Shoc

k
Def = an abnormality of the circulatory system that results in inadequate
organ perfusion and tissue oxygenation.
ovolemia is the cause of shock in most trauma patients

ATLS
Pathophysiology :
Early circulatory responses to blood loss are com- pensatory and include
progressive vasoconstriction of cutaneous, muscle, and visceral
circulation to preserve blood flow to the kidneys, heart & brain.

Response to acute circulating volume depletion associated with injury is

an increase in heart rate in an attempt to preserve cardiac output.

Tachycardia is the earliest sign in most cases

Release of endogenous catecholamines increases peripheral vascular

resistance increases diastolic blood pressure and reduces pulse
pressure (but does little to increase organ perfusion)

In cellular level, compensation occurs by shifting to anaerobic

metabolism, which results in the formation of lactic acid and the
development of metabolic acidosis.

If shock is prolonged and substrate delivery for the gen- eration of

adenosine triphosphate (ATP) is inadequate, the cellular membrane loses
the ability to maintain its integrity, and the normal electrical gradient is
lost
Hemorrhagic shock

Hemorrhage is the most common cause of shock after injury,

and virtually all patients with multiple injuries have an element
of hypovolemia.
Hemorrhage is defined as an acute loss of circulating blood
volume.
Normal adult blood volume is approximately 7% of body weight.
Several confounding factors profoundly alter the classic hemodynamic
response to an acute loss of circulating blood volume :
Patients age
Severity of injury, with special attention to type and anatomic location
of injury
Time lapse between injury and initiation of treatment
Prehospital fluid therapy
Medications used for chronic conditions

Therapy :
(A&B) Supplementary oxygen is provided to maintain oxygen
saturation at greater than 95%.

( C ) Bleeding from external wounds usually can be controlled by direct

pressure to the bleeding site, although massive blood loss from an
extremity may require a tourniquet. Surgical or angiographic control
may be required to control internal hemorrhage

( D ) Alterations in CNS function in patients who have hypotension as

a result of hypovolemic shock do not necessarily imply direct
intracranial injury and may reflect inadequate brain perfusion.

( E ) patient must be completely undressed and carefully exam- ined

from head to toe to search for associated injuries.
GASTRIC DILATION-DECOMPRESSION : In unconscious pa- tients,
gastric distention increases the risk of aspiration of gastric contents,
which is a potentially fatal complication. Gastric decompression is
accomplished by intubating the stomach with a tube passed nasally or
orally and attaching it to suction to evacuate gastric contents.

UrinaryCatheterization :
Bladder catheterization allows for assessment of the urine for hematuria
(indicating the retroperitoneum may be a significant source of blood
loss) and con- tinuous evaluation of renal perfusion by monitoring
urinary output.

INITIAL FLUID THERAPY :

Warmed isotonic electrolyte solutions, such as lactated Ringers and
normal saline, are used for initial resus- citation.

CROSSMATCHED, TYPE-SPECIFIC, AND TYPE O BLOOD

WARMING FLUIDSPLASMA AND CRYSTALLOID

MASSIVE TRANSFUSION

COAGULOPATHY
onhemorrhagic shock (cardiogenic)

Myocardial dysfunction can be caused by blunt cardiac injury,

cardiac tamponade, an air embolus, or, rarely, a myocardial
infarction associated with the patients injury.
All patients with blunt tho- racic trauma need constant
electrocardiographic (ECG) monitoring to detect injury patterns
and dysrhythmias.
FAST in the emergency department can identify pericardial fluid
and the likelihood of cardiac tamponade as the cause of shock.
nhemorrhagic shock (cardiac tamponade)

Most commonly identified in penetrating thoracic trauma, but it

can occur as the result of blunt injury to the thorax.
Tachycardia, muffled heart sounds, and dilated, engorged neck
veins with hypotension resistant to flu- id therapy suggest
cardiac tamponade.
Tension pneumothorax can mimic cardiac tamponade, but it is
differentiated from the latter condition by the findings of absent
breath sounds, tracheal deviation, and a hyperresonant
percussion note over the affected hemithorax.
Best managed by thoracotomy
nhemorrhagic shock (tension pneumothorax)

