Milanka Krämer (R1 MFyC) English Tutor: J. McFarland Tutor: J.F. Suárez Ayala CS Son Serra – La Vileta (Palma de Mallorca) 26.10.2015
§ Description of a clinical sindrom -> symptom complex, not diagnosis
§ With sudden onset under - 6 hours § Often accompanied by § reduced general condition § peritoneal symptoms § can lead to shock § Requires a fast approach and treatment
Clinical case
§ October 2011, 10:39 Cornelius Straße, Düsseldorf
§ 4th floor § 10:00 arrival at the patient
§ What should we do?
Possible causes of acute abdominal pain
s e s y o r n a g s s ia e d c l e ia ely n t n e t er u l f f o i d bs a 0 5 h c n a a o h r e t c app r o m ti a h t i m e w t s y s is a
§ Anamnesis - Pain history - Medical and surgical history - Medication § physical examination § Vital Signs - Pulse, blood pressure, respiratory frequency, temerature - SpO2 - Blood Sugar Test
§ Inspection § Auscultation § Palpation
Possible causes of acute abdominal pain
§ Anamnesis - pain history - Medical and surgical history
- Medication § physical examination § Vital Signs - Pulse, blood pressure - respiratory frequency - Temerature - SpO2 - ECG - Blood Sugar Test
57 years old patient sudden and permanent abdominal pain Hypertension, hyperlipoproteinemia, obesity smoker None
HF 110/min, BP 90 syst/60 dias RF 40/min 37,5°C 93% sinus rhythm, tachycardia BST: 154mg / dl
§ Inspection
Patient pale, tachypneic
§ Auscultation
Heart and Lungs: tachycardic, tachypneic
§ Palpation
Abdomen: pain, distention, tenderness, pulsating abdominal tumor
MANAGEMENT IN PRIMARY CARE Analgesia Oxygen therapy ECG monitoring nothing by mouth (NPO) Value hemodynamic stability. § If the patient is in shock: Ensure two venous accesses for electrolyte replacement that can be done with crystalloid (0.9% saline or Ringer's lactate), colloids. § Transfer § § § § §
Ranji et al., JAMA 2006 § 12 studies, placebo vs. opioids § 9 adults and 3 with children § Opioids may change the results of a physical examination § no increase of "management errors"
Manterola et al., The Cochrane Library, 2007 § 8 trials, placebo vs. opioids § Analgesia with opioids: improving patient comfort § Use of opioids do not increase the risk for a wrong diagnosis / treatment
Clinical case Probable diagnosis: (covered) ruptured abdominal aortic aneurysm Initial Management: § Oxygen application § Analgesia § Two larg peripheral intravenous catheters § circulatory stabilization § permissive hypotension (50-100mmHg - systolic) § restrictive volume replacement therapy § Transport to hospital - specialized center
van der Vliet et al. Hypotensive Hemostasis (Permissive hypotension) for Ruptured Abdominal Aortic Aneurysm, 2007 § Limitation of fluid resuscitation to 500ml crystalline infusion § Maintain blood pressure systolic 50-100mmHg, if necessary use of nitroglycerin
Clinical case Diagnosis:
(covered) ruptured abdominal aortic aneurysm
Clinical case Therapy:
Open aneurysm repair with a bifurcated prosthetic graft
Conclusion § Acute abdominal pain
§ description of a clinical sindrom § sudden, severe abdominal pain § with more than 50 differential diagnoses is a systematic approach absolutely necessary
§ Analgesics: § the Use of pain killers do not increase the risk for a wrong diagnosis / treatment and should be aplied if necessary
§ Ruptured abdominal aortic aneurysm § We should maintain ploodpresure systolic 50-100 mmHg, limit the fluid resuscitation to 500ml § fast transport to a specialized center
Thank you
UpToDate; Diagnostic approach to abdominal pain in adults; Literature review current through: Aug 2015 JAMA. 2006 Oct 11;296(14):1764-74. Ranji SR1, Goldman LE, Simel DL Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005660. Manterola C1, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain AMF 2010;6(7):405-407 407 Si administramos analgesia al paciente con dolor abdominal agudo, encubrimos síntomas... ¿de verdad?
AMF 2007;3(4):230-234 62 Miguel Ángel Castro Villamor, Pedro Arnillas Gómez; Sueroterapia UpToDate Jeffrey Jim, MD et al. Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm; SAGE Journals – Vascular; August 1, 2007 vol. 15 no. 4 197-200 J. Adam van der Vliet; Dennis L. van Aalst; Leo J. Schultze Kool; Jan J. Wever; Jan D. Blankensteijn Hypotensive Hemostatis (Permissive Hypotension) for Ruptured Abdominal Aortic Aneurysm: Are We Really in Control?
Foto p4+7: patient.info/doctor/acute-abdomen Foto p15: aortic aneurysm; Gefäßchirurgie BHB Linz; Foto p17: „Mallorca kann auch leise“; www.bild.de Flyer: Abdomen agudo; AMF 2007;3(4):186-224 201
