Abdominal Pain

Definition: (Acute Abdomen)

This is a term used to define a group of abdominal conditions in which early surgical treatment must be considered.

Few medical conditions mimic surgical conditions and sometime un-necessary surgery is performed e.g;
Some patient with myocardial infarction just present with epigastric pain and vomiting.
Patient of diabetes ketoacidosis or porphyria may present with abdominal pain.



Cases in Surgical Emergency present with abdominal pain:

Pain due to Inflammation:
Appendicitis.
Cholecystitis.
Pancreatitis.
Intra-abdominal abscess.
Pelvic inflammation disease.

Pain due to Perforation:
Peptic Ulcer.
Ovarian Cyst.

Pain due to Vascular Ischemia:
Ruptured aortic aneurysm.
Mesenteric infarction.

Pain due to Obstruction:
Intestinal Obstruction.
Ureteric Colic.



Cases in Medical Emergency present with Abdominal pain:

Referred pain:
Myocardial Infarction.
Pneumonia.

Metabolic Causes:
DKA.
Lead poisoning.

Functional Gastrointestinal Disorders:
Irritable Bowel Syndrome.

Renal Causes:
Acute pyelonephritis

Hematological Causes:
Sickle cell crisis.
Hemophilia.
Purpura.

Vasculitis:
Embolic.

Mechanism of Abdominal pain:

1. Visceral pain.
2. Referred pain.
3. Miscellaneous.

1. Visceral pain:

Irritation or Inflammation of peritoneum.

Vascular Insufficiency.

Spasm of hallow viscus.

Stretching of capsule of solid organs.

Ulceration of tissues.

2. Referred pain:

From the chest.

From the vertebral column.

From the Gonads.

3. Miscellaneous:

Metabolic disorders.

Psychogenic disturbances.

Cerebral Vascular Accident (CVA)

Stroke:
Definition:

Stroke is an acute brain disorder of vascular origin accompanied by neurological dysfunction that persists for longer than 24 hours.
The neurological dysfunction can be Focal and Global.

Focal; which is typical of vascular occlusion.
Global; it can occur when vascular rupture leads to hemorrhage and mass effect.

Classification of Stroke:
It can classified according to the different causes;

1. Ischemic.
2. Hemorrhagic.

1. Ischemic Stroke:

Shock

Definition:
It is a systemic state of low tissue perfusion, which inadequate for normal cellular respiration, with insufficient delivery of oxygen and glucose, cell switch from aerobic metabolism to anaerobic metabolism.
Pathophysiology:

• Cellular.
• Microvascular.
• Systemic.
• Ischemia-reperfusion syndrome.

Cellular: As perfusion of tissues reduced, the respiration switch from aerobic to anaerobic respiration, the end product of anaerobic respiration is not carbon-dioxide while it is lactic acid that cause metabolic acidosis.

Microvascular: As tissue ischemia progresses, changes in local milieu result in activation of the immune and coagulation system.

Systemic: There are many system involves;

CVS; Tachycardia, Decreased Blood pressure.

Respiratory system; Metabolic acidosis that cause respiratory alkalosis , reduced CO2 lead to Hyperventilation.

Renal System; Decreased perfusion pressure in the kidney leads to reduced filtration at the glomerulus and a decreased urine output.

Endocrine; Activation of sympathetic system.

Ischemia-reperfusion syndrome:

During the period of Ischemia, hypoperfusion, cellular and organ damage progresses because of direct effects of tissue hypoxia and local activation of inflammation.

Classification of Shock:

1. Hypovolaemic Shock.
2. Cardiogenic Shock.
3. Obstructive Shock.
4. Distributive Shock.
5. Endocrine Shock.
6. Anaphylatic Shock
7. Neurogenic Shock.
8. Septic Shock.

Classification of Shock

Severity of Shock:

• Compensated Shock.
• Decompensated Shock.
• Mild Shock.
• Moderate Shock.
• Severe Shock.

Multiple Organ failure Due to Shock:

Multiple organ failure is defined as two or more failed organ systems.

There is no specific treatment for multiple organ failure.

Management is by supporting organ system with ventilation, cardiovascular support and haemofiltration/ Dialysis until there is recovery of organ functions.

Effects of organ failure;

Lungs                           Acute respiratory distress syndrome (ARDS).

Kidney                         Acute Renal Insufficiency.

Liver                             Acute Liver Insufficiency.

Clotting                         Coagulopathy.

Cardiac                           Cardiovascular Failure.

