trauma/acute care surgery EOR

- PUD (gastric vs duodenal)

- GERD

- pancreatitis

what should the differential be for epigastric pain

acute MI

- chest pain/discomfort

- SHOB

- sweating

- n/v

- pain radiating to jaw, neck, arm

acute pancreatitis

- acute onset of persistent upper abd pain radiating to the back

- n/v

- abd tenderness

- fever

- tachycardia

chronic pancreatitis

- epigastric pain radiating to the back

- hx of chronic alcohol use or gallstones

PUD

- burning or gnawing epigastric pain related to meals

- bloating

- early satiety

- nausea

- epigastric dicomfort

gastric: worse with eating

duodenal: relieved by eating

what is the difference in gastric and duodenal ulcers

GERD

- heartburn

- regurgitation

- dysphagia

- epigastric discomfort

gastritis/gastropathy

- epigastric discomfort or pain

- nausea/vomiting

- bloating

- feeling of fullness after eating

- possible GI bleeding such as hematemesis

functional dyspepsia

- postprandial fullness

- early satiaiton

- epigastric pain

- burning

gastroparesis

- n/v

- abd pain

- early satiety

- postprandial fullness

- bloating

DM, post surgical vagal n injury, hypothyroidism, scleroderma, meds (opioids, anticholinergics)

what is gastroparesis associated with

biliary colic

- sudden, intense epigastric or RUQ pain after fatty meals

- may radiate to the right shoulder or back with n/v

gastric volvulus

- severe epigastric pain

- unproductive retching

- inability to pass a NG tube

- abd distension

mallory weiss tear

- vomiting followed by bright red blood

- epigastric or back pain

- possible signs of shock

- cholecystitis

- biliary colic

- hepatitis or liver pathology

what should your differential be for RUQ pain

gallstone temporarily obstructs the cystic duct leading to episodic pain

what causes biliary colic

acute cholecystitis

- prolonged (>4-6hrs) RUQ or epigastric pain

- fever, n/v

- abd guarding

- +Murphys sign

acute cholangitis

- charcots triad: fever, jaundice, RUQ pain

- may profress to reynolds pentad: hypotension and AMS

sphincter fails to relax properly or has increased tone, leading to obstruction and buildup of pressure in bile duct, pancreatic duct, or both

what causes sphincter of oddi dysfunction

sphincter of oddi dysfunction

- RUQ pain similar to other biliary pain

- often postprandial

- without clear etiology

acute hepatitis

- RUQ pain

- fatigue, malaise, n/v, anorexia

- jaundice, dark urine, light colored stools

perihepatitis (fitz-hugh-curtis)

inflammation of liver capsule associated with PID

perihepatitis

- RUQ pain with pleuritic component

- pain may radiate to R shoulder

- often associated with PID

liver abscess

- RUQ pain

- fever, chills, weight loss, malaise, abd pain

budd chiari syndrome

- fever

- RUQ pain

- abd distension (ascites)

- jaundice

- lower extremity edema

- GI bleeding

- hepatic encephalopathy

portal vein thrombosis

- abd pain

- GI bleeding

- dyspepsia

- signs of portal hypertension (ascites, splenomegaly)

liver tumors

- dull RUQ pain

- weight loss, anorexia

- jaundice

- abd swelling

- hepatomegaly

choledocholithiasis

- RUQ pain

- jaundice, dark urine, pale stools

- pruritus

- elevated liver enzymes

presence of gallstones in common bile duct

what is choledocholithiasis

perforated ulcer

- severe, sudden abd pain with signs of peritonitis (rigid abd, tenderness)

- possible shoulder pain from diaphragmatic irritation

pancreatitis

- severe epigastric pain radiating to the back

- n/v

- abd tenderness

- fever

- tachycardia

gastritis

- epigastric discomfort or pain

- n/v, bloating

- possible GI bleeding

pyelonephritis

- flank pain

- fever, chills

- painful urination, frequent urinartion, cloudy urination

nephrolithiasis

- sharp flank pain radiating to the groin

- RUQ pain

- hematuria

- n/v

- restlessness

appendicitis in pregnancy

- RUQ pain due to displacement of appendix

- n/v, fever, anorexia

PE

- sudden SHOB

- chest pain that may present as RUQ pain

- rapid heart rate

- hemoptysis

- anxiety

pericarditis

- sharp CP that improves when sitting up and leaning forward

- fever, palpitations, SHOB

- splenic injury

- gastritis or PUD

- pancreatitis especially if tail of pancrease involved

what should be on the differential of LUQ pain

splenic injury

- LUQ pain and tenderness

- left shoulder pain (kehr's sign)

- dizziness, low blood pressure

- often due to trauma

splenic abscess

- LUQ pain

- fever, chills, abd distension

- possible left sided pleural effusion

splenic artery aneursym

- LUQ pain

- sudden rupture can cause pain, hypotension, signs of hypovolemic shock

dissecting AA

- sudden, severe chest or back pain described as tearing or ripping

- possible abd pain, signs of shock

hiatal hernia

- chest or epigastric pain

- difficutly swallowing

- reflux symptoms

- possible vomiting blood

boerhaave's syndrome

- severe chest and upper abd pain after forceful vomiting

- subcutaneous emphysema (air underneath skin)

