Happy New Year Everyone! Conference switches to Wednesdays next week.
Williamson Study Guide
I am sorry I missed this excellent lecture.
Pt is on warfarin. He has a RLQ abdominal mass and is hypotensive. Pt had gingival bleeding over the last few days. Busy ED shift and there are patients in the queue for CT scan.
Ct abdomen shows markedly enlarged right kidney with large perinephric hematoma and ascites.
Dialysis arranged, 2u of PRBC’s started. FEIBA and Vitamin K given. Surgery consulted.
Pt goes to OR after receiving 3 units of PRBC’s. Dialysis was deferred until after surgery.
Pt arrests post op.
Opportunities for improvement: Double check orders and be sure you have ordered all the labs you need. Be an advocate for your patient and push the workup through a crowded ED system. Get consults involved early.
Non-traumatic retroperitoneal hemorrhage: Most patients with non-traumatic retroperitoneal hemorrhage are on anticoagulation and their INR’s are usually in the therapeutic range. Dialysis increases the risk in anticoagulated patients because these patients receive heparin and their platelets are dysfunctional. Cardiac caths can iatrogenically cause retroperitoneal hemorrhage. The posterior wall of vessel can be punctured. Retroperitoneal surgery can also cause retroperitoneal bleeds. Retroperitoneal hemorrhage can also be due to rupture of vascular aneurysms. Retroperitoneal bleeding can cause abdominal compartment syndrome. This adversely affects renal function, limites respiratory function , impairs vascular flow to bowel and compresses the IVC reducing preload. If abdominal compartment syndrome is present, the patient needs to go to the OR. CT is best test to identify retroperitoneal bleeding. Management of non-traumatic retroperitoneal hemorrhage is fluids, prbc transfusion, reversal of anticoagulation. Surgery has the risk of removing tamponade effect and increasing bleeding. IR embolization can be used for hemodynamically unstable patients. Unstable patients in which IR is unsuccessful or in patients with abdominal compartment syndrome should go to OR.
Harwood comment: SICU nurses know how to measure abdominal compartment pressure with specialized Foleys and arterial pressure monitor. Call up to the ICU for the special foley and possibly the expertise of the ICU nurse. Things to do in the ER are drain bladder, place NG in stomach, and drain ascites to decrease intra-abdominal pressure. Elise comment: There is a specialized foley made by Bard that has a pressure manometer for measuring abdominal compartment syndrome. You have to identify your sickest patients and mentally visualize that you are moving those very sick patients through the system while continually following up to make sure tests, procedures, and consults are getting done.
Right side retroperitoneal hematoma
There are five signs suggesting retroperitoneal bleeding. They generally appear 24 hours after bleeding starts, occurring when blood extravasates along ligamentous connections between the retroperitoneal space and skin surface.
1. Grey-Turner Sign: Named for the surgeon who identified it in 1920; a bluish hematoma across the lateral abdominal wall when blood from the pararenal space leaks along the quadratus lumborum.
2. Fox’s Sign: Described by Dr. Fox in 1966 in two patients, (ruptured AAA and pancreatitis); ecchymosis over anteromedial thigh secondary to blood seeping along the fascia of psoas and iliacus.
3. Cullen’s Sign: Dr. Cullen (gynecologist), described this in 1918 as a sign of a ruptured ectopic pregnancy; bruise around the umbilicus from retroperitoneal blood tracking along falciform ligament.
4. Bryant’s Sign: Dr. Bryant initially described this sign; ecchymosis of the scrotum from blood tracking down the spermatic cord.
5. Stabler’s sign: Ecchymosis over the inguinal ligament
Z. Dezman University of Maryland
Advanced Wound Management Workshop