Another case: Abdominal pain

[Solid]

I don't know what this is called, but it seems to fit the symptoms- a twisted/knotted intestine?

Solid

[Kyobanim]

All the symptoms seem to fit appenecitis. Add in Doc T's comment and I'll say Appendecitis

[Sacamuelas]

Well, due to my intense hangover/long recovery time from Saturday night(crawfish/beer/boat drinks/bourbon)... it appears this thread almost died on the vine before being picked when it was ripe. Sorry All...


No PM will be needed Ma’am, as it appears that the Dx was determined with the given info. I am sure NDD(the clinician-haha) had made the Dx as well, based on his line of questioning and given info in return. Doc T made it on the questions and confirmed with the radiograph.

Doc T- Ma'am, will you benefit us with your knowledge of what you see and why it only shows up specific to appendicitis and not just in a normal radiograph of the area? I ask for the 18D's that may have access to films and need to recognize this when/if it presents with these symptoms.

Note: the reason I did not include this radiograph in the original info is because from my understanding (limited, I admit) this visualization of an appendicolith in a patient with symptoms consistent with appendicitis is highly suggestive of appendicitis, but this occurs in fewer than 10% of cases. The consensus in the literature is that plain radiography is insensitive, nonspecific, and not cost-effective. As an 18D, you are much more likely to have to Dx this problem without an Xray facility available, but even with this radiograph you won't be able to rule out appendicitis even if it is not visible to you on the film. So, to me, it is MORE important to refresh on the diagnosis without having an obvious glaring sign like the x-ray presented to you up front.

To get the most potential learning from this thread...
From what little I know, it appears that this would have been a much more difficult diagnosis on a female patient than that of my Team Sergeant example. Anyone know why?

What other items were on everyone's differential Dx of these symptoms?
I will start off by noting that NDD was aware of and ruled out constipation early on in the thread. Through good history taking questions on bowel movements/frequency,etc a very common cause of some of the initial symptoms was ruled out. I doubt anyone would want to call for an emergency evac only to find out the Dx was constipation and you had not asked the obvious questions of the patient before making coms to command.

After we run through how we ruled out other potential causes ( to the best of our ability out in the field with limited technology), then we can go over what we would do. After all, remember that the scenario is that we don’t have access to evac for at least 48hrs.

(if you guys want to cut to the end... just give a shout and we can go directly to Tx- just trying to cover all the possible useful info)

[Sacamuelas]

Alright.. I let the thread die, so I will try and revive it with my internet ACLS.

Another observation I made from y’alls questioning.

Why was it important for Doc T to ask about nausea/vomiting and when it occurred when compared to pain?

Because when vomiting occurs due to appendicitis, it nearly always follows the onset of pain. Vomiting that precedes pain is more suggestive of intestinal obstruction, and therefore your diagnosis of appendicitis should be reconsidered and scrutinized.
-just another point that could be lost if we don't go over exactly how GOOD you guy's history taking questions were.

Anyone else want to report why they were asking a certain question? Or what certain info I reported back ruled out or made likely when it was given?

Or hell, if this is to boring for you "cutters", what would you do now that you have diagnosed it as appendicits?

[ccrn]

Originally posted by Solid
I don't know what this is called, but it seems to fit the symptoms- a twisted/knotted intestine?

Solid

AKA Volvulus.

I'm not good with KUB although I thought I detected gas in the transverse colon.

What I want to know is if it is hot appy (or meckel diverticulum) what could be done about it? If transport out is not available for 48H then the probablity of burst appendix with subsequent peritonitis is imminent. That is life threatening and means time in the hospital, possibly with an open incision for tx.

If it is volvulus or other type of obstruction is it possible to decompress it in the field with tubes?

ccrn

Edit for spelling
**edited FORMAT only...see note in your next post ccrn, thanks

[Sacamuelas]

Originally posted by ccrn
I'm not good with KUB although I thought I detected gas in the transverse colon.

I will leave that to Doc T for definitive answer. I do not want to mislead you, but to me gas on the radiograph would not be an uncommon finding and therefore would not help me diagnose this particular set of symptoms.

Originally posted by ccrn
What I want to know is if it is hot appy (ot meckel diverticulum) what could be done about it? If transport out is not available for 48H then the probablity of burst appendix with subsequent peritonitis is imminent. That is life threatening and means time in the hospital, possibly with an open incision for tx.

It could be life threatening if it ruptures, but again that must be tempered with the current situation that the SF medic in this thread is dealt. It is an unfortunate circumstance he finds himself in to be sure....BUT

I have read reports that describe the success of IV antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg, submariners, individuals on ships at sea). In one prospective study of 20 patients with ultrasound-proven appendicitis, 95% had resolution of symptoms with antibiotics alone, but 37% of these patients experienced recurrent appendicitis within 14 months.
***This may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure.

Originally posted by ccrn
If it is volvulus or other type of obstruction is it possible to decompress it in the field with tubes?

