Post on 27-May-2020
ABDOMINAL EMERGENCIESABDOMINAL EMERGENCIESIN THE ELDERLYIN THE ELDERLYIN THE ELDERLYIN THE ELDERLY
ECI Rural WorkshopsECI Rural Workshops20122012
THE ELDERLYTHE ELDERLY AGEAGETHE ELDERLY THE ELDERLY -- AGEAGE
“Young old” “Young old” 6565--7575 “Middle old”“Middle old” 7575 8585 Middle oldMiddle old 7575--8585 “Old “Old oldold”” >85>85
THE ELDERLYTHE ELDERLYDEMOGRAPHICDEMOGRAPHIC
13% of Australian population are >65yrs13% of Australian population are >65yrs 13% of Australian population are >65yrs13% of Australian population are >65yrs Projected 25% by 2042Projected 25% by 2042
“Old t ld” i th f t t i b t“Old t ld” i th f t t i b t “Oldest old” is the fastest growing subset“Oldest old” is the fastest growing subset “Physiological age” may be different to “Physiological age” may be different to
“Chronological age”“Chronological age”
AUSTRALIAN POPULATION AUSTRALIAN POPULATION GROWTHGROWTH
EMERGENCY MEDICAL CAREEMERGENCY MEDICAL CAREELDERLYELDERLY
>15% of all ED VISITS>15% of all ED VISITS >15% of all ED VISITS>15% of all ED VISITS 39% of Ambulance arrivals39% of Ambulance arrivals
46% d i i t46% d i i t 46% admission rate46% admission rate 47% of all ICU admissions47% of all ICU admissions
EMERGENCY MEDICAL CAREEMERGENCY MEDICAL CAREELDERLYELDERLY
Undergo 50% more lab and radiologyUndergo 50% more lab and radiology Undergo 50% more lab and radiology Undergo 50% more lab and radiology testingtestingMuch higherMuch higher bouncebackbounceback raterate Much higher Much higher bouncebackbounceback raterate
Much higher misdiagnosis rateMuch higher misdiagnosis rate Worse outcomes with delays in diagnosisWorse outcomes with delays in diagnosis
THE ELDERLYTHE ELDERLYTHE ELDERLYTHE ELDERLY
PHYSIOLOGICAL CHANGESPHYSIOLOGICAL CHANGES
IMMUNE SYSTEMIMMUNE SYSTEMIMMUNE SYSTEMIMMUNE SYSTEM Consider the elderly to beConsider the elderly to be Consider the elderly to be Consider the elderly to be
immunosuppressedimmunosuppressedDecreased cell mediated immunityDecreased cell mediated immunity Decreased cell mediated immunityDecreased cell mediated immunity
Decreased antibody titresDecreased antibody titresDec eased ba ie p otection f om skinDec eased ba ie p otection f om skin Decreased barrier protection from skinDecreased barrier protection from skin
Take longer to “demonstrate” infectionTake longer to “demonstrate” infection FeverFever Elevated WBCElevated WBC
May develop hypothermiaMay develop hypothermia May develop hypothermiaMay develop hypothermia
BASAL BODY TEMPERATUREBASAL BODY TEMPERATUREBASAL BODY TEMPERATUREBASAL BODY TEMPERATURE Basal body temperature decreases withBasal body temperature decreases with Basal body temperature decreases with Basal body temperature decreases with
age so that a fever of any level becomes age so that a fever of any level becomes much more meaningfulmuch more meaningfulmuch more meaningfulmuch more meaningful
Decreased response to temperature Decreased response to temperature changeschangeschangeschanges
Don’t sweat as earlyDon’t sweat as early Don’t sense heat as earlyDon’t sense heat as early Don’t get thirsty as earlyDon’t get thirsty as earlyDon t get thirsty as earlyDon t get thirsty as early
RENAL FUNCTIONRENAL FUNCTIONRENAL FUNCTIONRENAL FUNCTION
Decreased renal cell mass, so GFR Decreased renal cell mass, so GFR decreases with age (chronic disease, decreases with age (chronic disease, g ( ,g ( ,diabetes, hypertension)diabetes, hypertension)
Decreased drug clearanceDecreased drug clearance Decreased drug clearance Decreased drug clearance Greater risk of drug toxicitiesGreater risk of drug toxicities
Decreased production ofDecreased production of creatininecreatinine due todue to Decreased production of Decreased production of creatininecreatinine due to due to smaller muscle masssmaller muscle mass
CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM
Decreased response to both endogenous Decreased response to both endogenous and exogenousand exogenous catecholaminescatecholaminesand exogenous and exogenous catecholaminescatecholamines Both Both inotropicinotropic and and chronotropicchronotropic
E h d if b t bl kE h d if b t bl k Enhanced if on beta blockersEnhanced if on beta blockers
CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM
1% decrease in CO per year >35yo1% decrease in CO per year >35yo
Higher risk of CHF with medical stressorsHigher risk of CHF with medical stressorsS iS i Severe sepsisSevere sepsis
Pneumonia Pneumonia
SHOCK IN THE ELDERLYSHOCK IN THE ELDERLYSHOCK IN THE ELDERLYSHOCK IN THE ELDERLY
