dr. shamim ahmad bhat consultant emergency medicine king saud medical city riyadh. ksa
TRANSCRIPT
Dr. Shamim Ahmad BhatConsultant Emergency MedicineKing Saud Medical CityRiyadh. KSA
INTRODUCTION
Types of pain Special Populations Assessment
History Examination Investigations Differential Diagnosis
Management - overview Cases ( if time permits)
Visceral
Parietal Pain
Types Of Pain
Visceral Pain
Stretching of nerve fibres of walls or capsules of organs Crampy Dull Achy
Often unable to lie still
Bilateral innervation
Parietal Pain
Parietal peritoneum irritated Usually anterior abdominal wall Localised to the dermatome superficial to the site of painful stimulus
Course
Referred Pain
Examples of referred pain?
Most Common Causes in the ED Non-specific abd pain 34% Appendicitis 28% Biliary tract dz 10% SBO 4% Gyn disease 4% Pancreatitis 3% Renal colic 3% Perforated ulcer 3% Cancer 2% Diverticular dz 2% Other 6%
WOMEN OF CHILD BEARING AGE
OLD AGE (ELDERLY PATIENTS)
Special Populations
Elderly
May lack physical findings despite having serious pathology
As patients age increases diagnostic accuracy declines
Risk of Vascular Catastrophes Assume surgical cause until proven otherwise 30-40% of geris with abdo pain need surgery Biliary tract Disease is the commonest cause Age > 65 need to think of reasons not to CT! Mortality is 7% in the over 80’s - equivalent to AMI!
Elderly Patient think Nasties! AAA Ischaemic Gut Bowel Obstruction
Diverticulitis Perforated Peptic Ulcer
Cholecystitis Appendicitis
Women of Childbearing Age Must Ascertain whether PREGNANT ALL WOMEN OF CHILDBEARING AGE WITH ABDO PAIN NEED BHCG
Gravid uterus displaces intra-abdominal organs making presentations atypical
Pregnant women still get common surgical abdominal conditions
History
What are the key points of the abdominal pain history?
History
HPC Pain
Provocative Palliative Quality Radiation Symptoms associated with
Timing Taken for the pain
Consultations/ Presentations
Associated Symptoms – Gastro – intestinal
Genito-urinary Gynaecologic
History
PMH DM HT Liver Disease Renal Disease Sexually Transmitted Infections
PSH Abdominal Surgery Pregnancies
Deliveries/ Abortions/ Ectopics Trauma
History
Meds NSAIDs Steroids OCP/ Fertility Drugs Narcotics Immunosuppressant Chemotherapy agent
ALLS Contrast Analgesic
High Yield Questions
Which came first – pain or vomiting?
How long have you had the pain? Constant or intermittent? History of cancer, diverticulosis, gall stones, Inflammatory BD?
Vascular history, HT, heart disease or AF?
Examination
Lots of information from the end of the bed Distressed vs. non distressed Lying still - peritonitis Writhing – Renal Colic
Vital Signs NEVER ignore abnormal vital signs! Always document as part of your assessment
ABDOMINAL EXAMINATION
Investigations
Bedside UE
Blood? Leucocyte Esterase and nitrites Urine HCG
ECG – anyone with upper abdominal pain or elderly
Bloods ALL WOMEN OF CHILDBEARING AGE NEED BHCG
What are your differentials? Avoid machine gun approach!
Radiology
CXR –?perforation ?Extra abdominal pathology ?Complications of intra-abdominal disease
Which of the following is NOT an indication for plain abdominal imaging?
1.Bowel Obstruction2.Constipation3.Tracking Renal Calculi4.Foreign Body
SOME INTRESTING AXRs
Other imaging
ULTRASOUND Biliary Disease Good for gynae complaints Rule out Ectopic pregnancy Appendicitis in children No radiation
CT ABDOMEN
CT is accurate for diagnosis of Renal colic Appendicitis Diverticulitis AAA Intra abdominal Abscesses
Mesenteric Ischaemia
Bowel Obstruction
Avoid repeated CT scans
Limit use in younger patients
Avoid where possible in pregnant females
Management
Resuscitate with ABC APPROACH Large bore access N Saline bolus 20ml/kg x 2 if shocked If bleeding think hypotensive resuscitation All should be NBM until provisional diagnosis Ensure normothermia
Maintenance fluids and fluid balance Analgesia doesn’t mask signs
Use a the pain scale Morphine titrated to pain. Normally 0.1mg/Kg Paracetamol adjunct NSAIDs for renal colic
Correct Electrolytes Thromboprophylaxis
Cases
Case 1
21 year old female 24 hour history of vague peri-umbilical abdominal pain.