Air enters the pleural space, but a flap-valve mechanism

prevents its escape. Acute respira- tory distress, subcutaneous
emphysema, absent breath sounds, hyperresonance to
percussion, and tracheal shift supports the diagnosis
Immediate thoracic decompression without waiting for x-ray
confirmation of the diagnosis.
nhemorrhagic shock (cardiac tamponade)

Classic sign : hypotension without tachycardia or cutaneous

vasoconstriction.
Should be treated initially for hypovolemia.
The failure of fluid resuscitation to restore organ perfusion
suggests either continuing hemorrhage or neurogenic shock.
onhemorrhagic shock (septic shock)

Uncommon
Difficult to distinguish from those in hypovolemic shock, as both
groups can manifest tachycardia, cutaneous vasoconstriction,
impaired urinary output, decreased systolic pressure, and
narrow pulse pressure.
ACUTE ABDOMINAL PAIN
DEFINITION
Refers to any acute intra & extra
abdominal disease processes. Many
cases require urgent surgical
management, although some can be
managed nonsurgically.
 Abdominal pain is pain that is felt in the
abdomen
LOCATION

EPIGASTRIUM PANCREATITIS, APPENDICITIS, DUODENUM ULCER,

PEPTIC ULCER, KOLESISTITIS, CA PANCREAS,
MIOKARD INFARK
RIGHT KOLESISTITIS, HEPATITIS, PANCREATITIS, ABSES
HIPOKONDRIU SUBFRENICUS, PNEUMONIA, INFARK MIOKARD
M
LEFT INFECTION VIRUS, PEPTIC ULCER, PNEUMONIA
HIPOKONDRIU
M
PERIUMBILICAL PANCREATITIS, CA PANCREAS, INTESTINAL
IS OBSTRUCTION, AORTA ANEURYSMA, APPENDICITIS

