ACUTE ABDOMEN

DivisionExternal:

Ant. Abdomen.Post abdomen.Flank

InternalTrue abdomenThoracic partPelvic part.

Retroperitoneal

When to admit patientPain less than 48 hours.

Followed by vomiting.

History of: trauma, operation or hemorrhage.

History of loss of consciousness: because even in acute

pain abdomen is lax.

Extreme of age: they don’t have enough omentum to

protect from infection.

Abnormal physical sign:Tenderness. Distension.Rigidity. Guarding.Bowl sound: absent, hyperactive or

tingling.

Investigation:CBC.Urea.Lytes.PtPTT.Urine analysis.LFT.Serum amylase.Lipase.

Radiology.Plain abdominal x-ray.Erect: airUnder diaphragm.Air fluid level.Psoas shadow.Supine: To detect Distention and caliper of

bowlContrast study: Contraindicated in perforated

gut. Because it may cause granuloma.Gastrographine.IVP.

Endoscope:Upper GIT endoscope.Sigmoidoscope.Colonoscopy.

Emergency US: For renal, billiary or peritoneal dis.

Emergency CT: don’t pay unstable pt outside ER.

Abdominal lavage: It is rapid and sensitive.

Emergency laparoscopy: But you must have the facility.

Causes of acute abdomenMedical:

MILobar pneumonia.Diabetic ketoacidosis.Acute hepatitis.Congenital spherocytosis.Henoch-schonlen purpura.Congenital erythropoietin hepatic porphyriasis.Herpes zoster.Lead poisoning.Campylobacter infection.

Peritonitis:Acute peritonitis:

Bacterial:Primary: In immunocompromise patient. like:

pediatrics, female, chronic liver diseases, chronic renal failure.

Secondary: Chloecystitis, appendicitis and diverticulitis.

Non-bacterial: Rupture or leakage of bile. Chronic peritonitis:

Bacterial: Like TB and bovine.Non bacterial: Granuloma

Surgical:

Pneumoperitonium:Causes:

After laporotomy, abdominal pacentesis and peritoneal dialysis.

Gyn causes.After GIT endoscope.Escape of air from trachiobronchial tree.Pneumotosis cystoids intestinalis. (v-rare).

It will lead to peritonitis.Haemoperitonium:

Clinically, patient present with shock.Causes: Trauma, surgery, pelvic fracture, ectopic pregnancy,

2ry peritoneal carcinomatosis, abdominal aneurysm and hemorrhage or clotting disorders.

Ascitis:Fluid in abdomen clinically detected if reaches 1 liter.Causes:

Lymph obstruction.Liver dis.Inflammatory dis.Malignant dis.

Color of fluid: Serous. Chylous milky lymph obstruction malignancy. Pseudochylous turbid malignancy. Blood stain. Myxomatous mucous tumor of mexomatous cells.

Intractable ascitis:Massive and not respond to treatment.Causes: budd-chiary syndrome, advanced chronic liver disease and

peritoneal carcinomatosis.Lab: US and aspiration.

Mesenteric ischemia:Types:

Occlusive:Vein Artery 90%

Non-occlusive.FATAL GANGRENE.

Clinically: Sever pain, without any physical sign.

Intestinal obstruction:Mechanical:

Acute: pain and vomiting. Subacute off\on adhesive most commonly post-op. Chronic: something grows in the abdomen. Acute on chronic serius Dx.

Paralytic: 2ry to:

Late stage of mechanical obstruction. Anti-cholinergic drugs. Metabolic disturbance hypokalemia. Mesenteric ischemia. Peritonitis.

Management: Supportive: IV fluid, urinary catheter and NG tube. Surgery.

CPR

CARDIO-PULMONARY

RESUSCITATION

Candidates for CPR:

Compromised vital signs including oxygen

saturation.

Compromised conciousness.

ill appearance of patient.

Now you know this patient is critical!!

what to do?

Talk to the patent and look for his

response

Start ABC

If you come to the circulation and there is

no carotid pulse (don't compress for more

than 10 sec on the carotid pulse) start CPR

What is CPR?

Cardio pulmonary resuscitation

It is a cycles of compression and

artificial breathing.

How to do it?Hand position: Palm of the hands two fingers above

the xyphoid process .

Lock the elbows and press by your shoulders.

Shoulder should be vertical to your hands.

In infants compression by thumbs.

In children 1-8 years by the heal of one hand.

Depth of compression 1/3 of the AP diameter of the

chest (in adults 3cm).

In the hospital:

Give 5 compressions and one breath by ambu bag

In public:

If there is any assistance let him give two breaths

If you’re alone give 15 compressions then give one

breath for four cycles and then check the pulse

If there is no pulse repeat cycle. If you gain pulse

STOP CPR.

Aim: 100 compressions / min

1-Airway management

It's the first thing to do in ABCDE (A; airway

management and c-spine stabilization, B: breathing, C;

circulation, D ; disability, E: exposure)

We stabilize the c-spine by cervical collar and by

putting the patient on hard backboard.

Assessment of air way before assessing the airway we ask the patient are you ok. and

we look for his response

if the patient is talking this mean his airway is patent

if he is woning or unresponsive we do gaga reflex and look

If gaga reflex is present this mean the patient can protect his

airway only if you maintain it.

if no gaga this patient can't protect his airway so you have to

intubate him.

if the patient is wheezing or snoring this mean his airway is

obstructed.

A - Techniques :

head-tilt/chin left maneuver; It's contraindicated in head or

neck trauma where injury to c-spines if suspected

jaw thrust; suitable for trauma patient.

B- Instrument :

Oropharyngeal airway: It`s used to maintain the airway

and to prevent tongue fall. And also for aspiration of

secretion.

2-Airway management

Q ; how you check for it's fitness?

A; if it's length is equal to the distance between the

angel of mouth and the angel of mandible this mean its

appropriate and it can fit.

it is contraindicated in conscious patient

Endotracheal tubeIt's definitive airway because it protect and maintain the

airway.

● indication :

Orofacial trauma .

To prevent aspiration .

Apanic patient .

Sever shock and hypoxia with need to ventilator.

If you failed to secure the airways after all of that go for

other definitive airway which is cricothyrodectomy

[surgical airway]

This done by inserting a needle in hyoid membrane

between the cricoid cartilage and hyoid bone.

If you failed ask for trachestomy

other instruments are ventory mask and non-rebreathing

facial mask (it gives up to 85% of oxygen ) ,oxygen nasal

canula (it gives low concentration of oxygen about 40%).

Q : what is the diff. Between child and adult

laryngeoscope ?

The bald is strait and short in children

larygeoscope.

You have to oxygenated every patient by ambu or by

facial mask.

Q : How you do intubation? A : by 5 steps

 1- Prepare equipment and patient

Equipments are ETT,syringe to inflate ETT cuff, laryngeoscope ,k/y gel.

2- preoxygenate the patient. By ambuo baging for 5min. It can gives 100% oxg. Saturation.

3- premedicate .Sedation by propafol.Analgesia by morphin.Muscle relaxant by succinyl choline.In comatose patient give only muscle relaxant.

4- passing the tube.

5- post intubation assessment.

Auscultate first in the epigastrium (if there is no

air entry it is mean your tube is not in the

esophagus).

Auscultate all over the chest and listen for equal

air entry to make sure that your tube is in the

trachea.

visualization ; Look if the tube is going through the vocal

cords.

X-ray .