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ABDOMINAL EMERGENCIES.
Term Paper ID:20350
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Essay Subject:
ABC's of trauma treatment, types, evaluation, causes, lab data, medication, surgery.... More...
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10 Pages / 2250 Words
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Paper Abstract:
ABC's of trauma treatment, types, evaluation, causes, lab data, medication, surgery.
Paper Introduction:
Abdominal Emergency
Abdominal emergencies can be broadly grouped into patients who present with either abdominal injury, abdominal pain, or both. In any case, the physician must determine the severity of the situation (9:1418). Urgent circumstances require attentiveness to the patient's immediate needs (9:1418).
In cases of abdominal injury, immediate life threatening injuries should take precedence (9:718). A useful way to organize this effort is according to the ABCs of trauma: specifically, obtaining an airway, assuring adequate ventilation, and restoring circulating blood volume (9:718). Only at that point can further steps towards treatment be undertaken.
Furthermore, anytime a patient comes into the emergency department with severe abdominal trauma, a surgeon should be
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Approximately 9 % of all kidney injuries result from blunt trauma(9:726). Taourel, P.; Baron, M.P.; Pradel, J.; Fabre, J.M.; Seneterre, E.; Bruel, J.M. Somatic pain, in contrast, is localized, aggravated by movementand tends to be sharp and discrete; it arises in structures of the bodywall (9:1418). Laparoscopy in the emergency setting. Anestimation of significant visceral injury can be made from the history ofthe accident (9:72 ). The other major cause of abdominal emergencies, acute abdominal pain,is a very common presenting complaint (8:691). 4. These may reveal the presence of pancreatitis (6:877-878). In cases of abdominal injury, immediate life-threatening injuriesshould take precedence (9:718). Abdominal Emergency Abdominal emergencies can be broadly grouped into patients whopresent with either abdominal injury, abdominal pain, or both. Ros, P.R.; Bidgood, W.D., Jr. 11:1 7-123; 1993. These include an extremely rigidabdominal wall, suggesting peritonitis (5:875), or marked abdominaldistention with diffuse tympany, suggesting intestinal obstruction, ileus,or perforation (9:1419). 3 :367-388; 1992. Since many diseases present with acute abdominal pain, the emergencydepartment physician's first responsibility is to determine the severity ofthe problem (9:1418). Many patients will also benefit from early diagnosticnasogastric intubation (9:1421). Abdominal magnetic resonance imaging. Initially, it is safest to assume that a bullet wound of the trunkmay have injured anything in the abdominal or thoracic cavities (9:724).From knowledge of the caliber of the weapon, the position of the patient,and the distance from the weapon, inferences can be made regarding theextent of the injury (9:724). Early management of these patients follows theprinciples of the management of any acutely ill or acutely traumatizedpatient (9:1421). At the extreme, there may becoma, shock, and cardiac or respiratory arrest (9:1418). 8:869-887; 1992. Fluid thusobtained should be tested for cell count and differential, protein content,amylase, Gram's stain, routine cultures, anaerobic cultures, and cytology(9:142 ). Sackier, J.M. Finally, details of the accident or assault should beobtained and a complete physical examination must be performed (9:719). With extraperitonealrupture of the bladder, urine can dissect into the retroperitoneum; leftundrained, it can result in absorption, suppuration, and, possibly, death(9:732). 9:827-852; 1991.14. Bladder injuries also tend to occur in patients with a distendedbladder and are often associated with pelvic compression in automobileaccidents (9:731). New York: Churchill Livingstone Inc.; 199 .12. 8. Computed tomography in blunt abdominal trauma: An analysis of clinical management and radiological findings. Other diagnostic procedures that may be employed include plainroentgenograms, contrast radiographic studies, abdominal ultrasound(sonography), and CT (9:142 -1421). 16:1 83-1 88; 1992.16. Finally, one injury which is frequently overlooked is ureteral injury(9:731). A useful way to organize this effort isaccording to the ABCs of trauma: specifically, obtaining an airway,assuring adequate ventilation, and restoring circulating blood volume(9:718). If signs of infection are present, cultures should be obtained(9:1421). Kirkpatrick, J.R. In the stable patient, exploratorylaparotomy is performed if there are signs of peritoneal irritation,intraperitoneal bleeding, and roentgenographic evidence of rupture of ahollow viscus (9:721). Furthermore, needle biopsies of the liver or kidneys can causeintraperitoneal bleeding and percutaneous cholangiography may cause bileleakage (9:724). Peritonitis. The severity of a gunshot wound depends onthe energy expended by the bullet as it passes through the tissue (9:723).This, in turn, is related to the bullets velocity, weight, and tendency todeform (9:723). All patients shot in the abdomen should havean exploratory laparotomy (9:724). 