Surgery E.O.R. Trauma and Acute Care

Acute Abdomen

sudden onset of severe abdominal pain that requires urgent evaluation and often surgical intervention

Right Hypochondraic

(1)

gallstones

cholangistis

hepatitis

live abscess

cardiac abscess

lung causes

Epigastric

(2)

esophagitis

peptic ulcer

perforated ulcer

pancreatitis

GERD

Left Hypochondraic

(3)

spleen abscess

acute splenomegaly

spleen rupture

Right Lumbar

(4)

ureteric colic

pyelonephritis

Umbilical

(5)

appendicitis

mesenteric lymphadenitis

meckel diverticulitis

lymphomas

Left Lumbar

(6)

ureteric colic

pyelonephritis

Right Iliac

(7)

appendicitis

Crohn disease

cecum obstruction

ovarian cyst

ectopic pregnancy

hernias

Hypogastric

(8)

testicular torsion

urinary retention

cystitis

placental abruption

Left Iliac

(9)

diverticulitis

ulcerative colitis

constipation

ovarian cysts

hernias

MCC of Acute Abdomen Requiring Surgical Intervention

appendicitis -- most frequent

cholecystitis

perforated peptic ulcer

intestinal obstruction

diverticulitis

ectopic pregnancy

acute mesenteric ischemia

trauma

perforated diverticulum

Cholecystitis

inflammation of gallbladder, due to gallstones

Perforated PUD

results in peritonitis from gastric or duodenal perforation

Intestinal Obstruction

adhesions, hernias, or tumors

Diverticulitis

complicated by abscesses, perforation, or obstruction

Ectopic Pregnancy

emergency surgery

signs: gradually worsening pelvic pain +/- vaginal bleeding/spotting; often >6 weeks pregnant

PE findings: adnexal tenderness/mass, rebound/guarding in pelvic regions

diagnostics: serum hCG, TVUS, +/- Rhogam

management: laparoscopic salpingostomy (ruptured) or methotrexate (unruptured)

Acute Mesenteric Ischemia

arterial or venous occlusion

signs: sudden severe abdominal pain, pain out of proportion to the exam, usually in older adults (W>M)

PE findings: abdomen soft, non-distended, extreme pain

diagnostics: laparotomy for necrosis

management: anticoagulation (if no active bleeding), antibiotics

Trauma

blunt or penetrating leading to organ damage

Perforated Diverticulum

generalized peritonitis

Clinical Presentation of Acute Abdomen

sudden, severe, sharp/stabbing abdominal pain (location and nature dependent on underlying condition)

N/V, fever, anorexia, D/C (dependent of etiology)

peritoneal signs (rebound tenderness, guarding, rigidity)

distention and absent bowel sounds (obstruction)

hemodynamic instability (hemorrhage or sepsis)

Life-Threatening Acute Abdomen Etiologies

AAA dissection

bowel obstruction/volvulus

ectopic pregnancy

mesenteric ischemia

myocardial infarction

perforation of GI tract

splenic rupture

AAA Dissection

signs: severe abdominal or flank pain described as "ripping" or "tearing" sensation radiating to back, common in elderly

PE findings: hypotension, tachycardia, guarding/rebound, pulsatile mass

diagnostics: CT angiography

management: endovascular repair if stable

Bowel Obstruction/Volvulus

signs: vomiting, generalized abdominal pain and distention, constipation, hx of abdominal surgery

PE findings: vomiting + feculent material, tinking or absent bowel sounds

diagnostics: abdominal X-ray, CT AP w/contrast

management: bowel rest or surgical intervention

Myocardial Infarction

epigastric pain

signs: crushing, pressure-like chest pain worsened by exertion, radiating to jaw or left arm, N/V, dyspnea

PE findings: diaphoretic, clutching chest or upper abdomen (Levine sign)

diagnostics: EKG, troponin

management: MONA (morphine, oxygen, NTG, ASA), PCI or fibrinolysis

Perforation of GI Tract

signs: severe generalized abdominal pain +/- fever, signs of hematochezia, melena, or hematemesis

