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Abdominal Emergencies

Didactics

A 7 yo boy presents to the ED with right sided abdominal pain, vomiting and decreased appetite x 2 days. ROS negative for diarrhea or rash. On exam, patient with rebound tenderness and gaurding.

T38.4 C, HR 115, bp 88/50

Differential

Differential

Appendicitis

Incarcerated inguinal hernia

Testicular Torsion

Meckels Diverticulum

Constipation

Gastroenteritis

Foreign body

Volvulus

Appendicitis

Peak age onset is 12 yo, unusual in kids < 2 yo

Temporary relief of pain followed by fever, rebound and gaurding may be indicative of rupture

positive Rovsing sign (pain in RLQ w/left sided palpation)

positive Iliopsoas sign (RLQ pain w/hip extension

Imaging

Non compressible appendix > 6mm in diameter is diagnostic

Perforated appendix may be compressible with free fluid visualized

If not visualized on ultrasound, obtain CT scan

Features include thickened wall > 2mm

Management

Morphine 0.05 mg/kg, max 5 mg/dose for moderate to severe pain

Ceftriaxone 75 mg/kg

Metronidazole 30 mg/kg

Labs: CBCdiff, BMP, UA, CRP, upreg

Fluids fluids fluids and +/- pressors for hemodynamically unstable patient

A 15 yo female is presents to the emergency department with left sided abdominal pain and groin pain x 2 days. She denies fever or recent changes in stool pattern, but does complain of nausea and 4 episodes of vomiting. Pain is sharp, crampy. Denies medicatons.

Vitals: AF, HR 95, bp 119/77.

Physical exam with tender palpable mass in LLQ, but no rebound tenderness or guarding.

Differential

Differential

Ovarian Torsion

Ectopic Pregnancy

Ruptured Ovarian Cyst

Kidney Stone

Teratoma

Constipation

Ovarian Torsion

Complete or partial rotation of the ovary on its ligamentous supports

Risk factors include ovarian mass or cyst , especially is cysts > 5 cm in diameter

Patients may have palpable adenexal mass

Hemmoraghic infarction and necrosis 2/2 to vascular compromise can occur within hours

Diagnosis w/ultrasound or CT Scan

  • > 4 cm considered enlarged
  • Variable echogenicity, however a more longstanding torision may have cystic appearance and surrounding edema

  • Doppler findings can be variable, but absent venous flow is most common

Ultrasound

Treatment is rapid surgical detorsion, within 8 hours

Support hemodynamics with fluid resuscitation

Obtain CBC diff, CMP, type and screen, consider STI Testing, upreg

Adequate pain control with IV analgesics

Management

Ectopic Pregnancy

Similar presentation with lower qaudrant pain

May have palpable adenexal mass

If suspected obtain upreg, serum beta HCG, CBC, type and screen

Stat IV access with fluid resuscitation

Beta HCG >2000 should be able to visualize prenancy on ultrasound

Ultrasound

Phased Array probe with indicator pointing to patients head

Place probe right above pubic symphsis

Identify bladder and fan to either side

Pelvic Fast

A 6 yo male with autism is brought to the emegency department with acute onset vomiting that began 2 hours ago. Emesis initially NB, but now blood tinged. Patient lives with grandmother who reports that patient appears more sleepy. On exam patient arousable with painful stimuli, pupils equal and reactive, epigastric tenderess without rebound/gaurding, hypoactive bowel sounds. Vitals: AF, HR 110, RR 36, bp 100/60

Differential

Ingestion

Peptic Ulcer

Gastroenteritis

Volvulus

Obstruction

Pancreatitis

Ingestion

Support ABCs

Stat VBG

Lab work up generally broad: CBCdiff, BMP, Mg, phos, EKG, Utox, serum tylenol, serum salicylate, serum alcohol

XR can be helpful with radiopaque pills

CHIPES (Calcium carbonate, Heavy metal - lead, Iron, Phenothiazines, Enteric coated pills, Sustained release preparations)

GI Decontamination

Most common GI decontamination

Used in about 5% of ingestions

Most benefit if adminstered within 1 hour of ingestion

Risk of aspiration is biggest contraindication, especially with altered or depressed mental status

Contradicated in alcohol ingestion

Activated Charcoal

Whole bowel irrigation considered when extended release of toxin is anticipated. Requires a large amount of electrolyte solution (miralax) in the stomach. Contraindicated with airway compromise, ileus, bowel obstruction.

Ipecac no longer in use with ingestions

Gastric lavage ideal for very recent ingestion <1 hour of potentially lethal substance

additional

An 8 yo male presents to the emergency department after a motor vehicle accident. Patient was restrained, vehicle traveling 40 mph. On physical exam, patient with abdominal tenderness and epigastric bruising.

GCS 12, Vitals AF, HR 115, RR 30, 100/50

FAST EXAM

Evaluates pericardium and three potential spaces for fluid collection

Phased array probe, great for deep structures

FAST

RUQ

Start between rib space 8-11 with probe marker to patients head

Slide transducer caudally until liver edge and kidney pole visualized

Free fluid (black) will most likely collect in Morrison's pouch, a potential space between liver and kidney

RUQ

LUQ

Inspects splenorenal recess

Similar positioning of probe and downward sliding motion as RUQ

LUQ

Hemorrhagic Shock

Classification

Blunt abdominal trauma

Trauma

Spleen and liver most commonly injured organs

Can present with abdominal ecchymosis --> seatbelt sign

Obtain labs CBC, lipase, LFTs and preform FAST exam on any patient with suspected internal injury

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