Back to Basics2013 Dr. Brian Weitzman Department of Emergency Medicine Ottawa Hospital
Review of 14 Common Emergency Medicine Topics Today • Acute Abdominal Pain • Acute Dyspnea • Hypotension/Shock • Syncope • Coma • Cardiac Arrest
Other Emergency Medicine Topics • Malignant Hypertension • Animal Bites • Burns • Near-drowning • Hypothermia • Poisoning • Urticaria/Anaphylaxis
Abdominal PainMCC Objectives • Common causes of pain • Localized -Upper vs Lower Abdominal • Diffuse • History –list and interpret clinical finding • Physical exam: appropriate-vitals, abd, rectal, pelvic GU • -recognize peritonits • Investigate: order appropriate tests • Interpret clinical and lab data • Management plan: • Who needs immediate attention and treatment/surgery • Non-emergency management • Further investigation or specialized care
Case 1: Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ. What disease process is this typical for? What causes the change in the pain pattern? What other diseases must you consider?
Neurologic Basis of Abdominal Pain • Visceral • Somatic • Referred
Visceral Abdominal Pain • Stretch receptors in walls of organs • Stimulated by distention, inflammation • return to spinal cord: bilateral, multiple levels • Brain cannot localize source
Visceral Abdominal Pain • Pain felt as crampy, dull, achy, poorly localized • Associated with autonomic responses of palor, sweating, nausea, vomiting • Patients often writhing around • Movement doesn’t alter pain
Somatic Abdominal Pain • parietal peritoneum • Returns to ipsilateral dorsal root ganglion at 1 dermatomal level • Sharp, localized pain • Causes tenderness, rebound, and guarding • Patients lie still, movement increases pain
Referred Pain • What is it? • What are some examples?
Referred Pain • Pain perceived in an area that is distant from the disease process • Due to overlapping nerve innervations
Examples of Referred Pain • Shoulder pain with diaphragm stimulation • C 3,4,5 stimulation • Back pain with biliary colic, pancreatitis, or PID
Differential Diagnosis • Diffuse vs Localized
Diffuse Abdominal Pain • Peritonitis • AAA • Ischemic Bowel • Gastroenteritis • Irritable Bowel Syndrome
Causes of Abd Pain - Localized Upper Abdominal Lower Abdominal
Localized Abdominal Pain Gastritis,GERD/PUD Pancreatitis MI • Biliary Colic/Cholecystitis • Hepatitis / Hepatic Abscess • Pneumonia / Pleurisy • Splenic Infarction • Splenic Rupture • Pneumonia Incarcerated Hernia Bowel obstruction Inflammatory bowel disease Diverticulitis Ectopic Ovarian(torsion or cystA) Salpingitis/PID Renal Stones/UTI Testicular torsion • Appendicitis • Mesenteric lymphadenitis
Case 1: Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ.
Case 1: Questions 1. What further history do you need from the patient? 2. What would you do in your physical exam? 3. What are you looking for on physical examination? 4. What initial stabilization is required? 5. What is your differential diagnosis?
History • Onset / Duration • Nature / Character / Severity • Radiation • Exacerbating / Relieving Factors • Location • Associated Symptoms • Nausea / Vomiting • Diarrhea / Constipation / Flatus • Fever • Jaundice / other skin changes • GU (dysuria, freq, urgency, hematuria…) • Gyne (menses, contraception, STDs,,,) • PMHx • Prior Surgery • Medical Problems • Medications
High Yield Questions • 1. Age Advanced age means increased risk. • Which came first—pain or vomiting? • Pain first is worse (i.e., more likely to be caused by surgical disease). • 3. When did it start? Pain for < 48 hrs is worse. • 4. Previous abdominal surgery? Consider obstruction. • 5. Is the pain constant or intermittent? Constant pain is worse. • 6. Previous hx of pain? • 7. Pregnant? consider ectopic.
High Yield Questions cont’d • History of serious illness is suggestive of more serious disease. • HIV? Consider occult infection or drug-related pancreatitis. • Alcohol? Consider pancreatitis, hepatitis, or cirrhosis. • 11. Antibiotics or steroids? These may mask infection. • 12. Did the pain start centrally and migrate to the right lower quadrant? High specificity for appendicitis.