LUMBAL KIDNEY STONE, PIELONEFRITIS, CA COLON, ANSES

PEINEFRIK

INGUINAL & APPENDICITIS AT RIGHT INGUINAL, DIVERTICULOSIS,

SUPRAPUBIK SALPINGITIS, SISTITIS, OVARIUM CYST
ETIOLOGIC
Parietal peritoneal inflammation
Bacterial contamination : pelvic inflammatory
disease, perforated appendix
Chemical irritation : perforated ulcer,
pancreatitis
Mechanical obstruction of hollow viscera :
Obstruction of the small or large intestine
Obstruction of the biliary tree
Obstruction of the ureter
Volvulus
Hernia
ETIOLOGIC
Vascular disturbances :
Embolism or thrombosis
Vascular rupture
Pressure or torsional occlusion
Abdominal wall :
Distortion or traction of mesentery
Trauma or infection of muscles
Neoplasm intraabdominal
Congenital disease
ETIOLOGY
(ACCORDING TO AGE)
Neonatal causes of
Abdominal Pain
Colic
Milk Protein Allergy
Gastroesophageal reflux
Malrotation or Midgut
volvulus
Necrotizing Enterocolitis
Hirschprung's Enterocolitis
Infant causes of Abdominal
Pain
Intussusception
Infantile colic
Bowel Obstructionn
Pyloric stenosis
Incarcerated Herniaa
Internal hernia
Omphalomesenteric band
Hirschprung's Diseasee
Battered Infant
Jejunum perforation
Duodenal hematoma
Gastroenteritis
Constipation
Urinary Tract Infection
 ETIOLOGY
(ACCORDING TO AGE)
Child causes of Abdominal
Pain Adolescent
Constipation Appendicitis
Lactose Intolerance Gastroenteritis
Lead Poisoning Constipation
Helicobacte pylori
Gynecologic cause
Urinary Tract Infection
Pregnancy (or Ectopic Pregnancy)
Pneumonia
Mittelschmerz
Pancreatitis
Dysmenorrhea
Appendicitis
Pelvic Inflammatory Disease
Mesenteric Lymphadenitis
Ovarian torsion
Gastroenteritis
Testicular Torsion
Intussusception or Volvulus (children
under age 6) Drug and Alcohol use
Abdominal trauma Sexual abuse
Pharyngitis (e.g. Strep Throat) Gallbladder disease
Sickle Cell Crisis Neoplasm
Henoch-Schonlein Purpura Inflammatory Bowel Disease
ETIOLOGY/CAUSES/DIFFERENTIAL
DIAGNOSIS OF ACUTE ABDOMEN
Gastrointestinal
Appendisitis
Perforated peptic ulcer
Intestinal ischemia
Diverticulitis
Inflammatory bowel disease
Meckels diverticulitis
Pancreaticobiliary tract, liver, spleen
Acute pancreatitis
Calculous cholecystitis
Acalculous cholecystitis
Acute cholangitis
Hepatic abscess
Ruptured hepatic tumor
Splenic rupture
Urinary tract
Renal/ureteral stone
PHYSICAL EXAMINATION
Patient overall appearance
Ability to communicate and habitus ?
Lie quietly in bed or active move ?
Lie on his or her side with knees and
hips flexed?
Appear dehydrated with dry mucous
membranes?
Patient lying quietly in bed, avoiding motion,
and complaining of abdominal pain ->
serious intra-abdominal disease
PHYSICAL EXAMINATION
Evaluation of the vital signs
Low fever (37.2 C 37.8 C)
diverculitis, appendicitis, acute
cholecystitis
High fever (> 37.8 C) pneumonia,
urinary tract infection, septic
cholangitis, or gynecologic infection
Rapid heart rate and hypotension
complicated disease with peritonitis
PHYSICAL EXAMINATION
Inspection
Scars
Hernias
Masses
Abdominal wall defect
Contour abdomen scaphoid, flat,
distended
Abdominal distention intestinal
obstruction, ileus, or fluid including
ascites, blood, or bile
Peristaltic movement intestine
obstruction
PHYSICAL EXAMINATION
Auscultation
Bowel sounds obstruction of
small intestine, early acute
pancreatitis
Bowel sound chronic obstruction
of intestine, difuse peritonitis, ileus
PHYSICAL EXAMINATION
Palpation
Localized tenderness in :
McBurney poin appendicitis
RUQ inflamed gallbladder
LLQ diverticulitis
Throughout abdomen diffuse peritonitis
Rebound tenderness peritonitis
Deep palpation can detect abdominal masses
(Acute cholecystitis, acute pancreatitis,
abdominal aneurysm, diverticulitis)
PHYSICAL EXAMINATION
Percussion
Hyperresonance or tympany
gaseous distention of the intestine or
stomach
Resonance over the liver free
intraabdominal gas
Percussion pain which has the same
located with rebound tenderness
peritoneal irritation
Shiffting dullness + fluid on
CHARACTERISTIC OF THE
PAIN
Visceral pain, comes from abdominal viscera,
innervated by autonomic nerve fibers and respond
mainly to the sensation of distention and muscular
contraction. Typically vague, dull, and nauseating.
Somatic pain, comes from parietal peritonium,
innervated by somatic nerves, which respond to
irritation from infectious, chemical, or other
inflammatory processes. Sharp and well localized.
Referred pain, perceived distant from its source and
result from convergence of nerve fibers at the spinal
cord. Ex: scapular pain due to biliary colic, groin pain
due to renal colic, shoulder pain due to blood or
infection irritating the diaphragm
DIAGNOSIS ACUTE
ABDOMEN
History:
Acute appendicitis: periumbilical pain, low-grade fever,
anorexia with/without vomiting followed by movement of
the pain into the right lower quadrant McBurneys point.
Constipation: obstructive conditions, inflammatory
disorders produce ileus.
Watery diarrhea: gastroenteritis,
Bloody diarrhea: infectious colitis, inflammatory bowel
disease, mesenterial ischemia.
Jaundice: hepatic and pancreaticobiliary disease, sepsis.
Urinary frequency, dysuria, hematuria, and suprapubic
or flank pain : urologic disease.
APPENDICITIS
APPENDICITIS
DEFINITION
Appendicitis is a painful swelling and
infection of the appendix.
APPENDIX
The appendix is a closed-ended, narrow
tube up to several inches in length that
attaches to the cecum (the first part of the
colon) like a worm.
The inner lining of the appendix produces
a small amount of mucus that flows
through the open center of the appendix
and into the cecum.
The wall of the appendix contains
lymphatic tissue that is part of the
immune system for making antibodies.
Like the rest of the colon, the wall of the
appendix also contains a layer of muscle,
but the muscle is poorly developed.
ETIOLOGY
Obstruction caused by fecalith, which is accumulation
and inspissation of fecal matter around vegetable fiber
Enlarged lymphoid follicles associated with viral infection
Inspissated barium
Tumor
Appendiccal ulceration
Infective
Bacterial (Tuberculosis, Typhus, Actinomycosis, E. coli
and B. fragilis, Pseudomonas, Yersinia, Eikenella
corrodens infections)
Viral (Adenovirus, Cytomegalovirus infections
Fungal (Aspergillosis, Histoplasmosis)
Parasitic (Enterobius vermicularis, Strongyloides
stercoralis, Entamoeba histolytica infections,
Ascariasis, Schistosomiasis, Cryptosporidiosis,
Taeniasis)
 PATOPHYSIOL
opening appendix OGY
cecum is
blocked peri-
appendiceal
build-up of thick abscess
mucus within the Appendicitis
appendix or to stool
that enters the
appendix from the infection spread
cecum throughout the
abdomen
The mucus or
stool hardens, bacteria which
becomes rock-like normally are found
(Fecalith), and within the appendix
blocks the opening begin to invade
(infect) the wall of
the
the appendix
lymphatic tissue
Rupture
in the appendix
may swell and inflamation (respon
block the of the body)
appendix
 SIGNS AND SYMPTOMS
Aching pain that begins around your periumbilical and often
shifts to your lower right abdomen
Pain that becomes sharper over several hours
Tenderness that occurs when you apply pressure to your
lower right abdomen
Sharp pain in your lower right abdomen that occurs when
the area is pressed on and then the pressure is quickly
released (rebound tenderness)
Pain that worsens if you cough, walk or make other jarring
movements
Nausea
Vomiting
Loss of appetite
Low-grade fever ( 37,2-37.8C)
Constipation
Inability to pass gas
Diarrhea
Abdominal swelling
PHYSICAL EXAMINATION
Guarding : occurs when a person subconsciously tenses the
abdominal muscles during an examination
Rebound tenderness
by applying hand pressure to a patients abdomen and then
letting go
Pain felt upon the release of the pressure
Rovsings sign
by applying hand pressure to the lower left side of the abdomen
Pain felt on the lower right side of the abdomen upon the
release of pressure on the left side
Psoas sign
The right psoas muscle runs over the pelvis near the appendix
Pain felt if patient tries to lift the right thigh while lying down
Obturator sign
patient to lie down with the right leg bent at the knee
Moving the bent knee left and right requires flexing the
obturator muscle and will cause abdominal pain if the appendix
is inflamed
 Psoas
sign