6. Bode, P.J.; Niezen, R.A.; van Vugt, A.B.; Schipper, J. Furthermore, diagnosis can be difficult; in a stablepatient, an abdominal CT scan with GI contrast is the initial study ofchoice (9:723). Blunt trauma presents a difficult diagnosticproblem as many patients may initially be asymptomatic (9:72 ). 1 :27-46; 1992. They should also begiven oxygen, placed on an ECG monitor, and have frequent vital signsmonitored (9:719). This requires a comprehensive analysis of all thepresenting symptoms (7:3). Splenic injuriescharacteristically present with deep left-sided abdominal pain withcoughing, and pain in an epaulet pattern distributed over the left shoulder(9:722). For acute abdominal pain, relief can be provided parenterally withmeperidine, 1 mg, or morphine, 1 mg (9:142 ). However, computedtomography (CT) does provide an excellent noninvasive technique forassessing the abdomen (3:367); in fact, it is so valuable that CT haslargely replaced peritoneal lavage in major trauma centers (9:72 , 2172). When a situation is deemed urgent, surgical consultation should beobtained early (9:1421). Except for the peritoneal signs, extraperitoneal bladder rupturecan present with similar symptoms (9:732). 128:55-63; 1993.11. Perforation may resultfrom crushing injuries; whereas shearing injuries are produced bydecelerating forces frequently associated with wearing seat belts (9:723).Although the former is easily detected, the bowel which has undergoneshearing may not show signs of ischemia for several days (9:723). When there is clinical suspicion of a ureteral injury, an IVPshould be obtained (9:731). Journal of Trauma. In the unstablepatient, exploratory laparotomy is carried out when there is evidence ofcontinued blood loss with persistent or recurrent signs of hypovolemiadespite fluid replacement (9:721). For example, soft-nosed bullets become deformed and expendall their energy before exiting (9:723). Boston, MA: Little, Brown, and Company; 1992.1 . Furthermore, studies publishedwithin the past year also suggest that perhaps ultrasonography should playa greater role in emergency department care (1:27). Treatment consists of repair and drainage(9:733). Cystography and CT can be used toconfirm a diagnosis (9:733). Plewa, M.C. If it is not a surgical condition, the patient will probably beadmitted to the hospital--perhaps to a medical intensive care unit(9:1422). Early diagnosis of intraperitoneal rupture is important (9:731). Boston, MA: Mosby-Year Book, Inc.; 1993.15. Of the penetrating abdominal injuries, gunshot and stab wounds arethe most common (9:723-724). Furthermore, the medications should be usedcautiously if there is any sign of decreased respiratory reserve (9:142 ). Baltimore, MD: William & Wilkins; 1984. Ornato, J.P.; Gonzalez, E.R. Often it is only recognized following later complications(9:731). Therefore, initial laboratory tests tend to be oflittle diagnostic value (9:719). Computed tomographic evaluation of blunt abdominal trauma. Intraperitoneal rupture of the bladder may cause pelvicperitonitis, abscess formation, and death (9:732). Some of the urgent conditions which may be encounteredinclude appendicitis, perforated bowel, abdominal aortic aneurysm,intestinal obstruction, ischemia of the small intestine, acutecholecystitis, acute cholangitis, ruptured ectopic pregnancy, pancreaticabscess, myocardial infarction, large pulmonary insufficiency, acuteadrenal insufficiency, ruptured hepatic adenoma, hepatoma, or hemangioma,and a ruptured spleen (9:1419). Itshould be suspected in patients with trauma in the presence of elevatedblood urea nitrogen, potassium, abnormal serum creatinine, and decreasedmean serum sodium levels (9:733). 46:3 4- 31 ; 1992.13. Blunt abdominal trauma. Hill, A.B.; Meakins, J.L. In general, it can be managed in a conservative fashion: forexample, intravenous pyelography (IVP) and nephrotomography are reservedfor patients with greater than 3 red cells per high-powered field onadmission urinalysis (9:726). In addition, cystoscopic examination with aretrograde pyelogram or nephrotomography with high-dose contrast can alsobe employed (9:731). Heller, M.B.; Verdile V.P. Urgency is alsoindicated by tachycardia, orthostatic hypotension, and high fever (9:1418). Symptoms associated with intraperitoneal rupture includeperitoneal signs, suprapubic pain, ileus, or a strong desire to void(9:732). Any patient who has sustained a major impact shouldbe admitted to the hospital for 24 hours (9:721). Acute abdomen of unknown origin: Impact of CT on