PE findings: firm abdomen with generalized tenderness, rebound, guarding

diagnostics: erect CXR (free air), CT AP w/contrast

management: surgical repair of cause

Splenic Rupture

signs: LUQ pain +/- rebound or guarding; hx of blunt trauma or splenomegaly

PE findings: LUQ tenderness, Kehr sign (left shoulder pain from blood)

diagnostics: FAST exam, CT AP w/contrast

management: laparotomy with splenectomy or embolization

Rapid Onset Severe, Constant Pain

Gradual, Steady Pain

Abrupt, Excruciating Pain

Intermittent, Colicky Pain, Crescendo + Pain-Free Intervals

Acute Pancreatitis

epigastric pain

acute-onset, persistent upper abdominal pain radiating to the back, accompanied by nausea, vomiting, abdominal tenderness, fever, and rapid heartbeat

Chronic Pancreatitis

epigastric pain radiating to the back, often with a history of chronic alcohol use or gallstones

Peptic Ulcer Disease (PUD)

epigastric pain

burning or gnawing epigastric pain related to meals (worse with eating in gastric ulcers, relieved by eating in duodenal ulcers), bloating, early satiety, nausea, and epigastric discomfort

Gastroesophageal Reflux Disease (GERD)

epigastric pain

associated with heartburn, regurgitation, dysphagia, and epigastric discomfort

Gastritis/Gastropathy

epigastric pain

epigastric discomfort or pain, nausea, vomiting, bloating, feeling of fullness after eating, and possible gastrointestinal bleeding such as hematemesis

Functional Dyspepsia

epigastric pain

one or more of the following: postprandial fullness, early satiation, epigastric pain, or burning

Gastroparesis

epigastric pain

N/V, abdominal pain, early satiety, postprandial fullness, and bloating; associated with diabetes mellitus, post-surgical vagal nerve injury, hypothyroidism, scleroderma, and medications (e.g. opioids, anticholinergics)

Biliary Colic

epigastric pain

sudden, intense epigastric or right upper quadrant pain after fatty meals; may radiate to the right shoulder or back, with nausea and vomiting

Gastric Volvulus

epigastric pain

severe epigastric pain, unproductive retching, inability to pass a nasogastric tube, and abdominal distension

Mallory-Weiss Tear

epigastric pain

vomiting followed by bright red blood (hematemesis), epigastric or back pain, and possible signs of shock

Biliary Colic

right upper quadrant pain

occurs when a gallstone temporarily obstructs the cystic duct, leading to episodic pain

intense, dull discomfort in the RUQ or epigastrium; associated with nausea, vomiting, diaphoresis; generally lasts at least 30 minutes and plateaus within an hour; benign abdominal examination

Acute Cholecystitis

right upper quadrant pain

prolonged (>4-6 hours) RUQ or epigastric pain, fever, nausea, vomiting, abdominal guarding, and positive Murphy's sign

Acute Cholangitis

right upper quadrant pain

fever, jaundice, RUQ pain (Charcot's triad); may progress to hypotension and AMS (Reynold's pentad)

Sphincter of Oddi Dysfunction

right upper quadrant pain

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

Acute Hepatitis

RUQ pain with fatigue, malaise, nausea, vomiting, anorexia, jaundice, dark urine, and light-colored stools

Perihepatitis (Fitz-Hugh-Curtis)

right upper quadrant pain

inflammation of the liver capsule associated with pelvic inflammatory disease

RUQ pain with pleuritic component; may radiate to right shoulder; associated with PID

Liver Abscess

RUQ pain, fever, chills, weight loss, malaise, and abdominal pain.

Budd-Chiari Syndrome

fever, RUQ pain, abdominal distention (from ascites), jaundice, lower extremity edema, gastrointestinal bleeding, and/or hepatic encephalopathy

Portal Vein Thrombosis

RUQ pain

abdominal pain, gastrointestinal bleeding, dyspepsia, and signs of portal hypertension (e.g., ascites, splenomegaly)