Develops earlier and more easilyDevelops earlier and more easily Develops earlier and more easilyDevelops earlier and more easily Occult shock is commonOccult shock is common Needs aggressive treatmentNeeds aggressive treatment Needs aggressive treatmentNeeds aggressive treatment Have a low Have a low threshholdthreshhold for early lactate levels for early lactate levels
and following Lactate trendand following Lactate trendand following Lactate trendand following Lactate trend
GASTROINTESTINAL GASTROINTESTINAL TRACTTRACT
Slower GI motility including decreasedSlower GI motility including decreased Slower GI motility including decreased Slower GI motility including decreased stomach emptying time stomach emptying time IncreasedIncreased diverticulidiverticuli in colonin colon Increased Increased diverticulidiverticuli in colonin colon
Decreased fluid intake and mobility Decreased fluid intake and mobility ––i i ti tii i ti tiincrease in constipationincrease in constipation
GASTROINTESTINAL TRACTGASTROINTESTINAL TRACTGASTROINTESTINAL TRACTGASTROINTESTINAL TRACT
Decreased gastric mucous and Decreased gastric mucous and bicarbonate productionbicarbonate productionpp
Increased risk of GIT haemorrhageIncreased risk of GIT haemorrhage Be wary of Be wary of NSAID,AspirinNSAID,Aspirin & & WarfarinWarfarin use!use! 3030--35% of asymptomatic elderly have ulcer 35% of asymptomatic elderly have ulcer
diseasedisease 50% present50% present with perforation or haemorrhage 50% present 50% present with perforation or haemorrhage Steroids pSteroids predispose
GASTROINTESTINAL TRACTGASTROINTESTINAL TRACTGASTROINTESTINAL TRACTGASTROINTESTINAL TRACT
Decreased GI system blood flowDecreased GI system blood flow
Increased risk of mesenteric Increased risk of mesenteric ischaemiaischaemia AtheromaAtheroma AtheromaAtheroma Emboli from AFEmboli from AF
“Low flow” states“Low flow” states “Low flow” states“Low flow” states
CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM
Dementia/decreased cognitive function Dementia/decreased cognitive function lead to lead to Decreased sensation of painDecreased sensation of pain Downplaying of symptomsDownplaying of symptoms Downplaying of symptomsDownplaying of symptoms Denial of symptomsDenial of symptoms
Decreased and delayed pain perception atDecreased and delayed pain perception at Decreased and delayed pain perception at Decreased and delayed pain perception at nocioceptornocioceptor cellular levelcellular level
HIPPOCRATESHIPPOCRATESHIPPOCRATESHIPPOCRATES
““Those who are used to bearing anThose who are used to bearing anThose who are used to bearing an Those who are used to bearing an accustomed pain, even if they be weak accustomed pain, even if they be weak and old bear it more easily than theand old bear it more easily than theand old, bear it more easily than the and old, bear it more easily than the young and strong who are unaccustomed”young and strong who are unaccustomed”
POLYPHARMACYPOLYPHARMACYPOLYPHARMACYPOLYPHARMACY Average elderlyAverage elderly Average elderly Average elderly
44--5 prescription drugs5 prescription drugs 2 OTC medications every day2 OTC medications every day 2 OTC medications every day2 OTC medications every day
Drugs can mask symptoms and alter vital Drugs can mask symptoms and alter vital signssignssignssigns NSAIDsNSAIDs
St idSt id SteroidsSteroids DigoxinDigoxin (causes (causes sphlancnicsphlancnic vasoconstriction)vasoconstriction)
WarfarinWarfarin
VITAL SIGNS IN THE ELDERLYVITAL SIGNS IN THE ELDERLY
TEMPERATURETEMPERATURETEMPERATURETEMPERATURE
Lack of fever does not rule out Lack of fever does not rule out possiblitypossiblityof dangerous infectionof dangerous infectiongg
The elderly pt is 3The elderly pt is 3--4X more likely to 4X more likely to develop HYPOdevelop HYPO thermiathermia in response toin response todevelop HYPO develop HYPO thermiathermia in response to in response to sepsissepsis
If a fever is mounted it could be delayedIf a fever is mounted it could be delayed If a fever is mounted, it could be delayed If a fever is mounted, it could be delayed by hours or daysby hours or days
HEART RATEHEART RATEHEART RATEHEART RATE
May or may not mount tachycardiaMay or may not mount tachycardia
Beta blockersBeta blockers Calcium Channel blockersCalcium Channel blockers Calcium Channel blockersCalcium Channel blockers DigoxinDigoxin
BLOOD PRESSUREBLOOD PRESSUREBLOOD PRESSUREBLOOD PRESSURE
May already be low due to May already be low due to antihypertensive medsantihypertensive medsypyp
Hyper/hypotension can be relativeHyper/hypotension can be relative Hyper/hypotension can be relative Hyper/hypotension can be relative compared to normal BP e.g. compared to normal BP e.g.
