pp acute abdome

8/21/2019 PP Acute Abdome

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CUTEBDOMEN



• 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!!!



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



• 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



• Mechanical Obstruction

• Internal Bleeding

• Generalize Peritonitis

3



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



• More common

• Vomiting bilious early

• Bowel sounds high pitched

early, but diminishes withtime

• Pain periumbilical crampyand intermittent

• May have signsdehydration/shock

Small Bowel Obstruction



Hernia



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



Problems???• Performed USG?

• Performed X-Ray without NGT?

•

PD?

not meticulous – Not exposed abdomen

– Have “a scar”? Thank U



Internal Bleeding

Liver Trauma



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.



• Isolated liver injury occurs in lessthan 50% of patients.

• Blunt trauma 45% with spleen

• Rib fracture 33% with Liverinjury



• 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



• Elevated LFTs

•

DPL

high sensitivity• CT scandiagnostic procedure of choice

• US?? FAST??

• MRI ??

• Angiography: active bleeding embolization



I-Subcapsular hematoma<1cm, superficial

laceration<1cm deep.



II-Parenchymal laceration 1-3cm deep, subcapsular

hematoma1-3 cm thick.



III-Parenchymal laceration> 3cm deep and

subcapsular hematoma> 3cm diameter.



IV-Parenchymal/supcapsular hematoma> 10cm

in diameter, lobar destruction



V- Global destruction or devascularization of the liver.



VI-Hepatic avulsion



• BLS:


– Assist with ALS

procedures

– Transport

• ALS:

– Monitor Cardiac Rhytm

– Venous access

• Treat shock




• 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



Thank U



INTRA ABDOMINAL INFECTION



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.



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 .



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



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)



Management

• BLS:


– Assist with ALS

procedures

– Transport

• ALS:

– Monitor

– Venous access

• Treat shock




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



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



Problems???• Performed USG?

• Performed X-Ray without NGT?

• PD? not meticulous

– Not exposed abdomen

– Have “a scar”? Thank U



Radiology

Thank_U

pp acute abdome

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