First Problem Emergency

Medicine
Rilianda L Simbolon
405140172
 LI 1 Shock
• Cardiogenic
• Obstruktif
• Hipovolemic
• Distributif
 Shock
• Shock is the clinical syndrome that results from
inadequate tissue perfusion.
• The hypoperfusion-induced imbalance between the
delivery of and requirements for oxygen and substrate
leads to cellular dysfunction.
• This leads to a vicious cycle in which impaired
perfusion is responsible for cellular injury that causes
maldistribution of blood flow, further compromising
cellular perfusion; the latter ultimately causes multiple
organ failure (MOF) and, if the process is not
interrupted, leads to death.
 Shock
• MAP = CO x SVR
• O2 saturation
 Hypovolemic Shock
• This most common form of shock results either
from the loss of red blood cell mass and plasma
from hemorrhage or from the loss of plasma
volume alone due to extravascular fluid
sequestration or GI, urinary, and insensible
losses.
• The normal physiologic response to hypovolemia
is to maintain perfusion of the brain and heart
while attempting to restore an effective
circulating blood volume.
 Infusion Rates
Access Gravity Pressure

18 g peripheral IV 50 mL/min 150 mL/min

16 g peripheral IV 100 mL/min 225 mL/min
14 g peripheral IV 150 mL/min 275 mL/min
8.5 Fr CV cordis 200 mL/min 450 mL/min
• Primary Survey: A B C D E
• Secondary Survey
• Dugaan syok sepsit et causa peritonitis
 Sepsis
• Two or more of SIRS criteria
• Temp > 38 or < 36 C
• HR > 90
• RR > 20
• WBC > 12,000 or < 4,000
• Plus the presumed existence of infection
• Blood pressure can be normal!
 Septic Shock
• Sepsis (remember definition?)
• Plus refractory hypotension
• After bolus of 20-40 mL/Kg patient still has one of
the following:
• SBP < 90 mm Hg
• MAP < 65 mm Hg
• Decrease of 40 mm Hg from baseline
 Septic Shock
• Clinical signs:
• Hyperthermia or hypothermia
• Tachycardia
• Wide pulse pressure
• Low blood pressure (SBP<90)
• Mental status changes
• Beware of compensated shock!
• Blood pressure may be “normal”
 Treatment Algorithm

Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001:345:1368-1377.
 Treatment of Sepsis

• Antibiotics- Survival correlates with how quickly the

correct drug was given
• Cover gram positive and gram negative bacteria
• Zosyn 3.375 grams IV and ceftriaxone 1 gram IV or
• Imipenem 1 gram IV
• Add additional coverage as indicated
• Pseudomonas- Gentamicin or Cefepime
• MRSA- Vancomycin
• Intra-abdominal or head/neck anaerobic infections- Clindamycin
or Metronidazole
• Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae
• Neutropenic – Cefepime or Imipenem
 Persistent Hypotension

• If no response after 2-3 L IVF, start a

vasopressor (norepinephrine, dopamine,
etc) and titrate to effect
• Goal: MAP > 60
• Consider adrenal insufficiency:
hydrocortisone 100 mg IV
 Anaphylactic Shock

• Anaphylaxis – a severe systemic

hypersensitivity reaction characterized by
multisystem involvement
• IgE mediated
• Anaphylactoid reaction – clinically
indistinguishable from anaphylaxis, do not
require a sensitizing exposure
• Not IgE mediated
 Anaphylactic Shock

• What are some symptoms of anaphylaxis?

• First- Pruritus, flushing, urticaria appear

•Next- Throat fullness, anxiety, chest tightness,

shortness of breath and lightheadedness

•Finally- Altered mental status, respiratory

distress and circulatory collapse
 Anaphylactic Shock
• Risk factors for fatal anaphylaxis
• Poorly controlled asthma
• Previous anaphylaxis
• Reoccurrence rates
• 40-60% for insect stings
• 20-40% for radiocontrast agents
• 10-20% for penicillin
• Most common causes
• Antibiotics
• Insects
• Food
 Anaphylactic Shock

• Mild, localized urticaria can progress to full anaphylaxis

• Symptoms usually begin within 60 minutes of exposure
• Faster the onset of symptoms = more severe reaction
• Biphasic phenomenon occurs in up to 20% of patients
• Symptoms return 3-4 hours after initial reaction has cleared
• A “lump in my throat” and “hoarseness” heralds life-
threatening laryngeal edema
 Anaphylactic Shock- Diagnosis