180/100 120/60180/100 120/60180/100 120/60 180/100 120/60 “RELATIVE SHOCK”“RELATIVE SHOCK”
RESPIRATORY RATERESPIRATORY RATERESPIRATORY RATERESPIRATORY RATE
Very UsefulVery Useful
First First abnabn Vital Sign in sepsis is tachypnoeaVital Sign in sepsis is tachypnoea
IMPORTANT TO COUNT RESPIRATIONSIMPORTANT TO COUNT RESPIRATIONS
ELDERLY ABDO PAIN ELDERLY ABDO PAIN THE FACTSTHE FACTS
10% will die, even higher than the elderly 10% will die, even higher than the elderly patient presenting with chest painpatient presenting with chest painp p g pp p g p
Can present in any way possibleCan present in any way possible55% will have another diagnosis on55% will have another diagnosis on 55% will have another diagnosis on 55% will have another diagnosis on dischargedischargeMi di i i t lit 2XMi di i i t lit 2X Misdiagnosis increases mortality 2XMisdiagnosis increases mortality 2X
ACUTE APPENDICITISACUTE APPENDICITISACUTE APPENDICITISACUTE APPENDICITIS
8% of all 8% of all appendicectomiesappendicectomies Accounts for 5Accounts for 5--6% of all acute abdominal6% of all acute abdominal Accounts for 5Accounts for 5 6% of all acute abdominal 6% of all acute abdominal
emergencies in the elderlyemergencies in the elderly
High rate of delayed or High rate of delayed or misdiagnosedmisdiagnosed 25% sent home at first presentation25% sent home at first presentation Elderly 50% of all mortalityElderly 50% of all mortality
ELDERLY ACUTE APPENDICITISELDERLY ACUTE APPENDICITISELDERLY ACUTE APPENDICITISELDERLY ACUTE APPENDICITIS Nausea, vomiting, anorexia <50%Nausea, vomiting, anorexia <50%, g,, g, Pain Migration Pain Migration <50%<50% AfebrileAfebrile 2020 50%50% AfebrileAfebrile 2020--50%50% Normal WBCNormal WBC 2020--45%45% U/A may show RBCs +/U/A may show RBCs +/-- WBCs (leading to WBCs (leading to
misdiagnosis as UTI, cystitis, renal colic)misdiagnosis as UTI, cystitis, renal colic) >50% >50% perfperf rate @ time of diagnosisrate @ time of diagnosis Delay in presentation (3Delay in presentation (3--7/7 common)7/7 common) Delay in presentation (3Delay in presentation (3 7/7 common)7/7 common)
RUPTURED AAARUPTURED AAARUPTURED AAARUPTURED AAA
Even when rapid diagnosis made, Even when rapid diagnosis made, mortality >70%mortality >70%yy
Rate of misdiagnosis as high as 30Rate of misdiagnosis as high as 30--40%40%Only 5% of patients with rupture haveOnly 5% of patients with rupture have Only 5% of patients with rupture have Only 5% of patients with rupture have known AAA on presentationknown AAA on presentation
RUPTURED AAARUPTURED AAASYMPTOMSSYMPTOMS
AbdoAbdo +/+/-- Back painBack pain
HypotensionHypotension
Palpable pulsating tender abdominal aortaPalpable pulsating tender abdominal aorta
RUPTURED ABDOMINAL AORTIC RUPTURED ABDOMINAL AORTIC ANEURYSMANEURYSMANEURYSMANEURYSM
Often misdiagnosedOften misdiagnosed Severe “tearing” Severe “tearing” gg
abdominal pain abdominal pain radiating through to radiating through to b kb kbackback
Radiates to: flanksRadiates to: flanksthighsthighstestestestes
RUPTURED AAARUPTURED AAASYMPTOMSSYMPTOMS
AbdoAbdo pain absent in 20pain absent in 20--30%30% Back pain absent in 50%Back pain absent in 50% Back pain absent in 50%Back pain absent in 50% Hypotension absent in 65%Hypotension absent in 65%
T h di b t i 50%T h di b t i 50% Tachycardia absent in 50%Tachycardia absent in 50% Palpable aorta absent in 30%Palpable aorta absent in 30%
RUPTURED AAARUPTURED AAAPRESENTATIONSPRESENTATIONS
Presents as syncope in 18%Presents as syncope in 18%
May simulate renal colicMay simulate renal colicMost common misdiagnosisMost common misdiagnosis Most common misdiagnosisMost common misdiagnosis
Sharp sudden pain in flank often radiates to groinSharp sudden pain in flank often radiates to groin Can have microscopicCan have microscopic haematuriahaematuria Can have microscopic Can have microscopic haematuriahaematuria
OSLEROSLEROSLEROSLER
“There is no disease more conducive to “There is no disease more conducive to clinical humility than aneurysm of theclinical humility than aneurysm of theclinical humility than aneurysm of the clinical humility than aneurysm of the aorta”aorta”
MESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIA
Risk FactorsRisk Factors AtrialAtrial FibrillationFibrillation Dig and other drugs can slow Dig and other drugs can slow sphlancnicsphlancnic blood blood
flowflowR MIR MI Recent MI Recent MI
Low cardiac output CHF, Low cardiac output CHF, cardiomyopathycardiomyopathy HypercoagulableHypercoagulable statesstates HypercoagulableHypercoagulable statesstates
THR01.4BOSIS OF
1.4E.SENTERIC VEIN
THROMBOSIS OF
MESENTERIC ARTERY
MESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIA
Often misdiagnosed as GastroenteritisOften misdiagnosed as Gastroenteritis Nausea and Anorexia 80%Nausea and Anorexia 80% Vomiting 60%Vomiting 60% Diarrhoea 50%Diarrhoea 50%
Blood products in Stool (gross or occult) in Blood products in Stool (gross or occult) in <50%<50%
THINK OF MESENTERIC THINK OF MESENTERIC ISCHAEMIA!ISCHAEMIA!