Obturator
sign
 LAB EXAMINATION
CBC WBC
WBC count > 10,500 cells/mm3
Neutrophilia greater than 75%
CRP test
Urinalysis
Abdominal x-ray
CT scan of the abdomen:
Very good test for diagnosing appendicitis
Ultrasound of the abdomen
MRI scan of the abdomen
May be helpful in diagnosing acute appendicitis
in the pregnant female.
EMERGENCY
DEPARTMENT CARE
Treatment guidelines for patients with suspected acute
appendicitis
Patients with suspected appendicitis should not receive
anything by mouth
Administer parenteral analgesic and antiemetic as needed for
patient comfort
Consider ectopic pregnancy in women of childbearing age, and
obtain a qualitative betahuman chorionic gonadotropin (beta-
hCG)
Administer intravenous antibiotics to those with signs of
septicemia and to those who are to proceed to laparotomy
Nonsurgical treatment of appendicitis
Anecdotal reports describe the success of intravenous
antibiotics in treating acute appendicitis in patients without
access to surgical intervention (eg, submariners, individuals on
ships at sea)
Preoperative antibiotics
decreasing postoperative wound infection rates
APPENDICITIS TREATMENT: SURGERY
Surgery to remove the appendix is
called an appendectomy
The two types of appendectomy
include:
Open appendectomy:
An incision is made in the right lower abdomen
and the appendix is removed through the
incision.
Laparoscopic appendectomy:
A small incision is made in the umbilicus and
the surgeon uses a flexible fiberoptic scope to
remove the appendix through the small
incision.
COMPLICATION
Abses periappendicitis
Septikemia
Mucocele
Peritonitis
 Peritonitis
Acute Peritonitis
inflammation of the peritoneum
Maybe localized or diffuse in location,acute and chronic in
natural history, and infectious or aseptic in pathogenesis
infectious(primary peritonitis or spontaneus) and is usually
related to a perforated viscus (and calledsecondary
peritonitis)
Associated :
with decreased intestinal motor activity
resulting in distention of the intestinal lumen with gas and fluid
(adynamic ileus)
Accumulation of fluid in the bowel and oral intakerapid
intravascular volume depletioncardiac, renal, and other
systems.