High Yield Questions, cont’d 13. History of vascular or heart disease, hypertension, or atrial fibrillation? Consider mesenteric ischemia and abdominal aneurysm.
Physical Examination • Vitals • General appearance: writhing/motionless, diaphoresis, skin, mental status • Always do brief cardiac and respiratory exam • Abdominal exam: Look, listen, feel • Pelvic, genital and rectal exam in ALL patients with severe abdominal pain • Assess pulses!
Abdo Exam: Specifics • Always palpate from areas of least pain to areas with maximal pain • ?Organomegaly, ?ascites • Guarding: voluntary vs. involuntary • Bowel sounds: increased/decreased/absent • Rectal exam: occult/frank blood, ?stool, ?pain, ?masses • Pelvic exam: discharge, pain, masses • Peritonitis: • suggested by: rigidity with severe tenderness, pain with percussion/deep breath/shaking bed, rebound
Risk Factors for Acute Disease • Extremes of age • Abnormal vital signs • Severe pain of rapid onset • Signs of dehydration • Skin pallor and sweating
Initial Stabilization • All patients with acute abdominal pain: • Assess vital signs • Oxygen • Cardiac Monitoring/12 lead ECG • Large bore IV (may need 2) • 250-500 cc bolus of NS in elderly with low BP • 500-1000 cc bolus in younger patients with low BP • Consider NG and Foley catheter • Brief initial examination : history and physical • Consider analgesics • ??Do they need immediate surgical consultation?
Pain: ER Management • Is it OK to give a patient pain medications before you determine their diagnosis?
Abdominal Pain: ER Management • Anti-inflammatories (NSAIDs): • very effective, esp. for MSK or renal colic pain • Ex. Ketorlac (Toradol) 30 mg IV • Narcotics • sc/im/iv • very effective, esp. for visceral or undifferentiated pain • Ex. Morphine 2.5-5 mg, hydromorphone 1-2 mg
Nausea/Vomiting: ER Tx • Ondansetron (Zofran) : iv 4-8 mg • very useful in patients with refractory vomiting • Dimenhydrinate (Gravol): po/pr/im/iv 25-50 mg • beware of anticholinergic side effects • sedating, may cause confusion • Metoclopramide (Maxeran) 10 mg IV • Prochlorperazine (Stemetil): 10 mg IV • beware of possible EPS • less sedating; may help with pain control • Domperidone: po/iv • especially useful with diabetic gastroparesis
Investigations • Most patients with acute abdominal pain require: • - CBC, differential; may need type and cross-match • electrolytes, BUN, creatinine, • lactate • - liver function tests • - lipase • - beta-hCG • - urinalysis; stool for OB • They may also need: ECG, cardiac enzymes, ABG,
Investigations Imaging ultrasound CT scan plain Xrays
A 73 y.o. man presents to the ED with left lower abd pain to left flank x 5 hours. PMH: Hypertension. Abdomen is diffusely tender. No rebound/ guarding. P 120 BP 95/70 RR 18 T 37.5 02 95% • What is the most likely diagnosis? 1) Diverticulitis 2) Renal colic 3) Ischemic bowel 4) Pyelonephritis 5) Other
A 73 y.o. man presents to the ED with left lower abd pain to left flank x 5 hours. PMH: Hypertension. Abdomen is diffusely tender. No rebound/ guarding. P 120 BP 95/70 RR 18 T 37 02 95% • What is your immediate treatment? • What investigations will you do?
A 45 y.o. man presents to the ED with left lower abd pain to left flank x 5 hours.. Abdomen is mildly tender L side. No rebound/ guarding. P 120 BP 130/70 RR 18 T 37 02 98% • What is your diagnosis? • What is your immediate treatment? • What investigations will you do?
What is the cause of this 45 y.o. man’s LLQ pain? • Renal stone
A 75 y.o. man presents with 6 hours of LLQ pain which has become more diffuse. T 38, P 120, BP 130/60What is the cause of this man’s pain?
What is the cause of this man’s pain? • Double lumen sign of free air in abdomen • Perforated diverticulitis
Small Bowel Obstruction • Central location, plica circularis (valvulae coniventes) • Stacked coin appearance
Plica circularis Air fluid levels
What are the 3 leading causes of SBO • 1) adhesions • 2) hernia • 3) neoplasm