Moved down to the RIF. Now constant and sharp. Associated with 2x vomits and feels flushed
No appetite Normal Bowels
What clinical signs may lead you to a diagnosis of appendicitis?
Lie stillRIF tendernessReboundRovsig’s signPsoas Sign
Imaging?
AXR rarely useful
USS Not as good as CT Good for female to exclude gynae pathology If appendix is visualised is useful
CT Only if there is doubt about diagnosis Sensitivity up to 98% High radiation dose Diagnose other pathology if no appendicitis Elderly
Management
NPO Analgesia Anti-emetic if necessary Maintenance fluids IVABs – e.g. Ceftriaxone, Gentamicin and Metronidazole
Surgical Referral
Case 2
40 yr old obese female RUQ pain Pain is constant nausea, vomiting fevers and chills
PMH Asthma MEDS OCP SH
Drinks 2 std / week Smokes 20/day Nil drugs
On Examination
Looks distressed. Not jaundiced T 38 C P 120 BP 100/60 RR 20 Sats 98% RA Tender in the RUQ and Murphy’s positive.
What blood Tests will you order on this patient?
HB 13.8 WCC 16.0 Neuts 12.4 Lymph 1.6
EUC Normal Bil 9 (<18) ALP 450 (30-130) GGT 320 (<60) ALT 41 (5-55) AST 30 (5-55) Amylase 28 (<120)
Lipase 40 (<60)
Management
NPO IVF IV abs –Ampicillin + Gentamicin Analgesia +- anti emetic Refer to surgeons
Case 3
52 yr old alcoholic Constant epigastric pain
radiating to the back. Worsening over the past 2 days
Improved with sitting up and forwards
Nausea and vomiting Bowels OK
PMH Chronic Airways LimitationAlcoholic Gastritis
MEDS Thiamine 100 mg daily
SH Boarding house residentDrinks 4 litres wine/daySmokes 20/day
Looks unwell and dehydrated
T38.4C P105 BP 130/70 RR 18 Sats 93% RA
Reduced AE L base
Tender Epigastrium and RUQ
No guarding/ rebound
What blood tests will you order?
Blood Results
Biochem Na 129 K 4.0 Cr 62 Ur 8.0
Amylase 1080 (<120) Lipase 950 (<60)
Bil 11 ( 18) GGT 900 (<60) ALP 200 ( < 140) AST 300 (5-55) ALT 250 (5-55) LDH 800( 105-333)
Glucose 15 Alb 23 Ca (Corr) 2.0
Haem HB 114 WCC 17 Coags Normal
What imaging will you perform ( if any)?
