First Aid For Surgery - Acute Abdomen And Sicu

Front 1

Acute Abdomen: Definition

Back 1

Abrupt onset of abdominal pain usually accompanied by one or more peritoneal signs (i.e., rigidity, tenderness [with or without rebound] involuntary guarding). Most causes of acute abdomen are surgical.

Front 2

Visceral Pain

Back 2

Poorly localized, usually dull, achy pain arising from distention or spasm in hollow organs. Example: Crampy pain felt during early intestinal obstruction.

Front 3

Parietal Pain

Back 3

Sharp, well-localized, somatic pain arising from irritation (usually by pus, bile, urine, or gastrointestinal secretions) of the parietal peritoneum. Example: Inflamed appendix causing sharp right lower quadrant (RLQ) pain due to irritation of nearby peritoneum.

Front 4

Kehr's Sign

Back 4

Pain referred to the left shoulder due to irritation of the left hemidiaphragm. Often seen with splenic rupture.

Front 5

Fitz-Hugh–Curtis syndrome

Back 5

Perihepatitis associated with chlamydial infection of cervix.

Front 6

LLQ Pain

Back 6

(1) Sigmoid diverticulitis; (2) Volvulus

Front 7

LUQ Pain

Back 7

(1) Splenic rupture; (2) Splenic abscess

Front 8

Diffuse Pain

Back 8

(1) Bowel obstruction; (2) Leaking aneurysm; (3) Mesenteric ischemia

Front 9

Periumbilical Pain

Back 9

(1) Early appendicitis; (2) Pain from SBO

Front 10

RUQ Pain

Back 10

(1) Perf duodenal ulcer; (2) Acute cholecystitis; (3) Hepatic abscess; (4) Retrocecal appendicitis; (5) Appendicitis in pregnant women

Front 11

RLQ Pain

Back 11

(1) Appendicitis; (2) Cecal diverticulitis; (3) Meckel's diverticulitis with intussusception

Front 12

Suprapubic Pain

Back 12

(1) Ectopic pregnancy; (2) Ovarian torsion; (3) Tubo-ovarian abscess; (4) Psoas abscess; (5) Incarcerated groin hernia

Front 13

Possibility of MI-related pain

Back 13

Get an EKG on all patients presenting with midepigastric pain!

Front 14

Important NON-SURGICAL CAUSES of abdominal pain

Back 14

(1) MI; (2) Mittelschmerz; (3) Poisoning (lead, black widow spider); (4) Herpes zoster; (5) RLL pneumonia; (6) Endocrine (Addisonian crisis, DKA); (7) Sickel cell crisis; (8) Porphyrias; (9) Psychological (hysteria)

Front 15

Shock - basics

Back 15

If the skin is warm, it is distributive shock. If the skin is cold and clammy, it is hypovolemic or cardiogenic shock. Shock with bradycardia is neurogenic unless proved otherwise.

Front 16

Why are the kidneys affected first in "cold shock"

Back 16

Of the vital organs, the first “casualty” of hypovolemic or cardiogenic shock (both “cold shocks”) is the kidneys, as blood is shunted away from the constricted renal arteries. Therefore, it is crucial to monitor for renal failure. An adequate urine output is one of the crucial signs that the treatment is adequate.

Front 17

Why LR instead of NS for large volume resuscitations?

Back 17

(1) Large-volume NS infusion may result in hyperchloremic acidosis; therefore, LR (containing alternative anions to Cl-) is the preferred choice

Front 18

First symptom in hypovolemic shock?

Back 18

Tachycardia is the first symptom in hypovolemic shock. Beta blockers suppress this!

Front 19

Adequate UOP = ?

Back 19

Adequate (at minimum) urine output is 0.5 cc/kg/hr = 35 cc/hr for average 70-kg person.

Front 20

Distributive shock

Back 20

A family of shock states that are caused by systemic vasodilation (i.e., severe decrease in SVR). They include septic shock (most common), neurogenic shock, and anaphylactic shock. These patients will have warm skin from vasodilation.

Front 21

Poor prognostic signs in septic shock

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(1) DIC; (2) Multi-organ failure. NOTE: it is a continuum: SIRS → Sepsis → Severe Sepsis → Septic Shock

Front 22

If blood pressure is unresponsive to fluids…what is next?

Back 22

Pressors, classically norepinephrine (Levophed)

Front 23

Anaphylactic shock

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Systemic type I hypersensitivity reaction causing chemically mediated angioedema and increased vascular permeability, resulting in hypotension and/or airway compromise.

Front 24

Treatment of anaphylactic shock

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(1) Epi; (2) Antihistamines; (3) Steroids

Front 25

Neurogenic shock

Back 25

Central nervous system (CNS) injury causing disruption of the sympathetic system, resulting in unopposed vagal outflow and vasodilation. It is characterized by hypotension and bradycardia (absence of reflex sympathetic tachycardia and vasoconstriction). Usually secondary to spinal cord injury of cervical or high thoracic region.

Front 26

Cardiogenic shock

Back 26

Pump failure, resulting in decreased cardiac output (CO). This can be caused by myocardial infarction (MI), arrhythmias, valvular defects, cardiac contusion, or extracardiac obstruction (tamponade, pulmonary embolism, tension pneumothorax). Wedge pressure and SVR are elevated.

