Why are peds more susceptible to dehydration with NVD?
higher percentage of body water
Peds kidney function consideration?
immature kidney function = decreased ability to concentrate and dilute urine
kidneys are more mobile - not well protected by fat
Liver consideration in peds?
more anterior and not as well protected by ribs as in adults
GI S/S with peds?
vague s/s when they have significant abd injury
Peds pt can lose up to __ % of their circulating volume before they exhibit hypotension
Stomach position in body?
inferior to diaphragm with 80-85% L of midline
HCl stimulated by what 3 chemicals?
histamine, acetylcholine, gastrin
Functions of HCl?
denatures protein and break intermolecular bonds
Functions of gallbladder?
1. storage of bile, passageway for bile, bile release
secretion of pancreatic juice for digestion of carbs, proteins, and fats
- secreation of bicarb to neutralize chyme
- secretion of insulin and glucagon
mucoprotein necessary for intestinal absorption of vit B12 in ileum
deficiency of B12 causes pernicious anemia
How long does food usually stay in stomach?
2-6 hours after ingestion
responsible for phagocytosis, line the sinusoids, destroy old or defective RBC and remove bacteria and foreign particles from the blood
Bile is produced by the ____ and stored in the ____
The major bile pigment is ____, a breakdown product of ____
Alpha cells secrete ___
Beta cells secrete ____
Delta cells secrete ____
- alpha - glucagon
- beta - insulin
- delta - somatostatin
What triggers pancreatic secretions?
food in small intestine
Pancreatic secretions are controlled how?
vagus nerve and parasympathetic NS
hormonal: secretin and cholecystokinin
What arteries and veins supply liver?
hepatic artery and vein
____ vein collects and delivers blood from entire venous drainage system of GI tract to liver
Where does hepatic vein empty?
inferior vena cava
Parasympathetic NS effect on GI?
What nerve is involved?
increases activity of GI tract - innervated via vagus nerve
Where in brain is hunger controlled?
feeding center of hypothalamus
sateity center also in hypothalamus
Where in the body is vitamin K produced?
bacteria in lg intestine
Are intestinal losses acidic or alkaline?
What occurs with intestinal loss: biliary losses, pancreatic fistula, intestinal suction, diarrhea?
metabolic acidosis, hypokalemia, hyponatremia, hypovolemia
S/S of gastritis?
- 1. epigastric/L of midline pain
- 2. "indigestion"
- 3. NV
- 4. may have hematemesis
Peptic ulcer s/s?
- 1. epigastric/RUQ burning/gnawing pain
- 2. hematemesis/melena
- 1. epigastric/LUQ
- 2. may radiate to back, flanks, or L shoulder
- 3. boring/worsened by laying down
- 4 NV
- 5. mild fever
- 6. Cullen sign - bluish discoloration at umbilicus indicatioing intraperitoneal bleeding
- 7. Grey turner sign- bluish discoloration at flanks indicating retroperitoneal bleeding
- 1. epigastric/RUQ
- 2. referred to below R scapula
- 3. Murphy sign: pain with deep breath while nurse palpates under R costal margin
- 4. cramping
- 5. NV
- 6. tenderness RUQ
- 1. epigastric or periumbilical pain later lecalized to RLQ
- 2. McBurney sign: pain with palpation at McBurney point
- 3. Rovsin sign: pain in RLQ with palpation of LLQ indicates peritoneal irritation
- 4. dull to sharp
- 5. anorexia, NVD
- 6. fever
- 7. leukocytosis
- 8. rebound tenderness indicates peritoneal irritation
Intestinal obstruction s/s?
- 1. epigastric or umbilical
- 2. spastic to dull
- 3. change in bowel habits
- 4. melena or hematchezia
- 5. hyperactive to hypoactive bowel sounds
Flexing of knees to relieve abd tension frequently seen with _____
Leaning forward to relieve abd pain frequently seen with ____
seen with bilirubin >3.0
liver disease, biliary obstruction excessive hemolysis
Bluish abd discoloration?
due infiltration of abd wall with blood
Grey Turner sign?
cchymosis to flanks indicative of retroperitoneal bleeding
pancreas, duodenum, kidneys, vena cava, aorta
ecchymosis around umbilicus indicative of intraperitoneal bleeding: liver spleen
caused by B12 deficiency, liver disease, and pregnancy
cirrhosis, intra-abd malignancy, or R ventricular failure
end-stage heart failure or renal failure
Seeing waves of peristalsis across abd generally associated with what condition?