• Clinical diagnosis
• Defined by airway compromise, hypotension, or
involvement of cutaneous, respiratory, or GI
systems
• Look for exposure to drug, food, or insect
• Labs have no role
 Anaphylactic Shock- Treatment
• ABC’s
• Angioedema and respiratory compromise require
immediate intubation
• IV, cardiac monitor, pulse oximetry
• IVFs, oxygen
• Epinephrine
• Second line
• Corticosteriods
• H1 and H2 blockers
 Anaphylactic Shock- Treatment

• Epinephrine
• 0.3 mg IM of 1:1000 (epi-pen)
• Repeat every 5-10 min as needed
• Caution with patients taking beta blockers- can cause severe
hypertension due to unopposed alpha stimulation
• For CV collapse, 1 mg IV of 1:10,000
• If refractory, start IV drip
 Anaphylactic Shock - Treatment
• Corticosteroids
• Methylprednisolone 125 mg IV
• Prednisone 60 mg PO
• Antihistamines
• H1 blocker- Diphenhydramine 25-50 mg IV
• H2 blocker- Ranitidine 50 mg IV
• Bronchodilators
• Albuterol nebulizer
• Atrovent nebulizer
• Magnesium sulfate 2 g IV over 20 minutes
• Glucagon
• For patients taking beta blockers and with refractory hypotension
• 1 mg IV q5 minutes until hypotension resolves
 LI 2 Acute Abdomen
• Peritonitis
• Intususepsi
• Apendisitis Akut
• Abcess Appendix
• Hernia
• Perforasi usus
 ALS Indicators
• Shock signs & symptoms:
– Poor skin signs (pale, diaphoresis)
– Sustained tachycardia
– Hypotension
• Unstable vital signs
• Positive postural changes
• Evidence of on-going bleeding
• Severe, unremitting pain
 Patient Care
Medics?
Airway management/suctioning
Patient position of comfort
Provide O2
Maintain body temperature
Calm & reassure
Monitor vital signs every 5 minutes
Differential Diagnosis
 Abscess of the Appendix
• A palpable conglomeration of inflamed
tissues, including the appendix and
adjacent viscera.
• CT scan of the abdomen and appendix
can delineate a phlegmon an abscess.
• A difference of opinion revolves around
the necessity of an operative approach
• conservative regimen. A conservative
approach with antibiotics, the so-called
Ochsner method,
 Perforation

If Fever > 102*F & WBC> 18,000

If Ischemia continue

Necrosis of the appendicular wall

Gangrenous appendicitis

Perforation with free bacterial contamination of the

peritoneal cavity
 Phlegmonous Mass/ Paracaecal
abscess

Greater omentum & loops of small bowel become adherent to the

inflamed appendix

Walling off the spread of peritoneal contamination

Phlegmonous Mass / Paracaecal abscess

 Symptoms

Pain
– Initially periumbilical region
– Pain shift to right iliac fossa
– Parietal peritoneum irritated and inflamed

Anorexia

Nausea/ vomiting
 Clinical Sign

• Tenderness (localized) in the RIF

• Muscle guarding

• Rebound Tenderness/ BLUMBERG’S Sign

• Tachycardia: Perforation, Gangrene & Peritonitis

Ochsner method,
Based on the following three principles:

1. It is more difficult to remove the appendix

2. One can always revert to an operative approach
if the patient deteriorates
3. Conservative treatment works in > 80%

however, the conservative approach requires an extended

hospital stay initially, not to mention the interval
appendectomy that will be performed at a later date.
Appendicular abscess may be treated
with ;
• Percutaneous Drainage and concomitant IV
antibiotics. As it resolves, an interval
appendectomy can be entertained,
usually at least 3 months after the attack. It has
been shown that of the patients treated
nonoperatively for abscess as well as phlegmon

