The Washington Manual Internship Survival Guide (31 page)

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  Physical exam: Diagnosis of a hernia is made by examining the patient in a standing position with the patient performing Valsalva maneuver or coughing. A mass that protrudes is a hernia until proven otherwise.

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  Treatment:

•  Attempt to reduce an incarcerated, nonstrangulated hernia that does not protrude inferior to the inguinal ligament.
Do NOT attempt to reduce a hernia that you suspect is strangulated
.

•  Place the patient supine in the Trendelenburg position and slowly apply firm, constant, circular pressure with the palm of the hand to the hernia.

•  If the hernia reduces, then perform an abdominal examination an hour later to prove that ischemic bowel was not reduced.

•  If the patient has abdominal pain and you suspect ischemic bowel from the hernia, then call surgery urgently.

•  Most hernias require an operation if the patient can tolerate the risks of anesthesia. Therefore, a nonurgent surgery consult should be called even if the hernia is reduced (the consult can wait until morning).

•  Trusses or binders are usually not effective in the treatment of hernias.

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  Clinical pearls: Hernias are classified by both anatomy and status. Over 75% of hernias occur in the inguinal region, 10% are incisional or ventral hernias, 3% are femoral, and the rest are unusual types. The location is of less concern than the status of the hernia. Not all incarcerated hernias are strangulating.

Small Bowel Obstruction

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  Small bowel obstruction is an urgent consult. The most common causes are adhesions from previous abdominal operations (50% to 70%), incarcerated hernias, and carcinoma. As soon as a small bowel obstruction is diagnosed, intravenous fluids should be started, and a Foley catheter and nasogastric tube should be placed.

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  Pertinent information: The hallmarks of diagnosis are abdominal distension, nausea, vomiting, waves of abdominal pain progressing to constant pain (an ominous sign), and cessation of flatus and bowel movements.

•  Which symptoms are present? How long have they been present?

•  When was the patient’s last bowel movement? Last flatus?

•  Is the patient febrile (and do they have a leukocytosis)?

•  Are there any hernias?

•  Have they had any previous abdominal or pelvic operations?

•  What is the output from the nasogastric tube and Foley catheter? What are the patient’s vital signs and fluid status? With a persistent obstruction, hypovolemia often results due to impaired absorption, third spacing, and vomiting.

•  Does the digital rectal exam reveal impacted stool or a rectal mass?

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  Physical exam: Check for hernias in the groin and umbilicus and all scars for incisional hernias. Are the hernias incarcerated or strangulated? If peritoneal signs are present, urgent consult is indicated.

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  Diagnosis: An obstructive series (KUB, right lateral decubitus abdominal film, and CXR) should be obtained. What does the obstructive series show? Is there colonic or rectal air? Are there air-fluid levels? Most importantly, does the radiograph demonstrate any free air? A CT scan with intravenous contrast can be helpful to identify a transition point and subtle signs of intestinal ischemia.

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  Treatment options:

•  Patients with complete bowel obstruction or peritonitis generally require prompt surgical intervention. These are often associated with strangulation of bowel.

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Most patients with partial small bowel obstruction can be managed expectantly
with nasogastric tube decompression, fluid resuscitation, serial abdominal exams, and daily abdominal plain films.

Hints for Diagnosis of an Acute Abdomen

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  An acute abdomen warrants immediate surgical intervention. These hints are not rigid rules because the diagnosis of an acute abdomen can require much judgment. The most common signs indicating an acute abdomen are peritoneal signs due to peritoneal inflammation.
If at all there is any doubt, call …

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  Signs:

•  Rebound: This should never be tested for by pushing into the patient’s abdomen and releasing, since it can cause excruciating pain in the patient with peritonitis. Instead, be gentle: pain with percussion on the anterior abdominal wall is the best test. Tapping on a patient’s foot can also transmit vibrations to the abdominal cavity. Patients with an acute abdomen will not tolerate this.

•  Guarding: Involuntary guarding is another finding in peritonitis. To distinguish involuntary guarding from voluntary guarding, apply constant pressure to the abdominal wall in a location far away from the point of maximal pain and ask the patient to take a deep breath and relax. If the muscles remain spastic despite this, involuntary guarding is likely present.

•  Sitting up for posterior chest auscultation or rolling over for a rectal examination: Most patients with peritoneal signs will not do this.

Abdominal Pain with a Pulsatile Abdominal Mass

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Abdominal pain with a pulsatile abdominal mass is an incredible emergency!

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  Abdominal pain with a pulsatile abdominal mass, suggesting an AAA, is the easiest problem you will ever evaluate:

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Call surgery for a stat consult!

•  Type and cross the patient for six units of blood.

•  Ensure there is adequate intravenous access, at least two large-bore catheters.

Ischemic Lower Extremity

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An ischemic extremity is an emergency, call a consult immediately!

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  Symptoms of acute arterial insufficiency can occur abruptly. On exam, look for the 6 P’s: pain, pallor, pulselessness, paresthesias, paralysis, and poikilothermia.

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  An ischemic extremity may be due to acute events (embolic disease) or chronic disease (atherosclerosis). The acute event is an emergency because perfusion must be reestablished within 6 to 8 hours. Unlike patients with chronic disease, many patients with acute obstruction have not developed collateral circulation to supply the lower leg. If unsure whether the ischemia is acute or chronic, do not hesitate to call an immediate surgical consult.

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  Pertinent information:

•  Suspected source: embolism (atrial fibrillation/arrhythmia, LV aneurysm, AAA, or popliteal aneurysm) or chronic disease (atherosclerosis).

•  Did the pain come on suddenly? Is the pain unilateral?

