SURGERY CASES Review of Systems:

(CASE PRESENTATIONS) • Include all pertinent subjective information that are

(**Keynotes in blue are based on CVMC protocols; in red are missed out on PE
from Schwartz/Surg Plat) • For all trauma cases, always check for signs of
increase intracranial pressure to rule out traumatic
CASE 1: Blunt Abdominal Trauma brain injury
A 42y/o female was brought by Tuguegarao o Loss of consciousness
Emergency Response Team to CVMC ER with history of o +/- Dizziness
vehicular accident. Patient was driving an SUV which o +/- Headache S/S of TBI
accidentally hit an acacia tree. Upon arrival at ER, patient is o +/- Nausea and vomiting
conscious, coherent & oriented with the following vital signs: o Blurring of vision
Temp = 37.1oC
HR = 110bpm Initial Impression:
RR = 20cpm Blunt Abdominal Trauma secondary to Vehicular
BP = 120/80 mmHg accident
Patient was complaining of abdominal pain. (No need to input driver or passenger and GCS)

HPI: Diagnostics
NOI: Vehicular Accident, Driver (Other examples of • Blunt abdominal trauma is evaluated initially by FAST
nature of injuries include fall, gunshot wound, alleged examination
mauling) *Do not put abdominal pain • Diagnostic Peritoneal Lavage (DPL) is the gold standard for
TOI: n/a assessing intraperitoneal bleeding (But not done and
DOI: n/a available in CVMC)
POI: n/a • For patients initially hemodynamically stable, still watch
out for signs of shock and acute abdomen/peritonitis
Primary Survey: since some are delayed in progression
Airway o Peritonitis is an immediate indication for
Breathing and Ventilation emergency laparotomy
Circulation
Disabilities/Deformities ❖ FAST (Focused Assessment Sonography for Trauma)
Environment/Exposure - Initial evaluation tool to identify free intraperitoneal
fluid
Perihepatic PErisplenic Pericardium PElvis
Secondary Survey: - Components:
Allergies o Epigastric/Xiphoid region to check for
Medications pericardial fluid
Past Medical History o Morrison’s pouch, Right (Hepatorenal angle)
Last meal o LUQ, Splenorenal angle
Event/s prior to incident o Pouch of Douglas/Retroperitoneal space

Physical Examination: ❖ eFAST (Extended FAST)

- Still state all systems, and assume that all are normal
if not stated
- Include all pertinent negatives
- Don’t forget the vital signs
- First to assess in blunt trauma are vital signs
o Still attach on PE even if it was stated in the
Primary Survey
- ABDOMEN:
o Note for abdominal tenderness if objective
data (abdominal pain is subjective), and note
for the specific quadrant if possible (if not,
can be noted as generalized)
o Note for: tenderness, flabby, bowel sounds,
discoloration, surgical scars, bruising etc.
o Tender abdomen might be due to distention
o IAPePa Assessment
o For trauma cases, inspect for bruising and
lacerations
• extension to the Inferior and anterolateral pleural
space to rule out hemothorax or pneumothorax
• Anong titignan mo? Costophrenic angle hanggang
lower part of cavity (inferolateral location)
❖ DPL (Diagnostic Peritoneal Lavage)
• Procedure:
o Performed through an infraumbilical
incision, 2.5mm midline (SQ and linea alba)
after local anesthesia
o 3-5mm incision through the fascia
o Introduce catheter into the peritoneum and
advance to the pelvis
o IF DPA (ASPIRATION) ONLY, connect a 10-mL
syringe to the catheter and aspirate.
▪ (+) if >10mL of blood is aspirated
o FOR DPL, infuse 20mL/kg (1L in adults) of
LRS or NSS through the catheter if no blood
is returned

