presented by Mel Herbert
edited by Veronica Vasquez
edited by Veronica Vasquez
Blunt Abdominal Trauma in Pediatric Patients with Dr. Sanjay Arora and Dr. Mike Menchine
Pediatric patients are at higher risk for occult injuries such as duodenal hematomas and pancreatic contusions and have therefore traditionally been observed. In a prospective study of 1,295 pediatric patients with blunt abdominal trauma, 1,085 had a normal CT scan. Of these patients, 737 were admitted for observation. None of the 348 patients who were discharged returned to the emergency department. Of the patients who were admitted, only 2 had complications, neither of which required surgical intervention (1 perinephric hematoma and 1 mesenteric injury.) The authors’ of this study concluded pediatric patients with blunt abdominal trauma and a normal CT scan do not need to be admitted for observation. However, this study does not address other reasons for admission such as pain control, social issues, or polytrauma. Dr. Arora and Dr. Menchine go on to suggest admission and observation are warranted if one ore more of the following are present: abdominal or flank ecchymosis, seat belt sign, ileus, hematuria or hematochezia, vomiting, or persistent abdominal tenderness.
Acad Emerg Med. 2008;15(10):895-9
Pediatric patients are at higher risk for occult injuries such as duodenal hematomas and pancreatic contusions and have therefore traditionally been observed. In a prospective study of 1,295 pediatric patients with blunt abdominal trauma, 1,085 had a normal CT scan. Of these patients, 737 were admitted for observation. None of the 348 patients who were discharged returned to the emergency department. Of the patients who were admitted, only 2 had complications, neither of which required surgical intervention (1 perinephric hematoma and 1 mesenteric injury.) The authors’ of this study concluded pediatric patients with blunt abdominal trauma and a normal CT scan do not need to be admitted for observation. However, this study does not address other reasons for admission such as pain control, social issues, or polytrauma. Dr. Arora and Dr. Menchine go on to suggest admission and observation are warranted if one ore more of the following are present: abdominal or flank ecchymosis, seat belt sign, ileus, hematuria or hematochezia, vomiting, or persistent abdominal tenderness.
Acad Emerg Med. 2008;15(10):895-9
{mospagebreak title=The predictive value of prehospital hypotension}
Trauma Updates – The Predictive Value of Prehospital Hypotension with Dr. Swaminatha Mahadevan
Paramedics bring in a young male involved in a motor vehicle collision, restrained driver struck on the driver side, complaining of abdominal pain and back pain. In the field, his initial blood pressure was 75/P mmHg, which improved to 110/70 mmHg after a 500cc normal saline bolus. Do you trust the initial blood pressure in the field? Is it time to wake your surgeon? In a prospective study performed at Harbor-UCLA Medical Center, investigators evaluated hypotension in the field as a marker for hemorrhagic shock and further need for surgical intervention. In this study, 1,067 patients were enrolled, 1,028 of whom were normotensive on arrival. Hypotension was defined as < 90 mmHg in adults, < 70 + (2 x age) mmHg in children, or patients with a non-palpable pulse in any location. Of the approximate 7% of patients who were hypotensive in the field, over 33% required a therapeutic operation. In contrast, of patients who were both normotensive in the field and on arrival, only 11% required a therapeutic operation. Investigators concluded that if a trauma patient is hypotensive in the field, the need for an emergent, therapeutic operation was more than three times as likely compared with their normotensive counterparts. In addition, mortality was almost twice as high. Bottom line: take transient hypotension in trauma patients seriously. It is an early indicator for necessary surgical intervention and associated with greater mortality.
J Trauma. 2006 Nov;61(5):1228-33.
Paramedics bring in a young male involved in a motor vehicle collision, restrained driver struck on the driver side, complaining of abdominal pain and back pain. In the field, his initial blood pressure was 75/P mmHg, which improved to 110/70 mmHg after a 500cc normal saline bolus. Do you trust the initial blood pressure in the field? Is it time to wake your surgeon? In a prospective study performed at Harbor-UCLA Medical Center, investigators evaluated hypotension in the field as a marker for hemorrhagic shock and further need for surgical intervention. In this study, 1,067 patients were enrolled, 1,028 of whom were normotensive on arrival. Hypotension was defined as < 90 mmHg in adults, < 70 + (2 x age) mmHg in children, or patients with a non-palpable pulse in any location. Of the approximate 7% of patients who were hypotensive in the field, over 33% required a therapeutic operation. In contrast, of patients who were both normotensive in the field and on arrival, only 11% required a therapeutic operation. Investigators concluded that if a trauma patient is hypotensive in the field, the need for an emergent, therapeutic operation was more than three times as likely compared with their normotensive counterparts. In addition, mortality was almost twice as high. Bottom line: take transient hypotension in trauma patients seriously. It is an early indicator for necessary surgical intervention and associated with greater mortality.
