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