OK, yeah. Welcome to the webinar Acute abdomen. Try to put a little bit together a beginner's guide of, you know, if everything else fails, what potentially you could rely on.
To find out, A, is it in duct, and B, you know, how to find out a little bit more about it and what to do. So I try to include some things about the history taking, pain involved, fluid resuscitation, including some blood products, for example, that plasma, some diagnostics, and then also some further stabilisation. So the first question we're often presented with is, you know, we have a suspicion potentially it is an acute abdomen or the abdomen plays a role here, but is it really or is it what we call a look alike?
Is it another disease mimicking an acute abdomen? We'll talk about that later a little bit more in detail. Often, the presentation is acute.
And We can localise something towards the abdomen. Either we think there's pain involved, or there's a certain positioning or from the history and so on, we think the abdomen is the main suspicion here regarding gastrointestinal symptoms. We've seen vomiting or diarrhoea.
But remember also, that's Sometimes in, in very depressed patients, so patients that have already diminished vital functions, sometimes they would and do experience pain, but they might not be as able as other patients to display that kind of pain reaction. So remember and remind yourself of not judging, not, a, a patient that has no pain reaction to abdominal palpation as pain-free. We, we can only say there was no pain reaction, but potentially, that reaction was there, but diminished and not really shown properly.
So just be alert and and think about that. Prayer position, sometimes seen in vets, but most often in dogs. The history behind that is often, or the theory behind it is often that there is some form of pain and or.
A certain feeling of feeling uncomfortable, and the dog tries to adopt the position that makes this pain or this feeling, you know, subside a little bit more. So sometimes cranial abdominal pain can do this. You can see this in pancreatitis patients and so on.
They're trying to get a little bit stretch of the organs, and then they find a position that is more comfortable. And sometimes that ends up with this position. History has always put the cornerstone of a successful outcome, you know, to make sure that we have really asked the relevant questions.
But in acute abdomen cases, you know, some are more important than others. One is really important regarding ongoing, of course, the, the medical history, you know, has this dog, for example, Has this patient, have had, sootomy? You know, has he had surgery before?
For example, would there be adhesions or were there complications with it? What was the indication? And if not, is he on any medication?
Has he recently put on steroidal, non-steroidals, or has he, is he long term on non-steroidals? Are they obviously could contribute to a suspicion and a fear of ulceration. And GI, rupture of some sort, most often within the pyloric, region.
And any other substances, you know, that could show these kind of should could make these symptoms, you know, ingestions of anything that is not 100%, allowed and doesn't consist of food, may also be explored. So it would just be quite accurate in trying the history if time allows as accurate as possible. To go into the detail.
Now, obviously, we're also in the danger of pattern recognition, but there's nothing wrong with realising that, you know, are, are prone to have pancreatitis. We just need to watch out that we don't bark up the wrong tree by, yeah, by, by falling into the trap of pattern recognition. But we want to know, of course, you know, the gender of the patient.
And, we'll talk about that a little bit later. Young and old animal might make a difference regarding, you know, certain disease processes, you know, it's not always cancer and worst case scenario we're talking about, but surely that all needs to be taken into consideration. If we have a deep-chested breed and perhaps a sneaky GDV where you might not be able to palpate the stomach but you see spleen or you feel spleen spleen, splenomegaly and so on.
So just be alert of that as well. Sometimes that is not that straightforward as, we, think. And, all the other breeds, this is, of course, by far not inclusive list, you know, look for congenital problems in young dogs, look for other problems in other breeds and so on, but just as a reminder not to fall into the pattern recognition trap, but definitely.
Take history and be, you know, quite adamant about certain details to pinpoint the problem. The triage is, nothing has changed, you know, and I think in the near future, it will not change that airway, a patent airway, proper breathing and circulation will remain important for patients. And obviously, if any of those is not given, then it is a, a very quick move to the to the CPR area.