J Trauma. 2006 Nov;61(5):1228-33.
{mospagebreak title=Abdominal Pain in the Elderly}
Abdominal Pain in the Elderly – Part 2 with Robert McNamara, MD
*Continued from the June edition of EPM. Perforated Peptic Ulcer
Perforated peptic ulcer disease (PUD) is frequently misdiagnosed by emergency physicians due the atypical presentation and general lack of complaint by the elderly. Physical exam may reveal mild tenderness in the epigastrium and slightly increased tone, but often no overt rebound or guarding. Diagnostic exams in search of the potential diagnosis (electrocardiogram, lipase, ultrasound and upright chest X-ray) will frequently turn up negative. At long last, a computed tomography of the abdomen and pelvis is performed and reveals what the chest X-ray did not: free air. Despite common belief, an upright chest X-ray alone is insufficient to rule out free air in the abdomen, present on plain radiography only 60% of the time. In one case series of elderly patients with abdominal pain, perforated peptic ulcer disease was the number one fatal misdiagnosis. In all misses, no free air was apparent on plain film, which wrongly mislead physicians to exclude perforated PUD as the cause. A plain film in the lateral decubitus position may allow for better visualization, but computed tomography is the test of choice. If computed tomography is not readily available, insufflating air via a nasogastric tube may aid in diagnosis. Again, if an elderly patient reports a significant amount of pain, it must be taken seriously. The elderly tend not to complain and not to present to the emergency department. In a prospective study of patients age greater than 70 years old with perforated PUD, only 47% reported sudden onset of pain, and only 21% had epigastric rigidity present on physical exam.Med Clin North Am. 1989 Nov;73(6):1413-22; Am J Surg. 1982;143: 751-4
Acute Mesenteric Ischemia
Acute mesenteric ischemia is more commonly mismanaged than misdiagnosed. Past medical history (atrial fibrillation) or current medication (warfarin) will more often than not clue the emergency physician to include this in their differential. Regardless of knowing a patient’s medical history or medication list, the physical exam in itself is indicative. “Pain out of proportion to exam” is often evident, even in the elderly. Patients will appear extremely uncomfortable, yet with minimal tenderness on palpation. Gastrointestinal emptying is also common among these patients (i.e. vomiting, diarrhea) contrary to the notion that necrotic bowel will inhibit this. Despite our ability to recognize this entity, the mortality rate is still greater than 70%. Peritoneal signs, elevated lactate levels and heme positive stools are late findings – do not wait for these to present before getting a vascular surgeon involved. In a study by Boley et al, if angiography was performed prior to the development of hard signs, morality rate dropped to only 10%. Angiography is still considered the gold standard, therefore, advocate for it early. Lastly, consider other causes of acute mesenteric ischemia including dissection, mesenteric venous thrombosis and low-flow states, such as congestive heart failure and hemodialysis. Non-occlusive etiologies account for approximately 25% of cases of acute mesenteric ischemia. In a study performed in long-term hemodialysis patients who presented with an acute abdomen, 12 of 567 patients over 5 years were admitted for abdominal pain. Of these, 11 were found to have mesenteric infarction, none of which were diagnosed on admission. This further reiterates that patients who are subject to repeated episodes of low-flow states are at greater risk of developing mesenteric ischemia. Surg Clin North Am. 1992;72(1):157-82; Surgery. 1995;117(5):494-7
Non-specific Abdominal Pain
In elderly patients who present with intermittent, vague abdominal pain, it is tempting to simply discharge home if they are tolerating PO, having bowel movements, have a benign physical exam and normal lab results. Of these patients, approximately 50% will be admitted. Of those patients who will be discharged, it is imperative that the emergency physician consider cancer as a potential diagnosis and ensure follow up for the patient. In a British study performed on elderly patients with non-specific abdominal pain, 347 patients were followed for 1 year after initial presentation. Among these patients, 11% were ultimately diagnosed with an intra-abdominal cancer, 47% of which were colon cancer. This translates into 1 in 10 patients with non-specific abdominal pain with an undiagnosed malignancy.
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