What is aortic pulsation indicative of?
pulsatile swelling in the epigastrium suggests abd aortic aneurysm or an apigastric solid tumor overlying aorta
High-pitched "rushing" bowel sounds indicate?
early mechanical small intestine obstruction
Low-pitched "rushing" bowel sounds?
early mechanical large intestinal obstruction
if bruit noted check circulation to extremites: if decreased BF is noted, aneurysm should be suspected
Peritoneal friction rub?
scratchy sound heard over inflamed spleen or neoplastic liver
What does diffuse rigidity suggest?
infectious, neoplastic, or inflammatory process in peritoneal cavity
Rigid , boardlike abd is associated withwhat?
acute perforation of viscus with spillage of GI contents into peritoneal cavity
Consideration if palpate large, pulsating mass in abd?
REFRAIN FROM ADDITIONAL ABD PALPATION AS THIS MAY BE AN ABD AORTIC ANEURYSM
4 situations in which deep palpation should not be used?
- 1. polycystic kidneys
- 2. after renal transplant
- 3. malignant tumor - may cause seeding
- 4. recent surgery
Re bound tenderness is associated with
When is the spleen palpable?
when significantly enlarged: injury, leukemia, mononucleosis, portal HTN
When is chloride elevated/decreased?
elevated in dehydration
decreased in vomiting, diarrhea, or intestinal obstruction
What happens to calcium in acute pancreatitis?
normal phosphorus level?
When increased and decreased in GI probs?
- normal 3-4.5
- elefated in intestinal obstruction
- decreased in malnutrition or malabsorption sysndromes
When may magnesium be decreased with GI probs?
What happens to glucose with pancreatitis?
When is alkaline phosphatase elevated?
cirrhosis, RA, biliary obstruction, liver tumor, hyperparathyroidism
What causes amylase to be elevated?
- any pancreatic issues
- perforated peptic ulcer
- mesenteric thrombosis
- ectopic pregnancy
- renal failure
When is ALT elevated?
- any liver issues
- cholestasisinfectious mononucleosis
When is AST elevated?
liver issues, acute pancreatitis, dkeletal muscle disease or trauma
LDH (lactate dehydrogenase) normal?
Elevated lactate dehydrogenase/LDH?
liver issues, hemolytic anemia, pancreatitis, muscular dystrophy, pulmonary infarction, MI, pernidious anemia, renal disease
Clotting profiles in liver disease?
may be abnormal
When is urobilogen increase/decreased?
- increased in hepatocellular disease
- decreased in complete biliary obstruction
Dx biliary stones, ductal stricture, ductal compression, neoplasms of the pancreas and biliary system
contraindicated if pt is uncooperative or if bilirubin is >3.5
Considerations with endoscopy/colonoscopy?
- 1. bowel prep with gastric irrigation and cathartics required before lower Gi
- 2. NPO 4 to 8 hrs prior to study
- 3. keep NPO until gag reflex returns if sedation used
- 4. monitor for indications of perforation hemorrhage
extremely rare and mainly in preemies
Precipitationg factors appendicitis?
- most common in males age 10-30
- 2. foreign bodies
- 3. tumor of cecumor appendix
- excessive lymphoid tissue growth
- 5. recent barium enema
Most common cause of appendicitis?
hardened accumulated feces
S/S of infant appendicitis?
fussy and feeding poorly
Child appenidicitis s/s?
diarrhea and difficulty ambulating
appendicitis - palpate LLQ cuases pain in RLQ
2/3 way from umbilicus to anterior superior iliac spine
appendicitis - pain on extension of R thigh with patient on L side
Position of comfort appendicitis?
flex knees with pilows to help relax abd muscles
Complications of appendicitis?
perforation, sepsis, preterm labor in pregnanacy
acute longitudinal tear of the esophagus caused by forceful retchin
spontaneous tear or rupturing of esophagus associated with vomiting
Predisposing factors for upper GI hemorrhage?