I defer to Doc T, Eagle, NDD, or others to answer this one.

[ccrn]

Originally posted by Sacamuelas
I have read reports that describe the success of IV antibiotics in treating acute appendicitis in patients without access to surgical intervention....

I had considered this and wondered if even loading with a PO antibiotic prophylacticly wouldnt be prudent if nothing else was available. Do 18D's carry these types of meds?

ccrn

[Sacamuelas]

Originally posted by ccrn
I had considered this and wondered if even loading with a PO antibiotic prophylacticly wouldnt be prudent if nothing else was available. Do 18D's carry these types of meds?
ccrn

Recommended Non-surgical Tx:

• Establish IV access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration or septicemia.
  
• Do not give anything by mouth to patients with suspected appendicitis.
  
• Administer IV antibiotics to those with signs of septicemia and those who are to proceed to laparotomy.
  
• Administration of analgesics to patients with acute undifferentiated abdominal pain has historically been discouraged and criticized because of concerns that they would render the physical examination less reliable. At least 8 randomized controlled studies now report that administering opioid analgesic medications to adult and pediatric patients with acute undifferentiated abdominal pain is safe; no study has found that analgesics adversely effect the accuracy of the physical examination.

Again the above is an opinion from well researched literature. Doc T should be along to confirm and/or give her professional opinion based on experience.

[DoctorDoom]

x

[Sacamuelas]

Thank you Doctor Doom. That was an excellent post. You filled in some of my interpretations with facts and experience. Thanks for spending the time to post all that except that "bamboo tube into the sigmoid colon part! "... I bet that gave NDD bad flashbacks of his last over 40 exam in the jungles of Colombia. LOL

Originally posted by DoctorDoom

Even in patients with ruptured appendicitis it is often advisable to treat with IV antibiotics until the disease "cools down;" it's impossible to operate in an inflamed area with friable tissue. IV abx for about a week, observation, and then discharge with PO abx for follow up surgery is indicated in that situation. In field conditions I would imagine broad spectrum IV abx as treatment until evac is possible should be considered. Definitive treatment remains surgical.

be careful what you write.... there are different categories of a perforated appendix. It can perforate freely into the abdominal cavity or it can perforate and form a loculated abscess. The former requires immediate surgical intervention and no "cooling down" period. It is only the later case, which is less common, that you would treat with drainage and IV antibiotics and treat with an interval appendectomy rather than just intervening immediately.

I do agree that for the TS IV antiobiotics and hydration would be the indicated treatment until evac. I know of two surgical residents that resolved their bouts of acute appendicitis with antibiotics rather than undergo surgery.... they didn't want to mess up the call schedule by being out and chose this option. Obviously, this was before the 80 hour work week began.

doc t.

[ccrn]

Originally posted by Doc T
be careful what you write.... there are different categories of a perforated appendix. It can perforate freely into the abdominal cavity or it can perforate and form a loculated abscess. The former requires immediate surgical intervention and no "cooling down" period.

This is my own experience from not only working in ER but having my own appy removed. Most cases of acute appendicitis that present to ER will be tx this way...

I do agree that for the TS IV antiobiotics and hydration would be the indicated treatment until evac.

THis is ideal and the probably the only field tx for 18D that I am aware of thus far. I understand that abx tx would be well within the range of capability for 18D but just how spectrum can one or two men carry in the field.

Obviously, this was before the 80 hour work week began.

Nurses (and pts) the country over thank God for this-

ccrn

***edited to clarify the format only.. CCRN, put a [/quote] at the end of the desired quote instead of a [quote]. The board needs to know the beginning and end to look right once posted.

do you really believe this makes for better care? I lived through many years of every other night call and the only patients I cared for were my own service. I knew every patient I got called about.

Now the residents have to cross cover many other services in order to limit their hours leading to calls about patients you have never seen or heard of before except in a brief sign out or on a patient list.

tell me how this makes for better care...I have never understood the reasoning. Same number of people doing the work but now they can only work a limited number of hours. Trauma come 24/7 so coverage must include nights.

Keep in mind if you work monday thru friday from 6-6 with one night on call you are already at 72 hours... I work more than 80 hours on many weeks.


Does the military limit work hours for special ops medics?

[Sacamuelas]

Doc T... I think the Team Sergeant should make you Beef Wellington EVERY night. Good GOD...

I must say that I have never heard the argument for the long hours made.. I admit thinking that MD's should not be allowed to work on no rest for that long due to lack of sleep symptoms, but I had totally disregarded continuity of care issues in my thinking.

Thanks... now go train some more baby Doc T's so that you can get some rest, Ma'am. : )

my residency years were 1989-1997 if you include fellowship. It was a rarity that I got no sleep when on call for all services except trauma. Most of the general surgery services did not require the surgery resident to be up all night but simply to be in house for calls, problems, etc.

Now call for the residents does typically mean no sleep because one resident is covering all services rather than just their own. Much more work for one person than the same work divided among many.

my 2 cents...