Sudden onset Abdominal Pain (also AAA)Sudden onset Abdominal Pain (also AAA)Lower GI Bleed +Lower GI Bleed + AbdoAbdo PainPain Lower GI Bleed + Lower GI Bleed + AbdoAbdo PainPain
AtrialAtrial Fibrillation + Fibrillation + AbdoAbdo PainPainS CHFS CHF AbdAbd P iP i Severe CHF + Severe CHF + AbdoAbdo PainPain
Patients on Patients on DigoxinDigoxin + + AbdoAbdo PainPain Pain out of proportion to abdominal findingsPain out of proportion to abdominal findings Recent history of pain after eating Recent history of pain after eating ––
“ t i i ”“ t i i ”“mesenteric angina”“mesenteric angina”
MESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIATESTSTESTS
LeucocytosisLeucocytosis Lactic AcidosisLactic Acidosis Lactic AcidosisLactic Acidosis CT high resolutionCT high resolution
E l i hE l i h till G ld St d dtill G ld St d d Early angiography Early angiography –– still Gold Standardstill Gold Standard
High mortality which improves with early High mortality which improves with early diagnosisdiagnosisgg
ACUTE CHOLECYSTITISACUTE CHOLECYSTITISACUTE CHOLECYSTITISACUTE CHOLECYSTITIS
Most common cause of surgical abdominal Most common cause of surgical abdominal disease in the elderlydisease in the elderlyyy
1010--15% mortality in elderly15% mortality in elderlyGallbladder is more likely to perforate dueGallbladder is more likely to perforate due Gallbladder is more likely to perforate due Gallbladder is more likely to perforate due to thin calcified wallto thin calcified wall
• • I • • • • • I I I I I • • • I • • • • I
I I
• • • •
ACUTE CHOLECYSTITISACUTE CHOLECYSTITISSYMPTOMSSYMPTOMS
Nausea/vomiting absent in 50Nausea/vomiting absent in 50--60%60% Fever absent in 56%Fever absent in 56% Fever absent in 56%Fever absent in 56% WBC < 10,000 in 40%WBC < 10,000 in 40%
13%13% Af b ilAf b il ith llith ll ll l bl b 13% 13% AfebrileAfebrile with all with all normlnorml labslabs 16% no RUQ or 16% no RUQ or epigastricepigastric painpain 5% no 5% no abdoabdo pain at all! (these can have pain at all! (these can have
altered mental status)altered mental status)))
TAKE HOME MESSAGESTAKE HOME MESSAGESTAKE HOME MESSAGESTAKE HOME MESSAGES The elderly are not just “old” adultsThe elderly are not just “old” adults The elderly are not just old adultsThe elderly are not just old adults
Different diseasesDifferent diseases Different presentationsDifferent presentations Different presentationsDifferent presentations Different MindsetDifferent Mindset
Physiological changes occur with ageingPhysiological changes occur with ageing Physiological changes occur with ageingPhysiological changes occur with ageing Pharmacokinetics changes due to Pharmacokinetics changes due to
PolypharmacyPolypharmacy PolypharmacyPolypharmacy Increased risk of adverse drug effectsIncreased risk of adverse drug effects
TAKE HOME MESSAGES IITAKE HOME MESSAGES IITAKE HOME MESSAGES IITAKE HOME MESSAGES II
Some lab parameters change with ageingSome lab parameters change with ageing Acute functional decline presentations canAcute functional decline presentations can Acute functional decline presentations can Acute functional decline presentations can
mask acute illnessmask acute illness
Atypical presentations occur for common Atypical presentations occur for common dididiseasesdiseases
ACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTS
AmalAmal MattuMattu Frank NetterFrank Netter Frank NetterFrank Netter Emergency Medicine Clinics of N. AmericaEmergency Medicine Clinics of N. America
Vol 29 various articlesVol 29 various articles Vol 29, various articlesVol 29, various articles
Parker. Acad. Parker. Acad. EmEm Med 1997Med 1997
ASSESSMENT OF THE ABDOMENASSESSMENT OF THE ABDOMENASSESSMENT OF THE ABDOMENASSESSMENT OF THE ABDOMEN
HISTORYHISTORY
VITAL SIGNSVITAL SIGNS
PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT
SOME COMMON CONDITIONSSOME COMMON CONDITIONS SOME COMMON CONDITIONSSOME COMMON CONDITIONS
ABDOMINALLYABDOMINALLY--FOCUSSED FOCUSSED HISTORYHISTORY
Pain level and nature of onsetPain level and nature of onset Recent diet including alcoholRecent diet including alcoholgg Upper GIT symptomsUpper GIT symptoms
Appetite, weight loss, nausea, dry reaching, Appetite, weight loss, nausea, dry reaching, g gg gvomiting, haematemesisvomiting, haematemesis
Lower GIT symptomsLower GIT symptomsdiarrhoea, abdominal cramps, constipation, blood in diarrhoea, abdominal cramps, constipation, blood in stools, stool colour, amount, consistencystools, stool colour, amount, consistency
ABDOMINALLYABDOMINALLY--FOCUSSED FOCUSSED HISTORYHISTORY
Longstanding History of Bowel ProblemsLongstanding History of Bowel Problemse.g. Crohn’s disease, Ulcerative colitis,e.g. Crohn’s disease, Ulcerative colitis,e.g. Crohn s disease, Ulcerative colitis, e.g. Crohn s disease, Ulcerative colitis,
Haemorrhoids, Diverticular diseaseHaemorrhoids, Diverticular disease
Urinary SymptomsUrinary Symptoms Urinary SymptomsUrinary SymptomsBlood, pain, frequencyBlood, pain, frequency
Menstrual history in the femaleMenstrual history in the female Menstrual history in the femaleMenstrual history in the femaleLast period, contraceptive use etc.Last period, contraceptive use etc.