- 1. gastritis or peptic ulcer - genentic, substance abuse, diet, drugs/therapies: NSAIDs, corticosteroids, drugs that increase acid production: coffee, nicotine, hormones: estrogen
- 2. high physiologic stress situation: COPD, recent Sx, MI
- 3. Ingestion of strong acids or alkalis:
- 4. esophageal varices
- 5. cirrhoisis
- 6. hepatitis
- 7. chronic R ventricular failure
- 8. Mallory-Weiss tear or Boerhaave syndrome: forceful vomiting
Patho of development of esophageal varices?
fibrotic liver changes & resistance to normal venous drainage of liver to portabl vein -> portal htn -> pressure to collateral circulation -> dilation of submucosal veins of the distal esophagus & stomach -> predisposition to bleed
Esophageal varices bleeding triggered by?
- 1. increased intra-a bd pressure/valsalva maneuver
- 2. mechanical trauma: poorly chewed foods, insertion NG tube
- 3. chemical trauma: reflux
- 4. coagulopathies
S/S peptic ulcer?
- gastic pain usually occurs 30 min to 1 hr after meals
- duodenal pain usually occurs at night and 2-3 h after meals
Use of vasopressin for GI bleed?
1. slows blood loss by contricting arteries and decreasing portabl venous pressure
Adverse effects of vasopressin?
- 1. bradycardia
- 2. htn
- 3. water retention: hyponatremia
- 4. chest pain
- 5. dysrhythmias
- 6. abd cramping and pain
- 7. oliguria
Monitoring of vasopressin for GI bleed?
htn can increase bleeding - monitor BP
Medications that may be admin for GI bleed?
- octreotide acetate/sandostatin
Octreotide acetate/sandostatin for GI bleeding?
reduces splanchnic BF, gastric acid secretion, GI mobility, and pacreatic exocrine function
Tx of esophageal varices?
- 1. sclerosing agent injected into varix and surrounding tissue - scar tissue
- 2. esophageal variceal ligation: rubber bands placed on target vessels
- 3. stop bleeding through measures that lower venous pressure: beta blockers, placement of tube for balloon tamponade
Purpose of NG tube for GI bleed?
- allows visulization during endoscopy
- removes blood from GI tract to prevent digestion of protein causeing elevation of ammonia
Pharmacologic therapy for H pylori?
- 2 wk therapy with 3 drugs
- 1. bismuth subsalicylate/pepto bismol or proton pump inhibitor AND
- 2. metronidazole/flagyl and tetracycline OR
- 3. clarithromycin/biaxin and amoxicillin
What can occur r/t Gi bleeding -> blood in gut?
elevated ammonia -> toxic to the brain
reflux that occurs more than 2X per wk
neurogenic impairment of esophageal motility that affects lower 2/3 of the esophagus
Malfunction of LES?
flux of acidic contents into esophagus
S/S of GERD?
- burning or discomfort up and down epigastric area
- 1. worse bending over
- 2 radiate to back, chest, neck
- 3. worse 30 min after eating
- 4. may feel like something stuck in upper chest area
- 5. may c/o dyspnea and salivation
Dx of GERD?
- 1. upperGI/barium swallow: eval motility and ID reflux
- 2. endoscopy: condition of esophageal and gastric mucosa
- 3. esophageal manomotrey: measure function of LES
Predisposing factors cholecystitis?
- 1. F, especially multiparous
- 2. usually >40 years
- 3. oral contraceptives/estrogen hormone replacment
- 4. sedentary
- 5. obesity
- 6. familial tendency
- 7. tumor
Predisposing factors cholelithiasis?
- 1. infection: most common E coli
- 2. cholesterol synthesis abnormalities
- 3. pregnancy
- 4. immobility
What can cause cholelithiasis?
any mechanism that alters body's ability to keep cholesterol, bile salts, and Ca in solution
S/S of gallbladder probs?
