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