Front 27

Findings with cardiogenic shock

Back 27

Patients will have cold, clammy skin from peripheral vasoconstriction. Additionally, they will have jugular venous distention (JVD), dyspnea, bilateral crackles, and S3/4 gallop. Chest x-ray (CXR) will show bilateral pulmonary congestion. Echocardiography demonstrates poorly contractile left ventricle, pulmonary capillary wedge pressure (PCWP) > 20 mmHg, cardiac index (CI) < 2.0.

Front 28

Classic findings in spinal shock

Back 28

Classic findings in spinal shock: Hypotension, bradycardia, and absence of rectal tone on digital rectal examination.

Front 29

Intra-aortic balloon pump (IABP)

Back 29

Used as mechanical support in patients who do not respond to pressors or inotropes. IABP increases CO, and decreases work of heart by reducing systolic afterload and increasing diastolic perfusion to coronary arteries; device can be inserted via femoral artery at ICU bedside

Front 30

First physical exam and EKG finding of PE is what?

Back 30

TACHYCARDIA! Classic EKG findings: S1Q3T3: S wave in lead I, Q wave and T wave inversion in lead III

Front 31

Pulmonary artery occlusion pressure (PAOP or PCWP)

Back 31

Reflects pressures of left ventricle (end-diastolic pressure). Can be thought of as preload. Clinical Context: If pump fails, pressures in left ventricle increase and have increased wedge

Front 32

What is the significance of the wedge pressure?

Back 32

Reflects left ventricular pressure, which will be increased with left ventricular failure

Front 33

Alpha agonists: PHENYLEPHRINE, METHOXAMINE

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a1 > a2 >>>>> beta

Front 34

Alpha agonists: CLONIDINE, METHYLNOREPINEPHRINE

Back 34

a2 > a1 >>>>> beta

Front 35

Mixed alpha and beta agonists: NOREPINEPHRINE

Back 35

a1 = a2; b1 >> b2

Front 36

Mixed alpha and beta agonists: EPINEPHRINE

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a1 = a2; b1 = b2

Front 37

Beta agonists: DOBUTAMINE

Back 37

b1 > b2 >>>>>> alpha

Front 38

Beta agonists: ISOPROTERENOL

Back 38

b1 = b2 >>>>>> alpha

Front 39

Beta agonists: TERBUTALINE, ALBUTEROL, RITODRINE

Back 39

b2 > b1 >>>>>> alpha

Front 40

Dopamine agonists: DOPAMINE

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D1 = D2 >> beta >> alpha

Front 41

Dopamine agonists: FENOLDOPAM

Back 41

D1 >> D2

Front 42

Milrinone

Back 42

Not technically a pressor, but important inotrope that is a phosphodiesterase inhibitor, resulting in increased cyclic AMP, thus having positive inotropic effects on heart and also causing vasodilation; increases CO, decreases SVR

Front 43

Low-dose dopamine

Back 43

Stimulation of dopamine receptors (dilates renal vasculature) and mild beta1 stimulation. NOTE: The concept of low-dose dopamine’s being a “renal dose” and helping perfuse the kidney has been debunked. It dilates the vasculature, but no evidence shows that it is renal protective or improves renal failure.

Front 44

Intermediate-dose dopamine

Back 44

Stimulation of dopamine receptors , moderate stimulation of beta1 receptors (heart inotropy/chronotropy), and mild stimulation of alpha1 receptors (vasoconstriction). Results in increased CO

Front 45

Pressor of choice in septic shock

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Vasopressin!

Front 46

Indications for intubation

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(1) GCS < 8 with poor airway protection; (2) Failure to oxygenate: hypoxia despite high O2 delivery content and clinical signs of respiratory distress; (3) Failure to ventilate leading to progressive hypercapnia with acidosis and signs of mental status change

Front 47

Complications of mechanical ventilation

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(1) Ventilator-associated pneumonia; (2) Barotrauma and tension pneumothorax; (3) Decreased venous return (preload) and cardiac output

Front 48

When is PEEP used?

Back 48

PEEP is used primarily in congestive heart failure (CHF) or acute respiratory distress syndrome (ARDS). It maintains alveoli open, allowing more time for gas exchange. It is therefore used to increase the oxygen level. Problems with PEEP include hypotension (decreases preload).

Front 49

ARDS

Back 49

Acute lung injury due to inflammatory process in both lungs causing increased permeability of the capillaries and severe ventilation/perfusion mismatch. ARDS is a disease of altered lung compliance. These patients are tachypneic and hypoxic and have bilateral crackles on lung exam.

Front 50

Diagnostic criteria for ARDS

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(1) Bilateral fluffy infiltrates on CXR; (2) PaO2/FiO2 ratio <200; (3) No evidence of heart failure (PCWP < 18mmHg); (4) Acute onset; (5) Presence of an underlying cause

Front 51

Causes of ARDS

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(1) Direct lung injury: pneumonia, aspiration, near drowning; (2) Indirect causes: sepsis [MC of all causes], massive transfusion, severe trauma/toxins/burns, pancreatitis

Front 52

PCWP and ARDS vs CHF

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PCWP < 18 is ARDS; PCWP > 18 is CHF

Front 53

Management of ARDS

Back 53

(1) Intubate; (2) Treat underlying cause; (3) Low tidal volume ventilation!; (4) Use PEEP to improve gas exchange and keep lungs open at relatively low volumes; (5) FiO2 < 60% to avoid free radical injury