CXR
Imaging
CT Confirms diagnosis Identifies complications
Help’s grade severity Not always necessary in ED
USS Poor visualisation of pancreas
Good for looking at gall stones/ biliary tree dilatation
CXR Look for complications
Pleural Effusion, Atelectasis, ARDS
Management
O2 NBM IVF Analgesia +-Antibiotics (controversial) Correct Electrolytes Thromboprophylaxis ICD/Art-line/CVC depending on severity
Surgical Admit +_ ICU review
Causes
G all stones E toh T rauma S teroids M umps A utoimmune S corpion Bites H yperlidaemia/ hypercalcaemia/hypothermia E RCP D rugs
Case 4
27 yr old female 6/40 LIF constant severe sharp pain Radiating to the back Light bright red PV spotting Feels light headed
PMH IVF Previous D+C x 2 Ovarian Cysts
MEDS Nil
SH Lives with partner Non-smoker Non-Drinker
On Examination
Looks unwell. Pale, diaphoretic, restless
P 150 BP 70/40 RR 26 Sats 98% RA Tender and guarding in the LIF PV
Bright red blood spotting L adnexal tenderness ++
How do you manage this patient? Panic! ( don’t!) Call for senior help Large bore IV access x 2 (16 G or larger)
Urgent Cross Match Fluid resuscitation Call O+G urgently Needs OR immediately
Case 5
88 yr old female. Peri-umbilical, colicky abdominal pain for 2 days
Abdominal distension Vomits x 10 Reduced flatus for 2 days. PMH
Cholecystectomy appendectomy TAH BSO Hypertension
On examination
Looks distressed Lying Still T 37.5 P 110 sinus BP 150/80 RR 18 Sats 98% RA Abdomen
Distended Generally tender No guarding rebound or rigidity High pitched bowel sounds
Investigations
Investigations
Labs AXR CXR CT
Management
NPO Fluid resuscitation Monitor volume status – may have large volume shifts
Correct Electrolytes Analgesia NG if vomiting IV Abs – Ceftriaxone, metronidazole
Urgent Surgical consult for OR
Small Bowel
Adhesions Hernias Polyps Lymphoma Adenocarcinoma Gall Stones Inflammatory BD
Large Bowel
Almost never adhesions or hernia
CARCINOMA Diverticulitis Sigmoid Volvulus
Faecal Impaction
Case 6
73 yr old male presents with sudden onset of central abdominal pain radiating to the back. He also reports weakness to both legs
PMH HT Hypercholesterolemia Current smoker 30/day
MEDS Aspirin 100mg Daily Perindopril 5 mg Daily Atorvastatin 10 mg Daily
SH Lives Alone Fully independent with ALS Occasional alcohol
Examination
Distressed P 130 BP 80/60 RR 26 Sats 99% RA Abdomen
Non-distended Generally tender.
Bedside Ultrasound
9cm
Management of ruptured AAA Senior help ABC Large Bore IV Access x 2 Hypotensive resuscitation Analgesia Ensure O neg available Ensure normothermia Urgent Vascular Consult To OR
Last Case!
85 yr old male. Nursing home resident
Central Abdominal Pain Sudden onset. Severe PMH
Dementia MI
MEDS Clopidogrel 75 mg Daily Metoprolol 25 mg BD Perindopril 5 mg daily
SH Mild dementia Forgetful Requires some assistance with
bathing and toileting Feeds Self Walks with frame Non-smoker Non-drinker
Examination
Looks dry and emaciated P 120- 140 BP 110/70 RR 30 Sats 96% RA T 37.4 C Abdomen
Generally tender No guarding rigidity or rebound
ECG
Differential?
ABG
pH 7.10 pCO2 15 P02 80 Bic 8 BE -15 Lactate 10.2
Management
ABC NPO IV access IVF Analgesia IV abs Urgent Surgical Consult Urgent CT mesenteric angiogram OR
Mesenteric Ischaemia
Surgical Emergency Small bowel has warm ischaemic time of 2-3 hours
Rapidly progresses to gangrene, septic shock and death
Need high index of suspicion to diagnose it
Severe pain but little tenderness on examination
Case 7
40 yr old male presents with sudden onset of severe R loin to groin pain. Excruciating pain. Coming in waves. Feels nauseated and has vomited x 2.
Patient is agitated, pacing around the room, unable to sit still.
Screaming in pain. P 120 sinus BP 160/80 T 37.0 C RR 18 Sats 99% RA
R renal angle tender
Differential Diagnosis?
Renal Colic Pancreatitis Cholecystitis Appendicitis Ruptured/leaking AAA
UA Erythrocytes ++++ No leucocytes No nitrites
Investigations
UA EUC FBC (other bloods if diagnosis unclear)
CT KUB
Management
Analgesia NSAID Morphine IV titrated to pain IV fluids – maintenance only Observe
Who should we CT
CT On going pain Impaired renal function Fever Diagnosis not clear
Indications for admission Infection Impaired Renal Function Pain ongoing– needing IV opiates
Stone > 5mm Obstruction/hydronephrosis on CT
Stag horn Calculus on CT
Take Home Message
Exclude life threatening pathology BHCG in female of child bearing age Be mindful of radiation exposure Beware of Abdominal pain in the Elderly
Never ignore abnormal vital signs Ask for help if not sure about diagnosis/Rx
Thanks for your patience!