diagnosis and management. Ultrasonography has thus far played little role in the evaluationof abdominal trauma in the United States (4:36). One method for separating an abdominal catastrophefrom a minor abdominal complaint is according to the pattern ofpresentation (7:3). There are two major divisions of abdominal injuries--blunt trauma andpenetrating wounds (9:72 ). A ruptured spleen may call for a splenectomy (9:722). Emergency Medicine Clinics of North America. The spleen, for example, is the organ mostsusceptible to injury by blunt trauma (9:721). Inaddition, cases involving pelvic trauma may require the emergencydepartment physician to consult with an orthopedist, a urologist, and ageneral surgeon (9:719). Additionally, if acute cholecystitis is suspected, a hepatobiliaryiminodiacetic acid radioisotope scan can be very useful (9:1421).Moreover, arteriography may be indicated for pain due to an abdominalaortic aneurysm (9:1421). Hodgdon, A.K.; Wolfson, A.B. Thedrug inhibits the action of histamine on the H2-receptor of the parietalcell and can be used for maintenance therapy for duodenal, gastric, andstress ulcers (11:536). Archives of Surgery. The diversity of medications which may be appropriate in abdominalemergencies equals the diversity of conditions which may be encountered. In general, plain roentgenograms of the abdomen are also of littlediagnostic value for assessing abdominal trauma (2:1 8). Pancreatitis. Furthermore, the characterand location of the pain can be the same for many conditions and is alsofrequently nonspecific (9:1417). When the need for antibiotic therapyarises, a broad-spectrum agent such as an advanced-generation cephalosporinshould be used (1 :55). Unless treated promptly, these injuries areoften fatal (9:723). Moreover, there wasno interruption of resuscitation and stabilization efforts (1:31). Literature Cited 1. Emergency medicine. Thus,Bode et al., concluded that all patients with traumatic abdominal lesionsshould be examined with ultrasonography as part of a routine examination;diagnostic peritoneal lavage, CT, angiography, and MRI may subsequently beconsidered as suitable follow-up investigative methods (1:31). May, H.L.; Aghababian, R.V.; Fleisher, G.R., et al. The natural history and clinical findings in undifferentiated abdominal pain. Clinical Radiology. Various other diagnostic procedures employed in abdominal traumainclude gastroscopy, needle biopsies, and cholangiography (9:724).Fiberoptic gastroscopy, however, carries a small risk of perforation(9:724). Annals of Emergency Medicine. In addition,laparoscopy may help define the nature of obscure abdominal diagnoses(15:1 83). Such medication, however,should be deferred until completion of the physical exam and confirmationof the diagnosis (9:142 ). 7. Abdominal ultrasound as a reliable indicator for conclusive laparotomy in blunt abdominal trauma. Itshould also be considered in blunt trauma patients or those suspected ofhaving perforation of a gastric or duodenal ulcer (9:142 ). When the situation fits the criteria forbeing urgent, and the cause is a surgical condition, surgery is necessary(9:1422). If there is no indication of clinical urgency, however, a thoroughphysical examination should be performed (9:1419). 22:69 -696; 1993. Trauma to another organ, the liver, can result in a range ofpathology: it may be as inconsequential as a minor self-limiting lacerationor as severe as exsanguinating hemorrhage from major vessels (9:723).Right-upper-quadrant pain and evidence of intraabdominal bleeding generallycalls for laparotomy (9:723). Although ureteral injuries may occur from blunttrauma, they are more frequently the result of penetrating injuries (9:73 -731). In general, the signals of urgency for the acute abdomen are the sameas in most acute and severe illness (7:3). In addition, the duodenum and pancreas may be crushed against thevertebral column (9:723). One medication commonly used for ulcers is ranitidine (11:536). In most civilian emergency departments, the patient is seen soonafter an injury (9:719). In addition, diagnostic paracentesis should be performed in allpatients with chronic ascites or sudden recent onset ascites (9:142 ). Only at that point can further steps towards treatment beundertaken. Emergency Medical Clinics of North America. 3. 17:287-291; 1992.----------------------- 7 Prospective alterations in therapy for penetrating abdominal trauma. The presence of these signs mandate that immediate and repeated attentionbe given to vital signs (9:1418). Other tests whichmay be appropriate include serum amylase, urine amylase, and serum lipase(6:877-878). Blunt trauma can also perforate the small and large intestines orshear them from the mesenteric vessels (9:723). These patients should all have two large-bore intravenous lines andtubes to decompress the stomach and bladder (9:719). Furthermore, anytime a patient comes into the emergency departmentwith severe abdominal trauma, a surgeon should be called (9:719). In anycase, the physician must determine the severity of the situation (9:1418).Urgent circumstances require attentiveness to the patient's immediate needs(9:1418). Ultrasonography in emergency medicine. Visceral pain is often a dull,cramping, and gnawing midline pain arising from an abdominal viscus(9:1418). 