- typical s/s and
- 1. jaundice
- 2. Murphy sign: inability to take deep breath while abd is palpated beneath R colstal arch below hepatic margin
- 3. clay-colored stools, steatorrhea, dark amber urine if bile flow is obstructed
Study of choice for Dx cholecystitis/cholelithiasis?
Preciptitation factors for hepatic failure/encephalopathy?
- 1. herpes simplex and herpes zoster
- 2. epstein-barr
- 3. adenovirus
- 4. cytomegaloviurs
- 5. hepatitis, hepatotoxic drugs/toxins
- 6. ischemia and MODS
- 7. trauma
- 8. Reye syndrome
- 9. acute fatty liver of pregnancy
- 10. acute hepatic vein occlusion
occurs in children recovering from a virus
associated with aspirin use
liver cells fail to regenerate causing necrosis
What occurs in portabl htn and impaired hepatic function?
- Liver cannont:
- 1. produce products: proteins, carbs, bile - fat metabolism is impaired
- 2. make plasma proteins and inactivate hormones: aldosterone, estrogen
- increased levels of aldosterone cause Na and water retention and excretion of K -> hypocalcemia, hypocalemia, etc
- cumulative drug effects frequently occur
- increased susceptibility to infection and sepsis
Why does portal htn and liver failure cause increased susceptibilty to infection and sepsis?
- 1. inability to store viitamins and manufacture clotting factor
- 2. fat-soluable vitamin ADEK deficincies may occur
- 3. clotting abnormalities occdur
What may eventually occur in liver damage/failure?
hepatic encephalopathy r/t neurotixics such as ammonia accumlating
LP for in liver issues?
may be done to r/o neurologic cause of altered LOC
shows increase in glutamine
Antidote to tylenol OD?
When should it be admin?
must be admin within 24 h of acetaminophen ingestions
multiple diverticular that are not inflamed
infection of the diverticula
true congenital diverticulum present at birth
Early and late signs of alcohol withdrawal?
- 1. mild tachycardia & htn
- 2. NV
- 3. diaphoresis
- 4. pruritis
- 5. visual disturbances
- 6. time disoreientation
- 7. tremors
- 8. anxiety, agitation
- 9. sleep disturbances
- 1. marked tachycardia and hypertension
- 2. hyperthermia
- 3. dehydration
- 4. delirium
- 5. delusion
- 6. hallucinations
- 7. tonic-clonic seizures
Predisposing factors diverticulitis?
- 1. lowfiber/highfat diet
- 2. increases with age
- 3. chronic constipation
- 4. previous spisodes of diverticulitis
- 5. hereditary factors
S/S of diverticulits?
- 1. acute pain, constant, aching/cramping
- 2. may be LLQ or generalized
- 3. change in bowel habits
- 4. anorexia
- 5. low-grade temp
- 6. abd tenderness LLQ
- 7. palpable mass may be present
- 8. bowel sounds: decreased or nrmal
- 9. peritoneal irritation
- 10. older patients: mayu be afebrile with normal WBC and no abd tenderness
Preferred Dx tests for diverticulits?
barium enema and colonoscopy - rarely done emergently - may cause perforation if done during acute episode
inflammation of the mucosal lining of the stomach and intestine
Best position for patient if vomiting?
Diet for pt with diverticulitis?
initially NPO, fluids when vomiting stops
clear liquids X24 h then bland foods after 24 h (BRAT) bananas rice applesauce toast/tea
avoid carbonated, caffecinated, and high-sugar drinks
part of an internal organ bulges through and weakened area of a muscle
surgical emergency - cutting off blood supply and will result in necrosis if not relieved
Bowel sounds that suggest strangulation of hernia?
Preparation of pt for procedures if hernia?
- sedation if in ED
- possible Sx
mechanical bowel obstruction caused when a loop of bowel telescopes within itself
complete twisting of a loop of intestine around its mesenteric attachment site
Classic s/s of intussception?
classic red "currant jelly" stool
caused by venous engorgement and ischemia of intestinal mucosa bleeding -> mixed mucus and blood
S/S of intussusception?