Management of Shock:

Hepatic Failure

Definition:
It occur due to severe cause of hepatic encephalopathy.
Types of Hepatic Failure:

1. Fulminant hepatic failure.
2. Subfulminant hepatic failure.

1. Fulminant hepatic failure:

Defined as severe hepatic failure with development of hepatic encephalopathy within 8 weeks after the onset of acute liver disease.

Causes:

In the absence of evidence of pre-existing in chronic liver disease that also lead to hepatic encephalopathy.

2. Subfulminant hepatic failure:
It is term used when encephalopathy occur between 8 weeks and 6 months after the onset of acute liver disease and carries an equally poor prognosis.
Causes:
About 70% cases are caused  by acute viral hepatitis.
50% due to hepatitis B.
Other causes are hepatitis A. E & D.

Clinical Features:
Jaundice.
Hepatic encephalopathy.
Small live on examination.

Investigation:
Aminotransferases.
Prothrombin time.
Decreased Coagulation Factors.
Electrocardiography.

* Liver biopsy is contraindicated.

Management:

1. Hepatic Encephalopathy.
2. Cerebral Edema.
3. Nutritions.
4. Cardiovascular functions.
5. Hemorrhage.
6. Infections.
7. Renal failure.
8. Acetylcysteine.
9. Liver Transplantaion.

1. Hepatic Encephalopathy:

It occur due to nitrogenous substances e.g. Ammonia it enters in portal circulation that by-pass the liver and lead to cerebral dysfunction.

* Because liver becomes unable to detoxify them.

2. Cerebral Edema:

It is major cause of the death in Hepatic failure.

Its due to signs present of Increased Intracranial Pressure (ICP).

3. Nutitions:

Maintain glucose and other diet balance.

4. Cardiovascular functions:

To maintain the blood pressure, pulse and urine output.

5. Hemorrhage:

Impaired homeostasis due to failure of coagulation factor production can result in bleeding from any site especially from GIT.

* It should need to manage by Different drugs.

6. Infection:

For infection use the broad spectrum drugs.

7. Renal failure:

Perform Dialysis, if there is renal failure.

8. Acetylcysteine:

It is an anidot of Paracetamol (Local Name Pk)

It is helpful for managing Liver / Hepatic failure.

9. Liver Transplantation:

It is perform at the end stage of Hepatic failure.

Thyroid Crisis

Definition:
Thyroid crisis is a medical emergency in which there is rapid deterioration of thyrotoxicosis.
Clinical Findings:
Hyperpyrexia.
Severe tachycardia.
Nausea.
Vomiting.
Diarrhea.
Dehydration.
Extreme restlessness.
Precipitating Factors:
Stress.
Infection.
Surgery in the unprepared patient.
Radioiodine therapy.

Management:
Propranolol - 0.5-2 mg IV 4 hourly.
or
20 - 120 mg orally 6 hourly.

Carbimazole - 25 mg 6 hourly.

Iodine - given 1 hour later as Lugol's solution/ sodium iodine.

Steroids - Hydrocortisone 50 mg 6 hourly.

* Aspirin should be avoided.

Types of Thyroid Crisis:

• Toxic Solitary Thyroid Nodules.
• Toxic Multinodular Goiter.
• Subacute Thyroiditis.
• Hashimoto's Thyroiditis.

Hospital Acquired Pneumonia

Definition:

The Hospital acquired pneumonia (HAP) or nosocomial pneumonia is said to be any pneumonia that can occur to the patient in a hospital at least 48–72 hours after admission.
It is usually caused by a bacterial infection, instead of a viral infection.
HAP is the second most common nosocomial infection (urinary tract infection is the most common) and accounts for 15–20% of the total.
HAP typically lengthens a hospital stay by 1–2 weeks.

Sign & symptoms:

Fever > 37.8 °C (100 °F).
Sputum Purulent.
Leucocytosis > 10.000 cells/μl.

Types:

Bacterial pneumonia;
The majority of cases related to various gram-negative bacilli and S.aureus,.
Usually of the MRSA type.
Others are Haemophilus spp.
In the ICU results were S.aureus(17.4%).
P.aeruginosa (17.4%).
Klebsiella pneumoniae.
Enterobacter spp. (18.1%),.
Haemophilus influenzae (4.9%).[1]
Viral pneumonia;
influenza and respiratory syncytial virus.
In the immunocompromised host, cytomegalovirus- cause 10-20% of infections

Diagnosis:
In respiratory insufficiency; chest X-Ray (CXR).
Increasing leucocyte count.
In case of pleural effusion thoracentesis; is performed for examination of pleural fluid.

Arterial Blood Gases (ABGs)

Definition:
Measurement of PaCO2 and PaO2 and H+ Conc. in arterial blood is valuable in assessment of hypoxemia or acid-base balance in respiratory failure and asthama.