OTHER IMPORTANT THINGS IN OTHER IMPORTANT THINGS IN THE HISTORYTHE HISTORY
MedicationsMedications
Mechanism of Injury if traumaMechanism of Injury if trauma
AllergiesAllergies
ABDOMINAL PAINABDOMINAL PAINASSESSMENTASSESSMENT
Airway Airway Assess PatencyAssess Patency
BreathingBreathing Respiratory rate and effortRespiratory rate and effortOxygen saturationsOxygen saturationsOxygen saturationsOxygen saturationsListen to chestListen to chest
DisabilityDisability Note level of consciousnessNote level of consciousness
ABDOMINAL PAINABDOMINAL PAINCIRCULATIONCIRCULATION
AssessmentAssessment InterventionsInterventions
Skin TemperatureSkin TemperaturePulse rate/rhythmPulse rate/rhythm
IV cannulationIV cannulationPathology testsPathology testsPulse rate/rhythmPulse rate/rhythm
Capillary refillCapillary refillBlood pressureBlood pressure
Pathology testsPathology tests FBC/UECFBC/UEC ?LFT’s, Amylase, Gp&Hold?LFT’s, Amylase, Gp&HoldBlood pressureBlood pressure
Cardiac MonitorCardiac Monitor IV Normal Saline if shockIV Normal Saline if shockMonitor vital signsMonitor vital signsgg
VITAL SIGNSVITAL SIGNSVITAL SIGNSVITAL SIGNS
ESSENTIAL!!ESSENTIAL!! TemperatureTemperature <36 0<36 0 >37 2>37 2 TemperatureTemperature <36.0<36.0 >37.2>37.2 PulsePulse <60<60 >120>120
RRRR 1010 2424 RRRR <10<10 >24>24 SystolicSystolic BPBP <90<90 >180>180 Diastolic BPDiastolic BP >110>110 Urinalysis and colourUrinalysis and colour Urinalysis and colourUrinalysis and colour
ASSESSMENTASSESSMENTSTATE OF HYDRATIONSTATE OF HYDRATION
Signs of DehydrationSigns of Dehydration Decreased urine outputDecreased urine outputpp Dry mouthDry mouth Decreased skin turgorDecreased skin turgor TachypnoeaTachypnoea Empty fontanelle in childrenEmpty fontanelle in children
P t l T h di d H t iP t l T h di d H t i Postural Tachycardia and HypotensionPostural Tachycardia and Hypotension Supine Tachycardia and HypotensionSupine Tachycardia and Hypotension
ASSESSMENTASSESSMENTLEVEL OF BLOOD LOSSLEVEL OF BLOOD LOSS
< 20% V l< 20% V l < 20% Volume< 20% Volume Cool, pale moist skinCool, pale moist skin Collapsed neck veinsCollapsed neck veins
C t t d iC t t d i Concentrated urineConcentrated urine Postural hypotension and tachycardiaPostural hypotension and tachycardia
2020 40% Volume40% Volume 2020-- 40% Volume40% Volume ThirstThirst Supine hypotension and tachycardiaSupine hypotension and tachycardia
> 40% Volume> 40% Volume Agitation, confusion, obtundationAgitation, confusion, obtundation TachypnoeaTachypnoea
ABDOMINAL PAINABDOMINAL PAINHYDRATION INTERVENTIONSHYDRATION INTERVENTIONS
Indwelling catheterIndwelling catheter Indwelling catheterIndwelling catheterHourly urine measuresHourly urine measures
Fluid balanceFluid balance
VISUAL ASSESSMENTVISUAL ASSESSMENTVISUAL ASSESSMENTVISUAL ASSESSMENT
General appearanceGeneral appearanceJaundiceJaundice
P itiP iti PositionPositionLying still Lying still –– peritonitisperitonitisRolling aroundRolling around –– coliccolicRolling around Rolling around coliccolic
AbdomenAbdomenFlat or distendedFlat or distendedPulsatingPulsating
Scars, StriaeScars, Striae
PHYSICAL ASSESSMENTPHYSICAL ASSESSMENTPHYSICAL ASSESSMENTPHYSICAL ASSESSMENT
AUSCULTATIONAUSCULTATION Many bowel soundsMany bowel sounds No bowel soundsNo bowel sounds BruitsBruits
PERCUSSIONPERCUSSION
ABDOMINAL ASSESSMENTABDOMINAL ASSESSMENTMEASURE AND TESTMEASURE AND TEST
Pain Score Pain Score If Pain score 4If Pain score 4 –– 10 give IV or IM Morphine10 give IV or IM Morphine If Pain score 4 If Pain score 4 10 give IV or IM Morphine10 give IV or IM Morphine
Fingerprick BSLFingerprick BSL Fingerprick BSLFingerprick BSL
Urine TestingUrine Testing U/A, HCG, collect MSUU/A, HCG, collect MSU
ABDOMINAL PAINABDOMINAL PAINSPECIFIC TREATMENTSPECIFIC TREATMENTSPECIFIC TREATMENTSPECIFIC TREATMENT
Nil by MouthNil by MouthBowel restBowel restPreparation for theatrePreparation for theatre
Nasogastric TubeNasogastric Tube Nasogastric TubeNasogastric TubeFree drainage/amount of drainageFree drainage/amount of drainageLow suctionLow suctionLow suctionLow suction
