ACUTE ABDOMEN

Treat any acute abdominal pain as life-threatening until prove otherwise. Associated hypotension, syncope or pale, cool, and clammy skin bad!. Pain for > 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, flat sunken or distended, Cullens 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 pts hand or a stethoscope. Check for rigidity, guarding, bulges, subcutaneous emphysema

3
Mechanical Obstruction Internal Bleeding Generalize Peritonitis

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

Small Bowel Obstruction

More common Vomiting bilious early Bowel sounds high pitched early, but diminishes with time Pain periumbilical crampy and intermittent May have signs dehydration/shock

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, fixed position in relation to spine prone to blunt injury Right lobe larger, closer to ribs more injury Ligamentous attachment to diaphragm and the posterior abdominal wall, shear forces during deceleration injury.

 Isolated liver injury occurs in less than 50% of patients. Blunt trauma 45% with spleen Rib fracture 33% with Liver injury

 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 scan diagnostic 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:
High flow oxygen Position of comfort Assist with ALS procedures Transport

ALS:
Monitor Cardiac Rhytm Venous access
Treat shock Treat abdominal pain

BLS
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?????

Thank U

INTRA-ABDOMINAL INFECTION

PHYSIOLOGY
A. Peritoneal fluids: 50- 100 ml, fluid absorbed by mesothelial
lining cells and sub-diaphragmatic lymphatics, fluid exchange is affected by splanchnic bld flow & factors that alter permeability (intra-peritoneal inflam.)

B. Peritoneal fluid flow: Forces

that governs movement of fluids by gravity & negative pressure.

C. Peritoneal defense mechanism:

1. Peritoneal injury: Inflammation loss
mesothelial cells

2. Adhesion formation: Forms when

platelets and fibrin come in contact w/ exposed basement membrane 3. Peritoneal defense against intraabdominal infection: Mechanical clearance of bacteria via lymphatics & phagocytic killing of bacteria by immune cells.

Diagnosis

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 or traction of hallow viscus dull, poorly localized, crampy Somatic pain well localized, pain sensitive to stretch, light touch and cutting associated w/ tenderness and involuntary muscle spasm

Laboratory test:
1. 2. 3. CBC / Differential count Serum electrolyte/creatinine/liver profile Radiological techniques: FPA : a) pneumoperitoneum b) intestinal pneumatosis c) bowel obstruction d) widening of the space between loops e) mass effect indicative of abscess f) obliterated psoas shadow

Ultrasonography:
Diagnostic and therapeutic (Aspiration for culture of peritoneal fluid)

Management
BLS:
High flow oxygen Position of comfort Assist with ALS procedures Transport

ALS:
Monitor Venous access
Treat shock Treat abdominal pain

Management
Parts of treatment: Pre-operative preparation:
1. Intravascular volume loading Low dose of Dopamine improve renal bld flow 2. 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 or use of accessory muscles of respiration

4. Administration of Broad Spectrum Antibiotic 5. NGT to evacuate the stomach and prevent vomiting 6. NPO 7. Relieve pain ONCE DECISION to operate has been made: morphine IV 1-3 mg q 20-30 min 8. 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