But otherwise, if we have a patient that is not in that kind of dire straits, but, might qualify for the diagnosis of on suspicion of acute abdomen, then we check the major body systems. Respiratory, cardiovascular, central nervous. There's still the physical examination and the history take, there's nothing to bypass.
They are still the same thing we do in every emergency patient, you know, we accelerate that a little bit if the time doesn't allow for more thorough exams or triage, primary survey, secondary survey. And then we're trying to pinpoint a little bit more. Is this an acute abdomen or is this a look-alike?
Very important to think about, the vitals and not go into. So while we are treating these guys at the same time, we take the vitals to make sure that we're not missing anything. So, including in the vitals are blood pressure, and then we're also trying to pinpoint the pain involved with the caveat we mentioned before that some patients might not display that.
And we look at all these values to ascertain. How much resuscitation and how aggressive resuscitation the patient needs. So the abdominal physical examination, we've all, we do that on a daily basis.
I don't really, don't need to remind you of that. I just think nevertheless, it's worth putting in that perhaps palpations sometimes for a lot of people, it's not as structured perhaps as it could be. So, as a, as a general rule, I would try to, that's my personal, you know, kind of opinion or tip if you want.
If you begin, especially if you begin your career and you have the first patients to assess. Trying to virtually divide the abdominal area into a grid. So you can be a little bit more accurate regarding, you know, rather than abdominal mass or abdominal mass effect, you can really say it is mid, you know, cranial coral or is it dorsal or ventral.
And that makes it easier, especially if you work with colleagues where you hand over cases to, for example, so that they have a little bit more an idea. In the best case scenario, during handover, you can palpate that together. That you're talking about the same things and so on.
But at the end of the day, I just wanted to say, try to be as, you know, structured as possible with your assessment. Sometimes we have talked about the chested breath it's difficult to ascertain the whole abdominal area by palpation, and then it's sometimes helpful to lift the patient up on the front so that perhaps gravity takes some of those organs further down where they are palpable. We have all, all of us have ultrasound now available, but, you know, we clip a little bit first sometimes in an area where we have a suspicion, for example, for abdominal, trauma or for haemorrhage.
We clip that anyway, sometimes a little before an ultrasound examination, but inspect it as well before you put the probe on and on because some bruising could, lead to the suspicion of trauma anyway. We'll check for free fluid. We'll talk about that in a second.
And also try it when you palpate first, a little bit superficial so not to numb your fingertips and so on. Don't go in full throttle straight away. There some dogs, and especially some cats as well, A, do not like that, and B, might then tensesen up the abdominal muscles and then you have troubles actually to feel these patients through.
Yeah, organomegaly might be the only thing you palpate. We talked about the spleen in, for example, in GDV due to congestion, sometimes the spleen can be quite, quite large. It's difficult to ascertain in some breeds where German shepherds who have a large spleen, but that could be the only indication that there's actually something more going on.
So take that seriously if you find it and follow it up. And sometimes some palpation, it feels like there's a lot of fluid in there, but it could be fat and the other way around. So, always, I mean, nowadays, now with the, you know, ultrasound being so available, always a good idea.
I, I couldn't see a scenario where we have a suspicion of an acute process and we wouldn't have a look, an acute abdominal process and we wouldn't, use ultrasound to further investigate that. And, and the The story about, you know, diagnostic imaging within these cases is a whole webinar by by itself, probably best done by a diagnostic image. But we'll talk about that a little bit, what we can do as a general practitioner or as a beginner, a new graduate, just going into practise, how you can tackle that.
And also a reminder after trauma and so on that, you know, you might palpate the bladder. That's fine. That's good.
But that doesn't mean the urinary tract is intact. So remind yourself that that might just mean that, the bladder is able to have some form of shape and maintain it, but that doesn't tell you anything about integrity of the entire tract, and it surely doesn't rule out your. OK, and then a little bit the tricky ones they lookalikes, acute abdominal lookalikes.