2. 9. The team conducting the study found that within 5 minutes theywere able to tell whether or not a patient had sustained relevant damage tothe thoracic cage, axial skeleton, and abdomen (1:31). With stab wounds, the length of the weapon and the force with whichit was wielded generally determine the potential for injury (9:724).Management consists of laparotomy and closure of a perforated bowel(9:724). Although it is not always possible to make a diagnosis of specificorgan injury preoperatively, there are some differences in the presentationof various injuries (9:721). Nichols, R.L.; Smith, J.W.; Robertson, G.D.; Muzik, A.C.; Pearce, P.; Ozmen, V.; McSwain, N.E., Jr.; Flint, L.M. In addition, MRI is evenbecoming a valid alternative to CT (14:ix). Colucciello, S.A. Drug therapy in emergency medicine. The "gold standard" of diagnostic studies,excretory urography using contrast-enhanced CT, may also provide imaging ofthe upper urinary tract (9:727). These may include a mass in the abdomen associated with fever,chills, urgency of urination, and abnormalities of urinary sediment(9:731). The acute abdomen: Diagnosis and management. It is morelikely to indicate acute disease when accompanied by increasedpolymorphonuclear leukocytes and band forms (9:142 ). In many patients, a history alone may allow a good operatingdiagnosis (9:1419). Bowel sounds and abdominal percussion may alsoelucidate useful findings: for example, rebound tenderness upon percussionis indicative of peritoneal inflammation (9:1419-142 ). Gay, S.B.; Sistrom, C.L. Still though,chest films should always be ordered; also, radiographic views of theurinary tract can be helpful for investigating any degree of hematuria(9:72 ). Emergency abdominal radiography. Of laboratory data that should be collected, peripheral bloodleukocytosis has been given a great deal of emphasis (9:142 ). Emergency Medicine Clinics of North America. Finally, referred pain is similar to somatic pain incharacter and arises in areas remote from where it is perceived (9:1418). Emergency Medicine Clinics of North America. Padhani, A.R.; Watson, C.J.; Calne, R.Y.; Dixon, A.K. World Journal of Surgery. An airway and intravenous access must be established(9:1421). Blunt renal trauma has also beenassociated with severe delayed hypertension (9:728). They can, however, be used to providebaseline levels against which later results can be compared (9:719). Other studies frequently used include upper-gastrointestinal endoscopy and colonoscopy (9:1421). The best single approach for the evaluation of blunt abdominal traumais a series of careful physical examinations (9:721). Typically, abdominal pain is categorized as visceral, somatic(parietal), and referred (9:1418). Recent advances in the treatment of abdominal emergencies include agrowing trend towards non-operative management of visceral trauma using CTassessment of solid organ injury (12:3 4). Certain findings mayreveal unsuspected urgency (9:1419). Short of that,mental confusion, sweating, and pallor can occur (9:1418). Thus, the acute abdomen often presentsthe emergency department physician with a considerable diagnostic challenge(9:1418). Of the various conditions which give rise to abdominal emergencies,however, many may require surgery. Gastrointestinal Radiology. Clinics in Geriatric Medicine. Finally, CT patterns can be used to diagnoseappendicitis, diverticulitis, and intestinal obstructions (16:287). Radiographic findings with acuteabdomen patients, however, are rarely diagnostic (13:849).Ultrasonography, in contrast, may be useful for revealing the presence ofgallbladder disease, obstructive uropathy, appendicitis, or an aorticaneurysm (4:32-35). For example, the mostimportant preoperative objective in the management of abdominal traumapatients is to ascertain whether or not a laparotomy is needed (1:29).Bode et al., using hemoperitoneum and parenchymal damage as indicators forimmediate laparotomy, made correct diagnoses by ultrasonography with asensitivity of 92.8%, a specificity of 1 %, and an accuracy of 99.4%(1:29). 34:27-31; 1993. 8:873-885; 199 . In addition,rectal and pelvic examination may be indicated (9:142 ). Radiologic Clinics of North America. Subsequent to such action, a history should also be obtained(9:1419). Lukens, T.W.; Emerman, C.; Effron, D. Moreover, bullets are sterilizedby the heat generated in passage through the weapon and, therefore, neednot always be retrieved (9:724). 5.
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