Liver Tumors

RUQ pain

dull pain, weight loss, anorexia, jaundice, abdominal swelling, and hepatomegaly

Choledocholithiasis

RUQ pain

presence of gallstones in common bile duct

jaundice, dark urine, pale stools, pruritus, elevated liver enzymes

Confusion

Reduced mental clarity and reasoning

Drowsiness

Difficulty being aroused; cannot sustain alertness

Lethargy

Depressed awareness of self and surroundings

Stupor

Aroused only with vigorous stimuli; some avoidance of discomfort

Coma

Unarousable, no purposeful response to stimuli

Delirium

Acute, fluctuating cognition with impaired attention/consciousness

Hypovolemic Shock

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

tachycardia, hypotension, cool, calmmy skin

hemorrhage, dehydration, burns

Cardiogenic Shock

heart's inability to pump effectively, resulting in decreased cardiac output and perfusion

hypotension, pulmonary edema, elevated JVP

MI, heart failure, arrhythmias

Distributive Shock

systemic vasodilation, leading to relative hypovolemia and poor perfusion

warm, flushed skin, tachycardia, hypotension

spetic shock

Septic Shock

overwhelming infection, causing systemic vasodilation and increased capillary permability

severe bacterial infection

Anaphylactic Shock

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

Neurogenic Shock

spinal cord injury, causing unopposed parasympathetic activity and vasodilation

high spinal cord injury

Obstructive Shock

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

symptoms based on underlying cause

tension PTX, caridac tamponade, massive PE

Key Components of Risk Assessment

hypotension, tachycardia, signs of hypovolemia

need for intubation, chest tube placement, respiratory interventions

optimize comorbidities (CV disease, coagulopathy, DM)

Injury Severity Score (guide triage)

correct malnutrition

Common Perioperative Complications

hemorrhage

infection

DVT/PE

AKI, MI, resp. failure

surgical-specific complications

Hemorrhage

treat with hemostasis, transfusion, or reoperation

Manage Infection with...

perioperative antibiotics (cefazolin)

Prevent DVT/PE with...

early mobilization, mechanical compression, anticoagulation in at-risk patients

Preoperative Optimization

restore euvolemia w/crystalloids or blood products

reverse coagulopathy with FFP, vitamin K or specific agents

Spinal Procedures, Internal Fixation, Joint Replacement

common pathogens: S. aureus, S. epidermidis

antibiotics: Cefazolin, Vancomycin, Clindamycin

Antibiotic Use after Prosthetic Join Replacement

only use antibiotic prophylaxis for joint patients undergoing invasive dental procedures if patient has risk factors:

-- severely immunocompromised

-- prior prosthetic joint infection

-- poor BGL control

-- <1 year since joint replacement

Postoperative Monitoring

-- hypotension, tachycardia, hypo perfusion

-- hemoglobin, renal function, organ injuyr

-- escalate care for signs of infection, bleeding, or organ dysfunction

Anticoagulant Use

total hip or total knee = aspirin or anticoagulants

prefer DOACs over LMWH; LMWH over Warfarin

hip fracture repair = pharmacological prophylaxis (LMWH) over nonpharmacological options

Trauma/Acute Care Procedures

remember ABCDEs

resuscitative efforts begin by obtaining peripheral IV access and administering 1L IV fluids for adults and 20 mL/kg bolus for kids

Responses to Fluid Resuscitation: Vital Signs

rapid response: return to normal

tranisent response: transient improvement; recurrence of decreased BP and increased HR

minimal or no response: remain abnormal

Responses to Fluid Resuscitation: Estimated Blood Loss

rapid response: minimal (<15%)

transient response: moderate-ongoing (15%-40%)

minimal or no response: severe (>40%)

Responses to Fluid Resuscitation: Need for Blood

rapid response: low

transient response: moderate-high

minimal or no response: immediate

Responses to Fluid Resuscitation: Blood Preparation

rapid response: type and crossmatch

transient response: type-specific

minimal or no resposne: emergency blood release

Responses to Fluid Resuscitation: Need for Operative Intervention

rapid response: possibly

transient response: likely

minimal or no response: highly likely

Responses to Fluid Resuscitation: Early Presence of Surgeon

rapid response: yes

transient response: yes

minimal or no response: yes

Transfusion Indication

acute blood loss and symptomaic anemia

whole blood ideal, rarely used today; blood product selected depends on patient needs

Transfusioni Rate in Absence of Acute Hemorrhage

transfuse 1 unit of PRBCs (packed red blood cells) at a time preferred

PRBCs

raises hemoglobin by 1 g/dl

Fresh Frozen Plasma (FFP)

best used when coagulation factors are needed (i.e. cardiopulmonary bypass, massive transfusion, DIC, advanced liver disease)

Platelet Transfusion

indicated when there is a a platelet deficiency or other dysfunction

Cryopercipitate