Rosen & Barkin's 5-Minute Emergency Medicine Consult (524 page)

Initiate IV fluids for patients with history of vomiting or abnormal vital signs.

Treat hypotension/tachycardia with 0.9% normal saline:

• Adults: 500 mL–1 L bolus:
  
  • Repeat bolus as necessary permitting patient can tolerate aggressive fluid resuscitation
    
  • Consider vasopressors if fluids not tolerated or not sufficient to maintain physiologic stability
    
• Pediatric: 20 mL/kg bolus:
  
  • Considerations similar as in adult population
    

• Nasogastric tube
  
• Foley catheter
  
• Administer broad-spectrum antibiotics:
  
  • Cephalosporin/broad-spectrum penicillin +
    
  • Aminoglycoside/broad-spectrum penicillin/antianaerobe
    
• Immediate surgical consultation for operative intervention
  

Broad coverage antibiotics should be given for enteric gram-negative aerobic and facultative bacilli and enteric gram-positive streptococci

• Metronidazole 500 mg IV (peds: 30–40 mg/kg/d q8h) in addition to 1 of the antibiotics below
  
• Carbapenem:
  
  • Meropenem 1 g IV q 8h (peds: 60 mg/kg/d in div. doses q8h)
    
  • Imipenem–cilastatin 500 mg IV q6h (peds: 60–100 mg/kg/d in div. doses q6h)
    
  • Doripenem 500 mg IV q8h
    
• β-lactamase inhibitor combination:
  
  • Piperacillin–tazobactam 3.375–4 g IV q4–6h (peds: 200–300 mg/kg/d of piperacillin component in div. doses q6–8h)
    
• Flouroquinolones (used only if hospital surveys indicate >90% susceptibility of
  Escherichia coli
  to this class):
  
  • Ciprofloxacin 400 mg IV q12h
    
  • Levofloxacin 750 mg IV q24h
    
• Cephalosporin:
  
  • Ceftazidime 2 g IV q8h (peds: 150 mg/kg/d in div. doses q8h)
    
  • Cefepime 2 g IV q8–12h (peds: 100 mg/kg/d in div. doses q12h)
    
  • Ceftriaxone 1–2 g IV q12–24h (peds: 50–75 mg/kg/d in div. doses q12–24h)
    
• Morphine sulfate: 2–4 mg (peds: 0.1 mg/kg) IV q2–3h
  

FOLLOW-UP

Suspected or confirmed perforation requires admission and immediate surgical consultation.

Discharge not applicable in this situation, as acute perforations are surgical emergencies

• General surgery consult for operative intervention
  
• Consider trauma consult/transfer if applicable
  

Postoperative surgery follow-up

• Obtain upright CXR and abdominal radiographs for patients with suspected perforated viscous.
  
• CXR without free air does not rule out perforation
  
• If high clinical suspicion for perforation and plain films normal, obtain CT of abdomen to detect small perforation.
  
• Obtain immediate surgical consult for operative intervention.
  

• Gans SL, Stoker J, Boermeester MA. Plain abdominal radiography in acute abdominal pain; past, present, and future.
  Int J Gen Med.
  2012;5:525–533.
  
• Langell JT, Mulvihill SJ. Gastrointestinal perforation and the acute abdomen.
  Med Clin North Am.
  2008;92:599–625.
  
• Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients.
  Am Fam Physician
  . 2006;74:1537–1544.
  
• Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.
  Clin Infect Dis.
  2010;50:133–164.
  

See Also (Topic, Algorithm, Electronic Media Element)

Abdominal Pain

CODES

• 533.50 Chronic or unspecified peptic ulcer of unspecified site with perforation, without mention of obstruction
  
• 562.11 Diverticulitis of colon (without mention of hemorrhage)
  
• 868.00 Injury to other intra-abdominal organs without mention of open wound into cavity, unspecified intra-abdominal organ
  

BASICS

• Pericardial effusion:
  
  • Pericardial sac usually contains 15–40 cc of fluid
    
  • Collection of additional fluid = effusion
    
• Pericardial tamponade:
  
  • Accumulation of pericardial fluid causes an elevation of pressure in the pericardial space, resulting in impairment of ventricular filling and decreased cardiac output.
    
  • Depends on size and speed of fluid accumulation
    
  • Increase of as little as 80–120 cc of fluid may lead to a rise in pericardial pressure.
    
  • Up to 70% present in “early tamponade” and appear clinically stable
    
  • Occurs in 2% of patients with penetrating chest trauma
    

• Medical causes:
  
  • Pericarditis (20%):
    
    • 90% idiopathic or viral
      
    • Bacterial, fungal, parasitic, tuberculosis, HIV
      
  • Malignancy (13%):
    
    • Lymphoma, leukemia, melanoma, breast, lung
      
    • Metastatic disease, primary malignancy, postradiation
      
  • Postmyocardial infarction (8%):
    
    • Acute: 1–3 days after acute myocardial infarction (AMI)
      
    • Subacute (Dressler syndrome): Weeks to months after AMI
      
    • Incidence reduced with reperfusion therapy
      
  • End-stage renal disease, uremia (6%)
    
  • Autoimmune/collagen vascular disease (5%): Rheumatoid arthritis, systemic lupus erythematosus, scleroderma
    
  • Rheumatic fever
    
  • Radiation therapy
    
  • Myxedema
    
  • Congestive heart failure (CHF), valvular heart disease
    
  • Drug toxicity (isoniazid, doxorubicin, procainamide, hydralazine, phenytoin)
    
  • Idiopathic
    
• Surgical causes:
  
  • Penetrating chest trauma
    
  • Thoracic aortic dissection
    
  • Iatrogenic (cardiac catheterization, postcardiac surgery, central line placement)
    
  • Blunt trauma rarely causes pericardial effusion.
    

DIAGNOSIS

• Beck's triad = classic presentation of cardiac tamponade:
  
  • Hypotension
    
  • Muffled heart sounds
    
  • Jugular venous distention
    
• Dressler syndrome: Pericarditis seen several weeks after a myocardial infarction:
  
  • Fever
    
  • Chest pain
    
  • Pericardial friction rub
    

• Past medial history is key:
  
  • History of malignancy?
    
  • Recent viral illness?
    
  • Connective tissue disorder?
    
  • Recent MI?
    
• History of the present illness:
  
  • Most are asymptomatic.
    
  • Pulmonary symptoms: Dyspnea, cough:
    
    • Dyspnea is the most common symptom seen in tamponade (87–88% sensitivity).
      
  • Chest pain is the most common symptom:
    
    • Usually sharp, pleuritic, relieved by sitting forward
      
    • Can be referred to scapula
      
    • Can also be dull, aching, constrictive
      
  • GI symptoms: Nausea or abdominal pain from hepatic and visceral congestion or dysphagia from esophageal compression
    
  • Generalized symptoms: Fatigue, malaise
    

• Signs of shock or right heart failure:
  
  • Tachycardia, hypotension
    
  • Jugular venous distention (may be absent if the patient is also hypovolemic)
    
• Pericardial friction rub (100% specific):
  
  • High-pitched “scratchy” sound
    
  • Best heard at left sternal border
    
  • Increased by leaning forward
    
  • Can be transient/intermittent
    
• Pulsus paradoxus:
  
  • Fall in systolic BP >10 mm Hg with inspiration
    
  • When severe, this can manifest as lack of brachial or radial pulse during inspiration.
    
  • Sensitive but not specific
    
• Low-grade fever common; >38°C is uncommon; if present, consider purulent pericarditis (can also result from autoimmune/connective tissue disease).
  
• Lungs should be clear; if not, consider CHF or pneumonia.