GROUP 4 CLERKS - BATCH 2021 1

 o Attach catheter to close container and • Superior Mesenteric Vein (SMV)
100mL fluid should flow back then assess ▪ Inframesocolic area
fluid in the laboratory • Infrarenal aorta
o (+) DPL results >10,000/mL RBC in • Inferior Mesenteric Artery, IMA
ANT Abd ▪ RBC >100,000/mL Thoracoabdominal Stab Wound • Gonadal arteries
Stab wound ▪ WBC > 500/mL • IVC
▪ Amylase >19 IU/L o Zone II, Left and Right:
▪ ALP >2 IU/L ▪ Kidneys
▪ Bilirubin >0.01 mg/dL ▪ Paracolic gutter
▪ Renal vessels
❖ For patients that are hemodynamically stable and (-) o Zone III
FAST, check for indications for CT Abdomen: ▪ Pelvic retroperitoneum
o Altered Mental status ▪ Iliac vessels
o Confounding injury
o Gross Hematuria
▪ Possible kidney or bladder injury
o Pelvic fracture
o Abdominal tenderness
o Unexplained Hct <35%
• If no indications, monitor further decrease of Hct
and Hgb to rule out impending bleeding, then
repeat FAST in 30mins

Management:
• Surgical Management (Laparotomy), indications:
o Signs of Peritonitis
- Hypotension, decreased mental status,
tachycardia, fever
o Positive DPL
o Positive FAST/CT Scan for hemodynamically instable
patients
• (+) FAST, patient stable: Admit to ward and monitor
for signs of shock and peritonitis
• Pain medications are being hold in blunt abdominal
trauma
o It can mask symptoms appearance or
Zones of Abdomen Reference: Stamatatos, I., Theodorou, M., Metaxas, E., Klapsakis, D.,
progression of abdominal pain (sign of Bouboulis, K., Tzatzadakis, N., & Rogdakis, A. (2018). Zone 1 Vascular Abdominal Trauma:
peritonitis) Damaged Control and Staged Management. Clinics in Surgery, 1905.

Review:
• Regions of the abdomen (9) ADDITIONAL: (During discussion)
Hypochondriac, R Epigastric Hypochondriac, L FLAIL CHEST – fracture of 2 or more ribs in atleast 2 locations
PARADOXICAL BREATHING- is a sign of respiratory distress.
Lumbar, R Umbilical Lumbar, L The chest wall and abdominal wall move in opposite directions
with each breath.
Inguinal, R Hypogastric Inguinal, L
Upon arrival in the ER what to do?
• Quadrants of Abdomen (4) 1) Initial assessment: nakainom ba? Passenger? Driver?
RUQ LUQ Medication taken?
RLQ LLQ 2)Level of consciousness (How to assess) Where are you?
Name? What happened?
• Zones of the Abdomen (3) :Also ask – Was their loss of consciousness when you hit the
o Zone I: midline retroperitoneum extending from the tree? To r/o Traumatic brain injury
aortic hiatus to the sacral promontory 3) ABC – facial deformity? Debris in airway? RR, O2 sat,
▪ Supramesocolic area
immobilize cervical spine then give oxygen. Also note: DOB or
• Suprarenal aorta and its major branches
Distress, Capillary refill? pale? Hemodynamically stable?
– celiac axis, superior mesenteric artery,
and renal arteries
• Supramesocolic IVC and its branches

GROUP 4 CLERKS - BATCH 2021 2

 • What if there is tenderness in all quadrant? Do
Laparotomy

PERITONITIS: presents with abdominal tenderness, muscle

guarding
▪ This is an indication for operative management

Gross Hematuria indicates:

▪ Bladder injury
▪ Kidney injury
▪ Pelvic fracture/injury

HEMORRHAGIC SHOCK – reduced tissue perfusion, resulting in

inadequate delivery of oxygen and nutrients. Why should we
r/o because late ang manifestation.
HEMODYNAMICALLY STABLE – blood pressure and heart are
stable.

Classes of Hemorrhagic Shock (check for the patient’s

sensorium)

GROUP 4 CLERKS - BATCH 2021 3