Intravenous FluidsIntravenous FluidsHydrationHydrationHydrationHydrationBowel restBowel rest
Nausea and VomitingNausea and VomitingggIM ProchlorperazineIM Prochlorperazine
ABDOMINAL PAINABDOMINAL PAINMEDICATIONSMEDICATIONSMEDICATIONSMEDICATIONS
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ABDOMINAL PAINABDOMINAL PAINABDOMINAL PAINABDOMINAL PAIN
3 TYPES:3 TYPES:
VISCERALVISCERAL
PARIETALPARIETAL
REFERREDREFERRED
VISCERAL PAINVISCERAL PAINVISCERAL PAINVISCERAL PAIN
Mediated by autonomic Mediated by autonomic nerve fibresnerve fibresO i i t i bd i lO i i t i bd i l Originates in abdominal Originates in abdominal organsorgans
Character:Character: Character:Character:DiffuseDiffusePoorly localizedPoorly localizedIllIll d fi dd fi dIllIll--defineddefinedIntermittentIntermittent
Typically midlineTypically midlineyp yyp y
PERIUMBILICAL PAINPERIUMBILICAL PAINPERIUMBILICAL PAINPERIUMBILICAL PAIN
Acute appendicitisAcute appendicitis
Acute small gut Acute small gut obstructionobstruction
Simple intestinal colicSimple intestinal colicpp
Acute pancreatitisAcute pancreatitisAcute pancreatitisAcute pancreatitis
RIGHT ILIAC FOSSA PAINRIGHT ILIAC FOSSA PAINRIGHT ILIAC FOSSA PAINRIGHT ILIAC FOSSA PAIN
AppendicitisAppendicitis Leaking duodenal Leaking duodenal gg
ulcerulcer PyelonephritisPyelonephritis Crohn’s diseaseCrohn’s disease Mesenteric adenitisMesenteric adenitis Cholecystitis (low Cholecystitis (low
gallbladdergallbladder
RIGHT HYPOCHONDRIAL PAINRIGHT HYPOCHONDRIAL PAINRIGHT HYPOCHONDRIAL PAINRIGHT HYPOCHONDRIAL PAIN
Acute cholecystitisAcute cholecystitisyy Leaking duodenal Leaking duodenal
ulcerulcer Appendicitis with high Appendicitis with high
appendixappendix PyelonephritisPyelonephritis Pleural irritationPleural irritation
VISCERAL PAINVISCERAL PAINVISCERAL PAINVISCERAL PAIN
“Cramping, burning, aching, dull, colicky, gassy”“Cramping, burning, aching, dull, colicky, gassy” Accompanied by:Accompanied by:
NauseaNauseaNauseaNauseaVomitingVomitingDiaphoresisDiaphoresis Autonomic responsesAutonomic responsespp pp
TachycardiaTachycardiaPallorPallorR lR lRestlessnessRestlessness
Causes:Causes:Appendicitis, Cholecystitis, Intestinal ObstructionAppendicitis, Cholecystitis, Intestinal ObstructionAppendicitis, Cholecystitis, Intestinal ObstructionAppendicitis, Cholecystitis, Intestinal Obstruction
PARIETAL PAINPARIETAL PAINPARIETAL PAINPARIETAL PAIN
Develops after visceral painDevelops after visceral pain Originates in parietal peritoneumOriginates in parietal peritoneum Originates in parietal peritoneumOriginates in parietal peritoneum Cause: Cause: InflammationInflammation
t dt dsteadysteadyachingaching than visceral painthan visceral painmore severemore severe
PARIETAL PAINPARIETAL PAINPARIETAL PAINPARIETAL PAIN
Aggravated by Aggravated by changes in peritoneal changes in peritoneal tensiontensiontensiontension
palpationpalpationmovementmovementmovementmovementcoughingcoughingsneezingsneezingsneezingsneezing
More localized to site More localized to site of underlying diseaseof underlying diseasey gy g
REFERRED PAINREFERRED PAINREFERRED PAINREFERRED PAIN
Perceived at site distant Perceived at site distant from primary affected from primary affected organsorgansorgansorgans
Distant site innervated atDistant site innervated at Distant site innervated at Distant site innervated at spinal level of affected spinal level of affected organsorgans
Travels from initial site of Travels from initial site of painpainpainpain
MURPHY’S SIGNMURPHY’S SIGNMURPHY’S SIGNMURPHY’S SIGN
GASTROENTERITISGASTROENTERITISGASTROENTERITISGASTROENTERITIS
Mild to severe cramping Mild to severe cramping and painand pain
Nausea, vomiting, dry Nausea, vomiting, dry , g, y, g, yreaching diarrhoeareaching diarrhoea
NoNo involuntary guardinginvoluntary guarding NoNo involuntary guardinginvoluntary guarding NoNo localized tendernesslocalized tenderness NoNo peritonismperitonism