That means they are not actually the, the, the source of the problem is not located in the abdominal cavity, but it is. For example, giving a pain reaction when we examine the abdominal cavity, and that makes us think that the patient is suffering from an abdominal problem. A famous one is any kind of spinal pain where due to, you know, the need for stabilisation, the patient might, might, tensen all the muscles that can help, to immobilise the spine and that is abdominal muscles are in that group.
So you might approach a patient that is so tense from his abdomen that you think he's protecting, guarding his abdomen, but actually he's trying to stabilise and the spinal cord and minimise movement there. And remember, I mean, with intervertebral discs, you know, even overview radiographs can be astonishingly normal, despite problems or so, you know, that probably needs to further investigation if you have a suspicion and and you some obviously as a minimum. Then it is also, I think a good tip to not forget in these patients, the, rectal exam to rule out, you know, areas, within the pelvic canal, you can reach, you know, the bones and a male dog's prostate and so on that they are source of problems.
that is for me, always, a, a part of the physical examination in these patients and most of us. But don't forget that, . And you have sometimes situations of generalised muscle pain, you know, we see that sometimes when the weather is good, people take their dogs off for crazy runs.
And then the next day they're in trouble and perhaps pee out half of their muscles through the urine because they're dissolved. These kind of patients might look like they have extreme abdominal pain, but they are just overly sore from all the muscle, lysis and so on. But there's, they're not that difficult to diagnose and you will find that out.
Nevertheless, I just wanted to mention that it can play a role. When it comes to the acute abdominal pain, anything that we have learned in that school year one can trigger this, you know, inflammation, ischemia, stretching, or all of the above or combination, you know. So, technically, any it anywhere.
In the abdomen, can lead to an acute abdomen. That makes it a little bit more challenging sometimes to pinpoint the source, because obviously, as you can see in a second, the differential list is vast and we need to try to pinpoint. You know, this was by ruling out other underlying troubles.
When it comes to fluid resuscitation, there's nothing wrong still using the good old isotonic crystal it's the bolus dose, as you will know, has . You know, changed a little bit instead of 90 mL per kilo or 60, 66 mL per kilo in cats, we're giving that more now over in instalments. So we're giving 10 to 20 mLs, let's say as a, you know, rule of thumb per kilo over 15 or 20 minutes.
Or higher dosage over half an hour, and then assess the patient again. So Bolo's assessment. Fluid resuscitation goals not reached, further polos.
Assessment not reached, further boss, and so on and so on. The total choc dose in the old days was was came more or less from the blood volume, dogs and cats have. So dogs have roughly, you know, 90 mL per kilo of blood, and cats have 60, 66 mL per kilo, of blood, and therefore, we thought, well, if they lose that, for example, due to haemorrhage or severe, severe hypo you know, perhaps that's the amount we should give back.
But we do it more in instalments. And it is very quickly redistributed, so we always need to follow that up. And if we have patients that have decreased colloid osmotic pressure or they have increased vascular permeability, then we need to watch out a little bit.
We got so septic patients, for example, and so they have sometimes such an increased vascular permeability that actually with high pressure fluids, we might actually, contribute to problems. So, obviously, the old rules of starting fluid therapy in the mindset of needing to adjust it all the time is still valid, and that is very good advice. I think as well when you deal with a shock fluids when they are needed, absolutely necessary.
And then, you know, we're trying to get them into a better state on thicker ice, and then we can, you know, diminish the fluid therapy accordingly. There are some other products we can use, of course, you know, if haemorrhage acute abdomen due to trauma and we have a hemoabdomen, is the main culprit, and then we can use whole blood. That also if that, if you have that in the fridge, you don't need to warm that up, you just run it in, obviously.
We can use plasma as a colloid. We'll talk about that a little bit more in detail later. and plasma as such has been, So, change in use over the last 20 years and so on, that that is really a helpful kind of colour now, especially when oxyglobin and other substances are perhaps less available.