- 1. cries inconsolably
- 2. crampy abd pain
- 3. intermittent episodes of pain may be only s/s in older children
- 4. lethargy
- 5. facial grimacing, legs drawn up to chest
- 6. vomiting
- 7. sausage-shaped abd mass
- 8. red currant jelly stools
s/s of volvulus in infants?
- 1.crying incosolably
- 2. absence of stools
- 3. failure to thrive
- 4. severe pain and bloating
- 5. abd distention
- 5. perstaltic waves may be visible
- 5. emesis may be bile in color
- 6. clinical indications of shock
- 7. bloody diarrhea
Prepping pt for procedures for intussesception and volvulus?
- for intusssception:
- 1. hydrostatic reduction: enema using barium or water-soluble contratst
- 2. surgica correction
- 1. Sx - emergent if symptomatic
- 2. sigmoid volvulus: endoscopic derotation of sigmoid colon may be done
Predisposing factors for pyloric stenosis?
- Neonates: Dx within for 12 wks of life - occurs 4 X as often in males
- 1 erythromycin use in first 2 wks of life
- 2. turner syndrome - F with one of X chromosomes is defective or absent in some or all cells
- 3. phenylketonuria - inability of body to utilize phenylalanine (amino acid)
- 4. trisomy 18 - extra 18th chromosome
Adults: edema from PUD and scarring from PUD or carcinoma
What will occur if pyloric stenosis goes unrecognized?
stomach will become markedly dilated in response to near-complete obstruction
S/S of pyloric stenosis infants/adults?
- 1. no vomiting at birth - gradual onset
- 2. fussy, hungry after feeding
- 3. infrquent, hard stools
- 4. weight loss
- 5. decreased urination
Adults: abd bloating, vomiting
- 1. tachycardia, hypotension
- 2. projectile vomiting
- 3. jaundice
- 5. may have visible peristalsis noticeable prior to emesis
- 6. palpable epigstric/RUQ mass hard and mobile: olive shape
- 7. bowel sounds hypoactive
- 8. succussion splash: splashing sound audible when pt is rocked from side to side
- 9. clinical s/s of dehydration
- 10. restlessness/lethargy
Dx studies for pyloric stenosis?
- 1. electroltyes: hypokalemia, hypochloremia
- 2. bilirubin elevated
- 3. ABG metabolic alkalosis
- 4. flat plate of abd: air in stomac
- 5. ultrasound: dilated stomach and pyloric thickeingin
- 6. upper GI: gastric retention at 3-4 h - one or 2 thin bariu tracts and nonprogression of peristaltic wave from stomach to duodenum
Med that may be used for pyloric stenosis?
antispasmodics: atropine may be used to shorten pyloric canal and decrease thickening over several weeks
Prep for procedures for pyloric stenosis?
NG to decompress dilated stomach
Who more affected by IBS?
women more than men
How is IBS Dx?
rule out other problems
What should be done for Dx in women with suspected IBS?
pelvic exam - r/t ovarian tumors and cysts or endometriosis - mimic ibs
Inflammatory bowel disease?
chronic inflammation of GI tract
ulcerative colitis, crohn's
What areas of GI tract are affected by Crohn's?
segmental areas of entire GI tract
mouth to anus - most common is ileius
What areas of GI tract are affected by ulcerative colitis?
colon and rectum
Differences b/t Crohn's and ulcerative colitis?
- Crohn's Ulcerative colitis
- anywhere in GI only colon and rectum
- R side of colon L side of colon
- bleeding rare gross rectal bleeding
- abscess/fistulas no fistulas
- perianal lesion maybe no perianal lesion
- patchy ulcerations inflammation
- separate from health uniform/diffuse
- sarcoidlike granulomas no sarcoid
S/S of inflammatory bowel disease?
- abd pain
- UC - bloody diarrhea 15-20Xperday with or without pus
- Crohn's: diarrhea 3-5 Xperday - no blood but may have steatorrhea (fat in stool)
- abd tenderness: R side crohn's, L side UC
- acute abd if perforation occurs
Meds for inflammatory bowel?
corticosteroids, ABX, antipyretics
Complications of inflammatory bowel diseases?