•  Status of the vascular system: Has this patient had vascular surgery? If so, where does the bypass start and end? Where are the scars, and who was his or her surgeon?

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  Physical exam:

•  On exam, look for the 6 P’s: pain, pallor, pulselessness, paresthesias, paralysis, and poikilothermia.

•  Status of collateral flow: Palpate or perform a Doppler examination in the femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) arteries. Be able to tell the consultant if there is a temperature difference in the extremities and at what level (foot, shin, thigh, or whole leg).

•  Severity of ischemia: The peripheral nerve is the tissue that is most sensitive to ischemia. The most sensitive test to determine if the foot is viable is to test for proprioception of the toes. This will diminish within 5 minutes of cessation of blood flow. Next, test motor function and light touch.

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  Treatment options:

•  Most patients are started on intravenous
heparin
therapy.

•  Possible interventions include surgical bypass, surgical or interventional radiographic thrombectomy, or locally delivered intravascular thrombolytics.

Ischemic Ulcer of the Lower Extremity

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  Ischemic ulcer of the lower extremity is an elective consult.

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  Pertinent information:

•  These ulcers are commonly found on the first metatarsal head or tips of the toes and are due to a combination of unrecognized trauma, poor circulation, and infection. These are distinguished from venous stasis ulcers by location (usually found near the medial malleolus), appearance (heaped up, engorged edges), and sensitivity (very painful).

•  Status of the vascular system: Has this patient had vascular surgery? If so, where does the bypass start and end? Where are the scars?

•  Have any AAIs been performed? If not, use a Doppler and portable blood pressure cuff to do bedside AAIs. Place the blood pressure cuff on the arm and then using the Doppler, find a pulse in the radial artery. Inflate the cuff until the Doppler signal disappears. Record the pressure at which the signal disappears (the systolic blood pressure, SBP). Repeat on the opposite arm. Next, place the cuff on the calf. Using the Doppler, find the DP or PT pulse distal to the cuff and inflate until the signal is again lost. Divide the SBP of the left foot by the SBP in the left arm for the AAI. Repeat on the right side.

•  Plain radiographs should be obtained to document osteomyelitis of the underlying bone. Any exposed bone is assumed to have osteomyelitis until proven otherwise.

•  Is the patient a diabetic? Are his blood sugars well controlled? Diabetics can have calcified vessels that make AAIs unreliable. Some diabetics develop ulcers secondary to microvascular disease without obvious atherosclerosis in the larger vessels. Diabetics can also have poor wound healing if their blood sugars are poorly controlled.

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  Pertinent physical exam: Palpate or perform a Doppler examination of the pulses in the femoral, popliteal, dorsalis pedis, and posterior tibial arteries. Look for signs of infection (e.g., erythema, pain, fluctuance, pus discharge with palpation).

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  Treatment options:

•  Arterial: Amputation, debridement, or any procedure to increase vascular inflow in arterial disease and promote wound healing. Often these patients will need an imaging study such as a CT angio, MRA, or angiogram to determine the status of the vascular supply.

•  Venous leg elevation, Unna boots, or compression stockings to encourage venous drainage.

Retroperitoneal Bleeding

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Retroperitoneal bleeding is an urgent consult
. Retroperitoneal bleeding is most commonly seen in patients after coronary angiography as a complication from arterial puncture of the femoral artery. The frequent use of anticoagulant and antiplatelet medications contributes to the incidence of retroperitoneal bleeding in this patient population. The hallmark for this diagnosis is a decreasing hematocrit in a patient complaining of flank, back, or abdominal pain.

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  Pertinent information: What procedure was performed? What anticoagulants and antiplatelet agents were used, and have they been stopped? How much and how quickly has the hematocrit decreased? On the CT scan (go see it yourself; do not trust the radiologist), how large is it (in centimeters)? Does it compress the urinary system causing hydronephrosis or hydroureter, or compress the renal vein? These last two findings may necessitate urgent percutaneous nephrostomy tubes or surgery, respectively.

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  Pertinent physical exam: Neurologic status of the patient’s ipsilateral leg? Test this by asking the patient to perform a straight leg lift and then test light touch on the medial and lateral upper thigh. If these senses are diminished, the patient may need urgent operative decompression of the hematoma.

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  Diagnosis: Abdominal CT scan secures the diagnosis.

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  Treatment options:

•  Variable treatment depending on situation.

•  Serial CBC and coags (PT/PTT/INR).

•  Reverse anticoagulation with vitamin K and FFP as needed. Careful coordination with cardiologists will be necessary if an intervention such as angioplasty or stenting has taken place.

•  Supportive measures (fluids, blood) and/or operative intervention.

Femoral Artery Pseudoaneurysm

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Femoral artery pseudoaneurysm is an urgent consultation in most cases.

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  Pertinent information: This complication of arterial puncture occurs in the same patient population as retroperitoneal hemorrhages. What procedure was performed? What anticoagulants and antiplatelet agents were used, and have they been stopped? How large is the pseudoaneurysm by ultrasound and does it have a long, thin neck? These pseudoaneurysms are more likely to spontaneously thrombose or be amenable to ultrasound-guided compression.

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  Physical exam: The hallmark of diagnosis is a thrill or bruit over the puncture site. Is there any evidence of emboli to the ipsilateral foot? Look at the tips of the toes and search for petechiae or new larger purple or black spots. If present, the patient may need immediate operative intervention. Is there any evidence of compression of the femoral nerve? Test motor function and light touch sensation in the leg. If absent, the patient may need immediate operative intervention.

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  Diagnosis: Ultrasound confirms the diagnosis.

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  Treatment options vary from expectant management to ultrasonic compression, US-guided thrombin injection, or operative closure of the arteriotomy and evacuation of the hematoma.