So have a think about how you can do that in your practise, you know, how, how is the access to blood products, speak to the pet blood bank, make sure you have stuff ready. plus mine on you can put in the freezer and it's, it's such a long shelf life that it's really reasonable to have. Have at least a unit or two, available, because if you need it, it's really helpful.
And, although you can get it quickly. But that there, there are things to think about when you do more with acute abdominal patients and you see quite a few in your practise. That is something I would definitely think we should have in the fridge and or on the ship.
When you look at differentialist, and this is again not inclusive and so it's massive, you know, like we said. Any inflammation anywhere could do it. So if you look at GDVs, they might be more straightforward, gastric ulcerations and perforations at some point, you'll pick up some abdominal fluid that we can then analyse.
We'll talk about that in a second as well. So some are easier than others, but all of the, I think at this stage, diagnostic imaging is a very major part of being successful. And because you can identify it as deception.
Potentially volvullos as well, they're so abnormal structures and then to be visible on an ultrasound that, you know, even with limited training, you still would pinpoint that as an abnormality and if you if you if you do, if you do it more, you get better with that. Yeah, although, I mean, some are more drastic than others, mesenteric vul loss is not subtle, and that is some kind of penetrating abdominal trauma that is something you will pick up when the patient presents. Hepatobiliary, pancreas, spleen, everything from slight inflammation to, you know, end-stage cancer patients and so on, obviously.
Urinary tract can be tricky because like I said, there's sometimes There's big changes that can be life-threatening, can be subtle, you know, small amount of fluid, perhaps, perhaps, urethral tear or trauma or stone that is difficult to pick up. So that can be a little bit more challenging, but obviously, by use of, laboratory tests and diagnostic imaging all, all to be, you know, picked up eventually. Reproductive, make big difference male and female between presentations of course and.
Very rare to have prostate issues in female dogs, so just make sure somebody has examined the dog to the extent that we know, what gender it is, and then obviously some are taken off the list and some are more, common, but again, Diagnostic imaging and rectalex and palpation and so on will get us there eventually to voice the suspicion. So any, so unfortunately, I have to say, guys, any eye test in that area is unfortunately a suspect cause for the acute abdomen. But normally with the help of the tests we were mention today and, and further imaging and so on, we're normally able to pinpoint it somehow and then get to the To the solution of the riddle.
Now, technically not always good for the patient, but if you see abdominal fluid, free fluid in the abdomen. Then that is definitely something that will aid you. For the diagnosis, because that fluid is often telling you what kind of process you are expected to find if you would go in.
So there's very, very few occasions where, you have an amount of fluid that you cannot tap, but that is possible. We talk about, that as well, very soon, but most of the time. You would be able to get free abdominal fluid sampled by abdominal centesis and then analysed, and then you are by far ahead in the diagnostic process.
And it's far less, you know, challenging if you obtain fluid, to diagnose an underlying condition because of the fluid analysis giving you so many, most often, so many answers. So we normally use ultrasound. That doesn't mean you can do it blind, but, you know, pros and cons are obvious.
Abdominal centesis can be then performed. And if push comes to shove, and then the rare occasion, and I have to say, the last time I did that is a long time ago, because most often we get by ultrasound and a long needle at some point we get access to that fluid. But if you wouldn't get, you'll see a fluid pocket.
You can get access to it and you definitely think that analysis of the fluid would help in most cases it would. Then you could do something that we call diagnostic peritonal lavage, more or less installing fluid into the abdominal cavity and then retrieving it and seeing what you get. I'll talk about that in a second.
This is not trademarked, you know, colleague Leandro, Doctor Liandro, has very well described the use of ultrasound in the emergency patients, especially vast amount of information and great helpful, literature for that. So I encourage you to study that more. So we call it now a point of care ultrasound, and that means we will assess, any trauma patient, any, any.
Patient with, you know, suspicion of an abdominal, disease process with ultrasound. So we want to do that. This is not a full abdominal examination, and I'm sure most of you will do that now also on a recover all the time on a daily basis.