If any of the above, it is If any of the above, it is probably NOT gastroprobably NOT gastro
INTESTINAL PERFORATIONINTESTINAL PERFORATIONINTESTINAL PERFORATIONINTESTINAL PERFORATION
Sudden, severe, Sudden, severe, agonizing mid to agonizing mid to lower abdominal painlower abdominal painlower abdominal painlower abdominal pain
Nausea and vomiting Nausea and vomiting are commonare commonare commonare common
Abdomen is rigid and Abdomen is rigid and tendertender
Commonly history of Commonly history of diverticular diseasediverticular disease
REFERRED PAINREFERRED PAINREFERRED PAINREFERRED PAIN
Perceived at site distant Perceived at site distant from primary affected from primary affected organsorgansorgansorgans
Distant site innervated atDistant site innervated at Distant site innervated at Distant site innervated at spinal level of affected spinal level of affected organsorgans
Travels from initial site of Travels from initial site of painpainpainpain
APPENDICITISAPPENDICITISAPPENDICITISAPPENDICITIS
CommonCommon Incidence peaks in teensIncidence peaks in teens PainPain
colicky around navel colicky around navel (visceral)(visceral)
moves to RLQ (parietal)moves to RLQ (parietal)
Anorexia, nausea, Anorexia, nausea, vomitingvomitingvomitingvomiting
Fever (mild)Fever (mild) Altered bowel habitAltered bowel habit
APPENDICITISAPPENDICITISAPPENDICITISAPPENDICITIS
Localised tendernessLocalised tenderness InvestigationsInvestigationsgg
UltrasoundUltrasound CT scanCT scan
C li tiC li ti ComplicationsComplications PerforationPerforation AbscessAbscess
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONCAUSESCAUSES
MECHANICALMECHANICAL AdhesionsAdhesions TumoursTumours HerniaHernia VolvulusVolvulus
Crohn’sCrohn’s Diverticular diseaseDiverticular disease Faecal ImpactionFaecal Impaction
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONCAUSESCAUSES
PARALYTIC ILEUSPARALYTIC ILEUS
Intraabdominal: peritonitis, pancreatitis, postoperativeIntraabdominal: peritonitis, pancreatitis, postoperative Extraabdominal: Postoperative, pneumonia, spinal traumaExtraabdominal: Postoperative, pneumonia, spinal trauma
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONSIGNS AND SYMPTOMSSIGNS AND SYMPTOMS
Abdominal painAbdominal pain DistensionDistension Nausea and VomitingNausea and Vomiting Hyper/hypoactive bowel Hyper/hypoactive bowel
soundssounds ConstipationConstipation
Fever/ChillsFever/Chills
dd Deteriorating conditionDeteriorating condition Think of bowel Think of bowel
ischaemia/necrosisischaemia/necrosis
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONPHYSICAL EXAMINATIONPHYSICAL EXAMINATION
ObservationObservation Writhing or lying quietlyWrithing or lying quietly Abdominal girthAbdominal girth
Di t iDi t i DistensionDistension
AuscultationAuscultation Bowel soundsBowel sounds Bowel soundsBowel sounds
PercussionPercussion Tympanitic noteTympanitic note Tympanitic noteTympanitic note
PalpationPalpation Localised tendernessLocalised tenderness
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONMANAGEMENTMANAGEMENT
Relieve distensionRelieve distension Decompression by NG Decompression by NG
SuctionSuctionSuctionSuctionRelieves pain and Relieves pain and distressdistress
f hf hPrevents further Prevents further nausea and vomitingnausea and vomiting
EnemasEnemas
Nil by mouthNil by mouthNil by mouthNil by mouth
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONMANAGEMENTMANAGEMENT
Restore fluid and electrolyte balanceRestore fluid and electrolyte balance
IV FluidsIV Fluids
PotassiumPotassium SodiumSodium
Chl idChl id ChlorideChloride
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONMANAGEMENTMANAGEMENT
Ongoing careOngoing care Abdominal girthAbdominal girthgg Record intake and outputRecord intake and output Electrolytes and enzymes monitoredElectrolytes and enzymes monitored
Attention to Pain ManagementAttention to Pain Management Explain aspects of care to PatientExplain aspects of care to Patient