5% will fail this approach,and up to 40% will

return within a year with recurrent acute
appendicitis requiring appendectomy.4

• Open drainage
 Peritonitis
• Peritonitis is an inflammation of the
peritoneum; it may be localized or diffuse in
location, acute or chronic in natural history,
and infectious or aseptic in pathogenesis.
• When no intraabdominal source is identified,
infectious peritonitis is called primary or
spontaneous.
• The conditions that most commonly result in
the introduction of bacteria into the
peritoneum are ruptured appendix, ruptured
diverticulum, perforated peptic ulcer,
incarcerated hernia, gangrenous gall bladder,
volvulus, bowel infarction, cancer,
inflammatory bowel disease, or intestinal
obstruction.
 Types of Peritonitis
• Spontaneous peritonitis
– an infection that develops in the peritoneum
– Caused by
• Liver disease with cirrhosis
– Such disease often causes a buildup of abdominal fluid
(ascites) that can become infected.
• Kidney failure getting peritoneal dialysis.
– This technique, which involves the implantation of a catheter
into the peritoneum, is used to remove waste products in the
blood of people with kidney failure.
– It's linked to a higher risk of peritonitis due to accidental
contamination of the peritoneum by way of the catheter.
 Types of Peritonitis
• Secondary peritonitis
– which usually develops when an injury or infection in the
abdominal cavity allows infectious organisms into the
peritoneum
– Caused by
• A ruptured appendix, diverticulum, or stomach ulcer
• Digestive diseases such as Crohn's disease and diverticulitis
• Pancreatitis
• Pelvic inflammatory disease
• Perforations of the stomach, intestine, gallbladder, or appendix
• Surgery
• Trauma to the abdomen, such as an injury from a knife or gunshot
wound
• acute abdominal pain and tenderness, usually with fever
• widespread inflammation and diffuse abdominal tenderness and
rebound.
• Tachycardia, hypotension, and signs of dehydration are common.
• Leukocytosis and marked acidosis are common laboratory findings.
• Free air under the diaphragm is associated with a perforated viscus.
• CT and/or ultrasonography can identify the 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.
 Treatment
• Antibiotic to treat infection
• Emergency surgery
– if peritonitis has been caused by conditions such
as appendicitis, a perforated stomach ulcer, or
diverticulitis.
 Appendicitis
• The appendix is a small, tube-like organ attached to the first
part of the large intestine, also called the colon.
• It is located in the lower right area of the abdomen. It has no
known function. A blockage inside of the appendix causes
appendicitis
 Epidemiology
• Peak incidence : ages 10 – 30 years
• Most common acute surgical condition of
abdomen
• 250.000 cases / year in USA
 Etiology
• Obstuction, by:
– Fecalith
– Enlarged lymphoid follices, associated with a
variety of inflammatory and infectious disorders
including Crohn disease, gastroenteritis,
amebiasis, respiratory infections, measles, and
mononucleosis
– Worms (pinworms, Ascaris, and Taenia)
– Viral infections ( measles )
– Tumors
 Pathophysiology
• Appendix obstruction
• Bacterial multiply and invade appendicitis
• Inflamation of appendix
• Rupture of primary appendiceal abcess may
go to bladder,smallintestine,sigmoid or secum
 Classification
• Acute : manifestation of chron’s disease
• Chronic : tuberculosis,amebiasis ‘appendiceal
inflammation is not usually the cause of
prolonged abdominal pain of weeks or moths
duration .
• Recurrent acute appendicitis
 Symptoms
• wake up at night
• is new and unlike any pain felt before
• gets worse in a matter of hours
• gets worse when moving around, taking deep breaths,
coughing, or sneezing
• loss of appetite
• Nausea
• Vomiting
• constipation or diarrhea
• a low-grade fever that follows other symptoms
• the feeling that passing stool will relieve discomfort
 Clinical SIGNS
• Tenderness (Maximal
at the Mc Burney’s
p.)
• Rowsing Sign
• Iliopsoas Sign
• Obturator Sign
 Inguinal Hernia

• Protrusion of the
intestine through a
tear in the inguinal
canal.
• Usually identified by
abnormal mass in
lower quadrant, with
or without pain.
• Strangulation can lead
to necrosis.
 LI 3 GI Bleeding
• Esophagus Corrossive lession
• Varices sesophagus
• Peptic Ulcer
• Hemorrhoid
• Mwt
• Neoplasma
• VL
• Me
 Peptic Ulcer Disease

• Steady, well-localized
epigastric or LUQ pain
• Described as a “burning”,
“gnawing”, “aching”
• Increased by coffee,
stress, spicy food,
smoking
• Decreased by alkaline
food, antacids
 Peptic Ulcer Disease
• Erosion of the lining of the stomach,
duodenum, or esophagus
• May cause massive GI bleed
• Patient lies very still with complaint of intense,
steady pain, rigid abdomen with exam,
suspect perforation