2 Major Types
Primary
Caused by the spread of an
infection from the blood &
lymph nodes to the
peritoneum.Very rare < 1%
Usually occurs in people who
have an accumulation of fluid
Also, it can occur due to an
in their abdomens (ascites).
The fluid that accumulates
creates a good environment
for the growth of bacteria.
Caused by the entry of
Secondary
bacteria or enzymes into
the peritoneum from the
gastrointestinal or biliary
tract.
This can be caused due to
an ulcer eating its way
through stomach wall or
intestine when there is a
rupture of the appendix or
a ruptured diverticulum.
intestine to burst or injury
to an internal organ which
bleeds into the internal
cavity.
 Conditions Leading to Secondary
Bacterial Peritonitis
Perforations of bowel Perforations or leaking of other
Trauma, blunt or penetrating organs
Inflammation Pancreaspancreatitis
Appendicitis Gallbladdercholecystitis
Diverticulitis Urinary bladdertrauma, rupture
Peptic ulcer disease Liverbile leak after biopsy
Inflammatory bowel disease Fallopian tubessalpingitis
Iatrogenic Bleeding into the peritoneal cavity
Endoscopic perforation
Anastomotic leaks Disruption of integrity of peritoneal
Catheter perforation cavity
Vascular Trauma
Embolus Continuous ambulatory peritoneal dialysis
Ischemia (indwelling catheter)
Obstructions Intraperitoneal chemotherapy
Adhesions Perinephric abscessIatrogenic
Strangulated hernias postoperative, foreign body
Volvulus
Intussusception
Neoplasms
Ingested foreign body, toothpick, fish
bone
 acute abdominal pain and tenderness, usually with fever
Bowel sounds are usually but not always absent.
Tachycardia, hypotension, and signs of dehydration are
common
Localized peritonitis is most common in
uncomplicated appendicitis and diverticulitis, and
physical findings are limited to the area of inflammation
Generalized peritonitis is associated with widespread
inflammation and diffuse abdominal tenderness and
rebound.
Rigidity of the abdominal wall is common in both
localized and generalized peritonitis
 Clinical Features
Leukocytosis and marked acidosis are common
laboratory findings.
Plain abdominal films dilation of large and small
bowel with edema of the bowel wallFree air under
the diaphragm perforated viscus.
CT and/or ultrasonography presence of free fluid or
an abscess.
When ascites is present, diagnostic paracentesis
with cell count (>250 neutrophils/L is usual in
peritonitis), protein and lactate dehydrogenase
levels, and culture is essential.
In elderly and immunosuppressed patients, signs of
peritoneal irritation may be more difficult to detect.
 Management
Rehydration
Correction of electrolyte
abnormalities
Antibiotics
Surgical correction of the underlying
defect
 Prognosis
Mortality rates are <10% for
uncomplicated peritonitis associated
with a perforated ulcer or ruptured
appendix or diverticulum in an
otherwise healthy person.
Mortality rates of40% have been
reported for elderly people, those
with underlying illnesses, and when
peritonitis has been present for >48
h.
GASTROENTERITIS
Gastroenteritis definiton
Gastroenteritis is a common
condition where the stomach and
intestines become inflamed. It is
usually caused by a viral or bacterial
infection.
Gastroenteritis is an inflammation of
the lining of the intestines caused by
a virus, bacteria or parasites
The two main symptoms of
gastroenteritis arediarrhea and
vomiting.
etiology
virus

infection bacteria

parasites
Gastroenteriti
s
etiology
Malabsorption

Non infection Intolerance

mixture food
poison
(chemical)
Pathogenesis of
infectious diarrhea
classification
infection
etiology
Non-
infection

acute
diarrhea Time
Chronic

Secretori
Mechanis k
m
osmotic