Procedure:
Heparinize syringe with 0.1 ml heparin to prevent clot formation.
Draw blood from radial or brachial or femoral artery.
The sample should be immersed in ice bag immediately to prevent metabolism that can reduce PaO2 and increase PaCO2.

Normal values:
PH: 7.35 - 7.45
PaO2: 75 - 100 mm Hg
PaCO2: 35 - 45 mm Hg
HCO3: 24 - 28 mmol/L
O2 saturation: 95 - 100%

Types:
Respiratory Acidosis.
Respiratory Alkalosis.
Metabolic Acidosis.
Metabolic Alkalosis.

1- Respiratory Acidosis:
PH  < 7.35
PaCO2 increases > 45 mm Hg
HCO3 < 24 mmol/L

* If PH is normal, HCO3 is > 28 mmol/L, then it will be compensatory Respiratory Acidosis.

2- Respiratory Alkalosis:
PH > 7.45
PaCO2 < 35 mm Hg
HCO3 is normal or > 28 mmol/L

3- Metabolic Acidosis:
PH  < 7.35
PaCO2  is normal or < 35 mm Hg
HCO3 < 22 mmol/L

*  If PH is normal, PaCO2 is < 35 mm Hg, then it will be compensatory Metabolic Acidosis.

4- Metabolic Alkalosis:

PH > 7.45
PaCO2  35 - 45 mm Hg
HCO3 is > 28 mmol/L

Mechanical Ventilation

Definition:
When Patient fails to improvement in breathing by other measures, they should need oxygen therapy by Some respiratory support with mechanical ventilation, that improves the elimination of CO2.

Types of Mechanical Ventilation:
There are two types of mechanical ventilation;

• Non- Invasive mechanical ventilation.
• Invasive mechanical ventilation.

1- Non- Invasive mechanical ventilation:
In NIMV respiration is supported with face mask or nasal cannula and Endotracheal intubation avoided.
In this, Patient should be conscious, cooperative and be able to breath spontaneously and cough effectively by him or her self.
This Technique is commonly performed in COPD and Pneumonia.
2- Invasive mechanical ventilation:
In IMV Endotracheal tube is passed.
Patient may require;
* Full support and Partial support ventilator.
Full support Ventilator:
In this, all respiration controlled by ventilator.
In this case, Ventilator does not allow the spontaneous breathing.
Patient deeply sedative with short acting IV general anesthesia and paralyzed with muscles relaxant.
Partial support ventilator:
In this, all respiration does not controlled by ventilator, while patient also have his/her own effort.
It does not require deeply sedation or paralyses with muscles relaxant.

Indications:
Respiratory failure (Type II) that does not response to the medical treatment.
Head Injury- Patient have altered in mental status, and it controlled hyperventilation that reduce the Intra-cranial pressure.
Chest Injury- Flail chest, Pneumothorax and Hemothorax etc that reduces the breathing.
Severe Pulmonary edema.

Complications:
Tube insertion in one lung cause collapse of other lung.
Ventilator can induce the lung injury that leads to lungs infection.
It can cause Nosocomial, Hospital Acquired Pneumonia )HAP).
Abdominal Distention.
Fall in cardiac output (CO) due to positive pressure in lungs and thorax that reduce the venous return.

Monitoring and Pulse oximetery

Monitoring:
The cardiac monitoring commonly known as continue monitoring of the heart activity. Generally it shows, Electrocardiography (Relatively cardiac rhythm, Heart rate etc), It can also measure the hemodynamically status of patient via pressure of blood flow within the circulatory system, and can record also the patient's temperature, respiration and pulse oximetery.

Electrocardiography:

Heart rate
Rhythm
Diagnostic values

Hemodynamically status:
Blood Pressure;

Systolic BP
Diastolic
Mean BP

Temperature:

Normal value is;

98.6 F

37 C

* It is usually measured by anal canal.

Respiration:

It is normally 12 to 20 breathes in Adult.

20 to 25 in Childrens.

25 to 40 in Infants.

Pulse Oximetery:

It is use to measure the oxygen saturation and the pulse rate in the peripheral circulation.

Work:
By a low intensity light beamed, from a light emitting diode (LED) to a light receiving photo-diode.
Two thin beam of light, one of them is; Red and other is; Infrared are transmitted through blood and body tissues, and  Some of portion of light is absorbed by blood and body tissue, a photo-diode measure the proportion of the light that passes through the blood and body tissues, that show the pulse oximetery on monitor.
The relatively light absorbed by oxygenated blood is differ from the deoxgenated blood.