- 1. anemia
- 2. perforation
- 3. toxic megacolon - dilation of colon >5cm
- 4. abscess
- 5. sepsis
Why may hypovolemia occur with pancreatitis?
fluid leak into peritoneal cavity
progressive and irreversible destruction of the pancreas - necrosis of pancreas erodes into tissues and blood vessels -> hemorrhage
Predisposing factors pancreatitis
- 1. obstruction of common bile duct
- 2. alcoholism
- 3. hypertriglyceridemia
- 4. meds: thiazides, estrogen, steroids, abx, opiates
- 5. peptic ulcer with perforation
- 6. cancer, especially of pancreas or lung
- 7. injury to pancreas
- 8. pregnancy - 34d trimester, ectopic
- 9. ovarian cyst
- 10. infections
Patho of pancreatitis?
- activation of pancreatic enzymes & pancreatic cell injury -> auto digestion of pancreas ->
- edema, necrosis, hemorrhage
inflammation causes necrosis of fat in pancreas and exudates with high albumin content -> hypoalbuminemia & ascites
fat necrosis -> precipitation of calcium -> hypocalcemia
may have sepsis and/or SIRS r/t necrotic toxins
Clinical presentation pancreatitis?
- 1. recent heavy meal or drinking binge
- 2.epigastric pain: aggravated by food, alcohol, walking, supine position
- 3. anorexia
- 4. dyspepsia, flatulence
- 5. NV
- 6. dyspnea
- 7. weight loss
- 8. weakness
- 9. tachycardia, hypotension
- 10. fever - usually low grade
- 11. abd distention tenderness guarding
- 12. grey turner sign: ecchymosis over flank area
- 13. Cullen sign- ecchymosis at umbilicas
- 14. Chvostek sign- unilateral spasm of facial muscles when cheek tapped
- 15. Trousseau sign: carpal spasm occurs when upper arm compressed with tourniquet or BP cuff
- 15. ascites
- 16. rebound tenderness
- 17. epigasric mass may be palpable
- 18. steatorrhea
Electrolyte imbalances that may occur with pancreatitis?
decreased potassium, calcium, and magnesium
Effect of pancreatitis on glucose?
increased if endocrine function of pancreas is compromised
CXR with pancreatitis?
bilateral or only L pleural effusion, elevated L hemidiaphragm, L atelectasis
functional obstruction caused by loss of peristalsis
Patho of bowel infarction?
decrease BF to vessels that supply bowel -> prolonged ischemia increases permeability of bowel and edema of intestinal wall -> normal bowel flora may penetrate bowel wall -> peritonitis
necrosis and perforation may occur
Patho of bowel obstruction?
gas and fluids proximal to obstructions unable to move -> shifting of fluids from bowel into peritoneal cavity -> dehydration, hypovolemia, shock
S/S of bowel obstruction/infarction?
- 1. anorexia
- 2. abd pain/distention/tenderness with perforation & peritoneal irritation
- 3. weight loss
- 4. urgency for BM
- 5. tachycardia, tachypnea, hypotension
- 6. hypoactive or absent bowel sounds
- 7. vomiting - may be bloody
- 8. urgent diarrhea - may be bloody
- 9. dehydration s/s
- 10. elevated temp
Where is obstruction based on vomit contents?
clear gastric fluid, gastric contents and bile, brown fecal
clear gastric fluid: obstruction at pyloris
gastric contents and bile: proximal small intestine, paralytic ileus
brown fecal: obstruction in distal small intestine
S/S of large bowel obstruction?
change in bowel habits - thin, ribbonlike preogressing to constipation
Electrolyte issues that may occur with large bowel obstruction?
Na high/low/normal, decreased potassium and chloride
S/S of bowel perforation?
- 1. tachycardia, tachypnea
- 2. fever
- 3. vomiting
- 4. abd tenderness, rigid/boardlike abd, guarding, rebound tenderness
- 5. diminished/absent bowel sounds
Barium enema with obstruction?
may show point of obstruction
Test that may visualize bowel obstruction?
Drug that can enhance GI motility in partial intestinal obstruction?