- rapid onset of shosck

boerhaave's

life threatening condition characterized by spontanerous esophageal rupture, typically following severe vomiting or retching, leading to mediastinitis

- diverticulitis

- ovarian pathology (ovarian torsion, cyst rupture)

- infectious colitis

what should be on the differential for LLQ pain

diverticulitis

- steady LLQ pain

- fever, chills

- changes in bowel habits (constipation or diarrhea)

- tenderness and possible palpable mass

UTI

- lower abd discomfort

- painful uriantion

- frequent urge to urinate

- cloudy or strong smelling urine

IBD

- abd pain

- chronic diarrhea

- weight loss

- fatigue

- urgency to defecate

colon cancer

- LLQ pain

- changes in bowel habits

- blood in stool

- unexplained weight loss

- anemia

SBO

- crampy abd pain

- vomiting

- abd distention

- constipation

- high pitched bowel sounds

sigmoid volvulus

- abd distension

- pain

- constipation

- vomiting

- inability to pass gas

- tympanic abd upon percussion

- appendicitis

- ovarian pathology

- mesenteric adentitis (kids) or infectious ileitis

what should be on the differential for RLQ pain

mesenteric lymphadenitis

- RLQ pain following an upper respiratory infection

- fever

- enlarged abd lymph nodes

- symptoms mimicking appendicitis

cecal diverticulitis

- RLQ pain

- fever

- n/v

- tenderness similar to diverticulitis on left side

meckels diverticulum

- RLQ pain

- painless rectal bleeding

- signs of intestinal obstruction

- possible perforation

intussusception

- intermittent severe crampy abd pain

- vomiting

- currant jelly stools

- palpable sausage shaped mass

ovarian cysts/torsion

- sudden RLQ or pelvic pain that is often severe

- n/v

- possible menstrual irregularities

PID

- RLQ or pelvic pain

- fever

- abnormal vaginal discharge

- pain during intercourse

- irregular menstrual bleeding

hernia

- RLQ or groin pain

- worsened by activity or straining

- palpable bulge

confusion

reduced mental clarity and reasoning

drowsiness

difficultly being aroused and cannot sustain alertness

lethargy

depressed awareness of self and surroundings

stupor

aroused only with vigorous stimuli with some avoidance of discomfort

coma

unarousable, no purposeful response to stimuli

delirium

acute, fluctuating cognition with imparied attention/consciousness

- alcohol, acidosis

- electrolyte, endocrine

- infeection

- overdose, oxygen deficiency

- uremia

- trauma, tumor

- insulin (hypoglycemia, hyperglycemia)

- psychiatric, poisoning

- stroke, seizure, shock

what are the causes of altered mental status (AEIOU-TIPS)

hypovolemic shock

significant loss of intravascular volume leading to decreased perfusion and oxygen delivery

tachycardia, hypotension, and cool, clammy skin

what are the sx of hypovolemic shock

cardiogenic shock

hearts inability to pump effectively resulting in decreased cardiac output and perfusion

hypotension, pulmonary edema, and elevated JVP

what are the sx of cardiogenic shock

MI, HF, arrhthymias

what can cause cardiogenic shock

distributive shock

systemic vasodilation, leading to relative hypovolemia and poor perfusion

warm, flushed skin, tachycardia, hypotension

what are the sx of distributive shock

most commonly septic shock due to profound vasodilation (also anaphylactic and neurogenic shock)

what cases distributive shock

septic shock

overwhelming infection, causing systemic vasodilation and increased capillary permeability

anaphylactic shock

severe allergic reaction leading to widespread vasodilation, bronchospasm, and increased capillary leakage

neurogenic shock

results from spinal cord injury causing unopposed parasympathetic activity and vasodilation

obstructive shock

impaired blood flow due to a mechanical obstruction reducing cardiac output and perfusion

not a source of hypovolemic shock

what is true about closed head injury

30-40% blood loss

hypotensive in a supine position suggests

immediate OR

a pt presenting with signs of shock and peritonitis means

hemodynamically stable pts with CT blush

when should splenic embolization be utilized

ideally 2 wks postop or before discharge

when do you vaccinate against encapsulated bacteria after splenectomy

mesenteric artery bleeding, small bowel injury, or bladder rupture

what should be considered with free fluid in the abdomen without solid organ injury

acute blood loss and for symptomatic anemai

when are blood transfusions indicated

1 unit of PRBCs at a time

in the absence of acute hemorrhage, what is preferred

1g/dl

one unit of PRBCs raises the hemoglobin by

coagulation factors are needed

- cardiopulmonary bypass, massive transfusion, DIC, advanced liver disease

FFP is best used when

plt deficiency or other dysfunction

when are plt transfusions indicated

fibrinogen, fibronectin, factor VIII, vWF, and factor XIII

what does cryoprecipitate contain

acute DIC or in cases of massive blood loss

when is cryoprecipitate used