
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Common causes:
• Small bowel:
– Adhesions
– Incarcerated hernia – Intussusception
– Lymphoma
– Stenosis
– Foreign body/bezoar – Superior mesenteric
artery syndrome
• Large bowel:
– Carcinoma
–
Fecal impaction – Ulcerative colitis
– Volvulus
– Diverticulitis
– Intussusception
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• More common
• Vomiting bilious early
• Bowel sounds high pitched
early, but diminishes withtime
• Pain periumbilical crampyand intermittent
• May have signsdehydration/shock
Small Bowel Obstruction
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Hernia
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Mechanical Obstruction
• BLS:
– High flow oxygen – Position of comfort
– Left lateral if vomiting
– Assist with ALS
procedures
– Transport
• ALS:
– Monitor
– Venous access
• Treat shock
• Treat nausea/vomiting
• Treat abdominal pain
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Problems???• Performed USG?
• Performed X-Ray without NGT?
•
PD?
not meticulous – Not exposed abdomen
– Have “a scar”? Thank U
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Internal Bleeding
Liver Trauma
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Why the liver……
• Largest organ
• Friable parenchyma, thin capsule, fixedposition in relation to spine proneto blunt injury
• Right lobe larger, closer to ribs moreinjury
• Ligamentous attachment to diaphragmand the posterior abdominal wall,shear forces during deceleration injury.
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• Isolated liver injury occurs in lessthan 50% of patients.
• Blunt trauma 45% with spleen
• Rib fracture 33% with Liverinjury
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• Upper right quadrant pain
• Abdominal wall muscle rigidity, spasm.or involuntary guarding
• Rebound tenderness
•
Hypoactive or absent bowel sounds• Signs of hemorrhage and/or
hypovolemic shock
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• Elevated LFTs
•
DPL
high sensitivity• CT scandiagnostic procedure of choice
• US?? FAST??
• MRI ??
• Angiography: active bleeding embolization
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I-Subcapsular hematoma<1cm, superficial
laceration<1cm deep.
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II-Parenchymal laceration 1-3cm deep, subcapsular
hematoma1-3 cm thick.
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III-Parenchymal laceration> 3cm deep and
subcapsular hematoma> 3cm diameter.
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IV-Parenchymal/supcapsular hematoma> 10cm
in diameter, lobar destruction
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V- Global destruction or devascularization of the liver.
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VI-Hepatic avulsion
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• BLS:
– High flow oxygen – Position of comfort
– Assist with ALS
procedures
– Transport
• ALS:
– Monitor Cardiac Rhytm
– Venous access
• Treat shock
• Treat abdominal pain
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• 86% of liver injuries stopped bleeding by the
time of surgical exploration• 67% of operations performed are
nontherapeutic
• More serious injuries (Grade III,IV) have been
successfully managed without surgery• Past VS now treatment 86% VS 67%
• CT scan diagnosis and follow up
• HCU?????
BLS
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Thank U
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INTRA ABDOMINAL INFECTION
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PHYSIOLOGY
A. Peritoneal fluids: 50- 100
ml, f luid absorbed by mesothelial
lining cells and sub-diaphragmatic
lymphatics, fluid exchange isaffected by splanchnic bld flow &
factors that alter permeability
(intra-peritoneal inflam.)
B. Peritoneal fluid flow: Forcesthat governs movement of fluids
by gravity & negative pressure.
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C. Peritoneal defense mechanism:1. Peritoneal injury: Inflammationloss
mesothelial cells
2. Adhesion formation: Forms when
platelets and fibrin come in contact w/exposed basement membrane
3. Peritoneal defense against intra-abdominal infection: Mechanicalclearance of bacteria via lymphatics &
p hagocytic killing of bacteria by immune
cel ls .
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Clinical History: – Length of time pt is ill
– Chills and fever, anorexia
– May have signs dehydration/shock
– Diminish bowel sound – Pain:
• Visceral pain – due to distention ortraction of hallow viscus dull, poorlylocalized, crampy
• Somatic pain – well localized, painsensitive to stretch, light touch andcutting associated w/ tenderness andinvoluntary muscle spasm
Diagnosis
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Laboratory test:1. CBC / Differential count
2. Serum electrolyte/creatinine/liver profile3. Radiological techniques:
FPA : a) pneumoperitoneum
b) intestinal pneumatosis
c) bowel obstruction
d) widening of the space between loopse) mass effect – indicative of abscess
f) obliterated psoas shadow
Ultrasonography:Diagnostic and therapeutic (Aspiration for culture of
peritoneal fluid)
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Management
• BLS:
– High flow oxygen – Position of comfort
– Assist with ALS
procedures
– Transport
• ALS:
– Monitor
– Venous access
• Treat shock
• Treat abdominal pain
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Parts of treatment:
Pre-operative preparation:1. Intravascular volume loading
• Low dose of Dopamine improve renal bld
flow2. High O2 conc. until intravascular vol. is restored
3. Assess respiratory function (ABG) :
• Ventilatory support:
1. PaCO2 of 50mmHg or greater
2. PaO2 below 60mmHg hypoxemia
3. Shallow rapid respirations, muscle fatigue oruse of accessory muscles of respiration
Management
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4. Administration of Broad Spectrum
Antibiotic
5. NGT to evacuate the stomach and
prevent vomiting6. NPO
7. Relieve pain ONCE DECISION to
operate has been made: morphine IV
1-3 mg q 20-30 min8. Monitor V/S & hemodynamic :Urine
output monitoring – foley catheter
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Problems???• Performed USG?
• Performed X-Ray without NGT?
• PD? not meticulous
– Not exposed abdomen
– Have “a scar”? Thank U
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Radiology
Thank_U
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