When is Sx needed with bowel obstruction?
vascular obstruction, complete bowel obstruction, and perforations
Considerations with high-velocity penetrating trauma to abd?
blast effect on surrounding tissues
liver most often affected by penetrating trauma
Consideration with blunt trauma to abd?
spleen most often affected by blunt trauma , pancreas frequently injured with spleen
S/S of abd trauma?
Kehr sign - L shoulder pain indicative of splenic rupture caused by blood below diaphragm tht irritates phrenic nerve
Rovsing sign- RLQ pain with palpation of LLQ indicates peritoneal irritation
seatbelt sign - ecchymosis across lower abd caused by seatbelt
hematoma, entrance/exit wounds,
Grey Turner or Cullen sign
Coopernail sign - ecchymosis of scrotum or labia - indicates fractured pelvis
- rigid abd - may indicate abd bleeding
- - Balance sign - resonance over R flank with pt on L side - indicates ruptured spleen
- - hypoperfusion or shock s/s
Myoglobinuria indicates what?
crush injury tor muscle breakdown occurring
Why need CXR with abd injuries?
r/o concurrenty thoracic injury
ID free air under diaphragm
What will abd Xray show with stomach or bowel perforation?
free air in peritoneum
What does FAST show?
fluid/blood in pericardium, abd, or pelvis
visualization of spleen and liver
S/S of liver injury?
- 1. seatbelt sign
- 2. hematoma or ecchymosis in RUQ
- 3. lower R rib Fx
- 4. blunt/penetrating trauma
- 5. accel/decal MVA
- 6. presence of other abd injuries
- 7. RUQ pain/guarding - worse during inhalation
- 8. referred pain to R shoulder
- 9. increased abd girth/rigidity
- 10. tachycardia, hypotension
- 11. increased WBC
- 12. elevated liver enzymes
- 13. decreased Hgb and Hct
- 14. abnormal clotting studies
- 15. CXR - may show elevated diaphragm on R side
- 16. injury evident on FAST
S/S of spleen injury?
- 1. seatbelt sign
- 2. local sign of injury LUQ
- 3. L pneumothorax
- 4. blunt or penetrating trauma to abd
- 5. accel/decal MVA
- 6. presence of other abd injuries
- 7. LUQ pain, tenderness, and guarding - increased with inspiration
- 8. increased abd girth and rigidity
- 9. Keher sign
- 10. balance sign
- 1. tachycardia, hypotension
- 12. decreased Hgb and Hct
- 13. injury evident on FAST
s/s of pancreatic injury?
- 1. seatbelt sign
- 2. other abd injuries
- 3. MVC
- 4. blunt or penetrating injury to abd
- 5. epigastric, back, or shoulder pain
- 6. abd tenderness and guarding
- 7. increased abd girth
- 8. decreased bowel sounds
- 9. electrolyte imbalances - hyperglycemia or hypoglycemia
- 10. elevated serum lipase
- 11. elevated WBC
s/s of stomach injury?
- 1. penetratring trauma to abd
- 2. presence of other abd injuries
- 3. epiastric or LUQ pain and tenderness
- 4. hematemesis or bloody aspirate from NG tube
- 5. rebound tenderness
- 6. tachycardia, hypotension
- 7. elevated WBC
- 8. abd flat plate - free air
s/s of intestinal injury?
- 1. seatbelt sign
- 2. presence of other abd injuries
- 3. blunt trauma with decal
- 4. penetrating injury
- 5. local sign of injury
- 6. NV
- 7. abd pain, may be referred or rebound
- 8. absent bowel sounds
- 9. elevated WBC
- 10. abd flat plate - free air
- 11. positive fecal occult blood test
s/s of abd vessel injury?
- 1. other abd injuries
- 2. blunt or penetrating abd injury
- 3. sudden decal in MVC or fall
- 4. abd distention and guarding
- 5. increased abd girth and rigidity
- 6. diminished femoral pulses if aorta or iliac injury
- 7. mottled lower extremities
- 8. Cullen sign
- 9. decreased Hgb and Hct
- 10. tachycardia, hypotension, shock
Position of pt with peritoneal irritation?
knees flexed while in supine position
Considerations for children and orthopedic/wound emergencies?