UPPER GASTROINTESTINAL UPPER GASTROINTESTINAL BLEEDINGBLEEDING
CAUSESCAUSES
Peptic UlcersPeptic UlcersGastritisGastritisGastritisGastritisOesophageal VaricesOesophageal VaricesOesophagitisOesophagitisOesophagitisOesophagitisMalloryMallory--Weiss TearWeiss Tear
UPPER GASTROINTESTINAL UPPER GASTROINTESTINAL BLEEDINGBLEEDING
Important Clinical Important Clinical SignsSigns
Pulse > 100/min shockPulse > 100/min shockBP < 100 systolicBP < 100 systolicMeleana stools purple toMeleana stools purple toMeleana stools purple to Meleana stools purple to
blackblackVomitus coffee grounds Vomitus coffee grounds
to bright redto bright redto bright redto bright redHaematochezia bright Haematochezia bright
red rectal bleedred rectal bleedAbdominal painAbdominal painAbdominal painAbdominal pain
UPPER GASTROINTESTINAL UPPER GASTROINTESTINAL BLEEDINGBLEEDINGBLEEDINGBLEEDING
SIGNSSIGNS Important HistoryImportant History
Recent vomitingRecent vomiting Alcohol AbuseAlcohol Abuse NSAID useNSAID use Steroids/anticoagulantsSteroids/anticoagulantsgg
InvestigationInvestigationgg endoscopyendoscopy
UPPER GASTROINTESTINAL UPPER GASTROINTESTINAL BLEEDINGBLEEDINGBLEEDINGBLEEDING
MANAGEMENTMANAGEMENT Restore VolumeRestore Volume
IV fluidsIV fluids BloodBlood
H2 AntagonistsH2 Antagonists AntacidsAntacids VaricesVarices
VasopressinVasopressin SclerotherapySclerotherapy
DietDiet High Mortality (10%)High Mortality (10%)
BILIARY COLICBILIARY COLICBILIARY COLICBILIARY COLIC
Post ingestion of foodPost ingestion of food Begins abruptlyBegins abruptlyg p yg p y Subsides gradually (up to 6 hrs)Subsides gradually (up to 6 hrs) Epigastric, may radiate to left Epigastric, may radiate to left oror rightright
D hi ith t t l itiD hi ith t t l iti Dry reaching without actual vomitingDry reaching without actual vomiting Usually prior attacksUsually prior attacks
PERFORATED PEPTIC ULCERPERFORATED PEPTIC ULCERPERFORATED PEPTIC ULCERPERFORATED PEPTIC ULCER
SuddenSudden severe abdominal painSh ld i Shoulder pain
Generalized peritonitisA tii fl t i Antiinflammatories
Fluid may track down paracolic guttersparacolic gutters
X-ray may show gas under diaphragmp g
GAS UNDER THE DIAPHRAGMGAS UNDER THE DIAPHRAGMGAS UNDER THE DIAPHRAGMGAS UNDER THE DIAPHRAGM
URETERIC COLICURETERIC COLICURETERIC COLICURETERIC COLIC
Sudden, severe flank Sudden, severe flank pain followed by pain followed by some degree ofsome degree ofsome degree of some degree of haematuriahaematuria
History of stonesHistory of stones
May radiate to testis May radiate to testis and tip of penisand tip of penis
PYELONEPHRITISPYELONEPHRITIS
DysuriaDysuria Frequency Frequency
FeverFever FeverFever Sometimes rigorsSometimes rigors Pain over costovertebral Pain over costovertebral
angle or lateral abdomenangle or lateral abdomen Nausea, vomiting, Nausea, vomiting,
malaisemalaisemalaisemalaise Bacteria and leukocytes Bacteria and leukocytes
on urine microscopyon urine microscopy
ECTOPIC PREGNANCY WITH ECTOPIC PREGNANCY WITH RUPTURERUPTURE
Sudden severe pelvic Sudden severe pelvic pain spreading pain spreading upwardsupwardsupwardsupwards
Referred to shoulder Referred to shoulder if free bloodif free bloodif free bloodif free blood
Pain may be vague or Pain may be vague or intermittentintermittent
Symptoms of Symptoms of pregnancypregnancy
ECTOPIC PREGNANCY WITH ECTOPIC PREGNANCY WITH RUPTURERUPTURE
Pain radiates to low Pain radiates to low back and thighsback and thighs
Similar to menstrual Similar to menstrual pain (worse)pain (worse)
Pallor ++Pallor ++ VeryVery tender P.V.tender P.V. Bluish cervixBluish cervix
RUPTURED ABDOMINAL AORTIC RUPTURED ABDOMINAL AORTIC ANEURYSMANEURYSM
RUPTURED ABDOMINAL AORTIC RUPTURED ABDOMINAL AORTIC ANEURYSMANEURYSM
Signs of bleeding presentSigns of bleeding present
May be a palpable midline May be a palpable midline pulsating masspulsating mass
Lateral abdominal xLateral abdominal x--ray ray will show aneurysm in will show aneurysm in 90% of cases90% of cases