Unreliable:
If patient have poor peripheral perfusion, by vasoconstiction, hypotension, BP cuff inflated by the sensor, hypothermia, other causes of poor blood flow the pulse oximetery not show the accurate results.

Venous Access

Introduction:
To familiarize to the physician with the importance of Short and long caliber peripheral lines are preferred for rapid volume resuscitation.
Access to Circulation:
Its use in the management of traumatized patient.
Venous access can use for investigation, blood sampling, fluid resuscitation and medication via injection.
There are Following Places in body that use for the Venous Access;

• Percutaneous peripheral venous access.
• Central access.
• Surgical cut-down.
• Intra-osseous access.

Percutaneous peripheral venous access:
Most Suitable site for PVA is Forearm, Cubital fossal vein.
Mainly there are used two large bore IV catheters (14 and 16 gauge).
Sterilize technique should be use in emergency and urgency situation.
Lower limbs can also be used for the venous access but complication can occur like thrombosis, cellulitis and phlebitis.

Central access:
It is use in traumatized unstable patient or in shocked patient.
There is use of CV line, in size of (8 to 12 French).
They provide high flow rate because of large diameter (2.5 to 4 mm) of catheter (Swan Sheath).
It can also use for the monitoring, assessing, to check volume status and for resuscitation.

* There are some sites where you can perform the central venous access;

1. Subclavian vein.
2. Internal Jugular vein.
3. Femoral vein.

1. Subclavian vein:
Criteria : Its selection depend on an experienced physician.

Advantages:
Easily accessible
It maintain CV line in fixed position due to fibrous tissue (Attached to the 1st Rib, clavicle and subclavicle muscles).
Allows the measurement of CVP (Central venous pressure).

Disadvantages:
It can cause suspected cervical spine injury.
In Complication Pneumothorax, arterial puncture, Hemothorax etc can occur.

2. Internal Jugular vein:
Criteria : IJV is most popular in CV line insertions.
But this site is not preferred in neck trauma (C-spine).

Advantages:
Right IJV have extra advantages rather than left IJV;
It Provide the straight route to the right heart.
It is Slightly larger than left IJV.
The dome of pleura is lower on the right side.

Disadvantages:
On left side it can cause thoracic duct injury which not occur on right side.

3. Femoral vein:
Criteria : Its is easy to cannulation because it is large in diameter of vein.

Advantages:
Ease of insertion.
No risk of thoracic injury.

Disadvantages:
Limits the flexion of leg at the hip.
Thrombosis.
Femoral artery puncture.

Surgical cut-down:
The procedure in which a vein is exposed through an incision and cannulated under the direct vision.
It is particularly performed in those patient in whom Percutaneous and central access are contraindicated that are traumatized patient and this procedure normally performed in children.

Sites for venous Cut-down:
It is mostly performed in superficial veins;

1. Long/Greater saphenous vein at the ankle.
2. Proximal long/Greater saphenous veins.
3. Antecubital veins.

1. Long/Greater saphenous vein at the ankle:

It is Approx. 1 cm above and anterior to the center of the medial malleolus.
This is safe site and have low morbidity.
It is of smaller in size at the ankle difficult to perform the procedure.
It is away from the central circulation.
It is not beneficial in leg fractures and splinting etc.

2. Proximal long/Greater saphenous veins:
It is Approx. 5 cm inferior to the inguinal ligament and 5 cm medial to the femoral pulse (or 5 cm medial to the mid point of the inguinal ligament in a pulse less patient).
It is better alternative to the ankle venous cut-down, it is near to the central circulation.

3. Antecubital veins:
Basilic vein, Proximal and distal cephalic veins in the arm can be used for a cut-down.
Basilic vein, because of its less acute union with the Subclavian vein is preferred site.
In complication damage to the brachial artery and median nerve.

Intra-osseous access:
The ability of the bone marrow to accept an infusion of fluids and drugs with subsequent effects like those of an intravenous infusion has been well documented.
Criteria: This route should be utilized for initial resuscitation.
Sites: Any marrow containing cavity is a potential site for infusion, These are the commonly recommended sites;

1. Proximal Tibia.
2. Distal Tibia.
3. Distal Femur.

1. Proximal Tibia:

Anteromedial surface, 2-3 cm below the tibial tuberosity.

2. Distal Tibia:

Anterior surface of the distal tibia, approximately 2 cm above the medial malleolus.

3. Distal Femur:

Antero-lateral surface, 3 cm above the lateral condyle of femur.

Advantages:
This route can be quickly, safely and reliably established and permits rapid venous uptake of the drugs and fluids.

Complications:
It can cause infections like local cellulitis and abscess.
Osteomyelitis.
Fracture of the bone.
Compartment syndrome.
Epiphyseal plate injury.