- 1. open epiphyses until after adolescence
- 2. dislocations are rare - if they occur there is usually a Fx involved
- 3. limping in children is rare - look for a possible hip disorder
Bones are primary storage site for ___ and ___ and help with the regulation of these substances
calcium and phosphate
Osteoblasts, osteocytes, and osteoclasts?
- osteoblasts: build new bones
- osteocytes: maintain bone tissue
- osteoclasts: maintain bone reabsorption
Parathyroid hormone effect on calcium and phosphate?
increased parathyroid hormone -> calcium and phosphate absorbed and moved into blood stream
Vitamin ___ affects bone deposition and absorption
breakdown of cartilage
Systemic lupus erythematous?
autoimmunie disorder that can affect joints and cause symptoms similar to those of arthritis
alteration of the normal bone growth process of breakdown and rebuilding breaks down more quickly and grows back softer - bones bend and break more easily
autoimmune disorder that causes chronic inflammation that can affect joints
low bone density
brittle and weak bones
Tobacco use affect on bones?
smoking weakens bones
Medications that can reduce bone density?
Discoloration indication of wound age?
- reddish blue to purple - 24-48 hours
- greenish - 5 to 7 days
- yellow - 7 to 10 days
- brownish - 10-14 days
- no injury evident - 2 to 4 wks
angle of part is away from midline of body to an abnormal degree
deformity in which angle of part toward midline of body to abnormal degree
Causes of increased calcium r/t bones?
- prolonged immobility/immobilization
- Paget disease
- metastatic bone cancer
When may troponin increase not r/t heart?
skeletal muscle damage
When may creatine kinase increase?
Lactate dehydrogenase increases with ?
skeletal muscle damage
Uric acid increses with ___ and ___
- acute tissue distruction
What labs will be positive with RA?
- antinuclear antibodies
- serum rheumatoid factor
Imaging studies for extremity injury?
need 2 views of injured extremities with view of joint above and below
Consideration of cervical injuries in pediatric patients <8 years old?
spinal cord injury without radiographic abnormality common
Tx of puncture wounds?
soak puncture wounds for 10 to 15 minutes. other wounds should not be soaked
pull across wound rather than away from wound
Six P's of neurovascular assessment?
- 1. pain
- 2. paresthesia
- 3. pallor
- 4. polar - cold
- 5. pulselessness
- 6. paralysis
Ice application to injuries?
apply to injures <24to 48 hours
20 to 30 min at a time for up to 48 hours after initial injury
use for chronic injuries/pain after exercise
Use of heat for injuries?
chronic injuries or injuires that have no inflammation or swelling
before exercising to increase elasticity of joint connective tissues and stimulate BF
15 to 30 minutes at a time
do not place directly on skin
When should sutures to face, scalp, neck, chest, abd, bac, joint surfaces, nonjoint surfaces of extremities, palm of hand/sole of foot be removed?
- face 3-5
- scalp 5-8
- neck 3-5
- chest 7-10
- abd 7-10
- back 10-12
- joint surfaces 10-12
- nonjoint surfaces 7-10
- palm/sole 7-12
Should be ___ inches between axilla and top of crutches
Elbows slightly bent _____ degrees of flexion.
Cruthces should be ___ inches forward and ____ inches to the side of the body when walking.
1 to 1/2 inches b/t axilla and crutches
30 dgree flexion of elbow
12 inches forward and 6 inches to side
Up and down stairs with crutches?
up stairs: uninjured leg goes up on first step then followed by injured leg and crutches
down stairs: crutches placed down one step and then followed with injured leg and then the uninjured leg
Walking with a cane?
- cane should reach pt wrist - handgrip level with ulnar side of wrist
- hold cane with elbow slightly bent in hand opposite injured side
- cane and injured leg should move together - cane 4 to 5 inches forward
- up stairs uninjured leg moved first and followed by cane and injured leg
-= down stairs - cane placed on the step first and followed by injured leg then uninjured leg
handgrips should be level with the wrist crease