And very quick assessment, to assess, free fluid more, let's say in the abdomen. So this is from the original paper and so on and so on. Diaphragmatic, area.
Well, at, at, at the end of the day, if you think about a clock, let's say 9 o'clock, 12 o'clock, 3 o'clock, 6 o'clock, you can read up a little bit more in detail in the literature from, Doctor Lisandra and I really encourage you as well to go on his website and join courses and so on. If he does that, he's very, very helpful in getting you started with. At all, and that is really a super helpful technique to master when it comes to emergency patients.
So very quickly, ventral midline, just under the end of the sternum, flank left, flank right, and ventral midline just before the pelvis. So we do two views on each side. And the main thing about this ultrasound examination, I think, is in your emergency patient, you need several to establish a trend.
Because obviously, when a patient comes in and you scan it, and there is a 0 out of 4 areas with free fluid. Half an hour later, it could be a 2 out of 4. And an hour later, it could be 4 out of 4, and then you know there's an ongoing bleed that is getting worse and you might get ready for surgery or or transfusion.
So that's how we use it, so initial examination and then subsequent examination to make sure, you know, we do not miss a trend. So it's not a fire and forget missile in the case of, of scan, it's fine. Discharge.
OK, so be aware. Oh, just quickly, abdominal centesis for DPL and so on. So, abdominal centesis, no ultrasound blind, you think there's fluid in there, you know, normally in the gravity dependent areas, obviously a much higher chance to get fluid, but, you know, sometimes it's pocketed, but with ultrasound, like I said, very rarely needed to be blind.
If you want to do a DPL, roughly, what you would do is clip and clean the area, make it very shiny and surgically prepare the area, introduce an IV catheter right into that area. Take the Dila out and inject roughly. Plus minus 10 mL per kilo of warm sterocena slowly let it dwell a little bit.
Don't shake the patient like a Polaroid picture like I suggest it's only fun. We're not doing that. But you would try over the idea is that that fluid goes into the abdomen and then engulfs the area that has free fluid.
Now, let's say there's a hidden source of inflammation, somewhere and you can't reach that fluid. So that fluid will go around that flush bacteria, for example, or neutrophils or other nasty cells out. And then we will collect that fluid again, and then analyse it, right?
Withdraw, you might not get all the fluid back out that you have given in, that is OK. But the fluid you get out, you then, analyse, you know, native ants button down and look for, especially bacteria and, you know, the neutrophils, for example, the size and shape of neutrophils, character of it, and are there any, bacteria in it. I think I have pictures of that later.
So what we can analyse quite a lot. Once you have the effusion, like I said, you have really a lot of means of analysing that fluid to an extent that you can determine, you know. The most likely source of that fluid.
So we can look at cytology, how many cells are in there. We can run biochemistry, run that through your normal machines. And of course, we can also culture some of that fluid.
But in the emergency settings, and sometimes we can't wait for results. So we need to be a little bit more quick and a little bit more. Yeah, imminent.
Cytology, again, that school year 3 or something, you know, transodate, modified transodate X. That's fine, but still important and not to be, you know, not to be ignored. And transodate, and, and exudate will have most likely very, very different reasons, for their presence and so on.
For us, it gets especially exciting. When it is a septic effusion, obviously, as emergency clinicians, that is, what we get excited about. That doesn't mean transoates are, that could also be, doesn't mean it's good or bad disease and so but obviously we look for.
When it comes to surgical patients, for example, is this, and this is later on will be the questions to cut or not to cut. We'll talk about that in a second. Then it comes often to the case that most translates perhaps often do not need, you know, .
Yeah, very quick surgical assessment. Septic effusion, if that's the case, then we would expect the following. So normally they have their exceptions and so on, it's not 100% that makes the job so interesting, but as a general rule, you would expect a very high cell count.
You would expect degenerate neutrophils, . Really, really an aulator, but really, really degenerate neutrophils that have worked a lot and that are spent and, you know, and are really, really foamy of the, the, the, the plasma is very foamy and so well anyway. And intracellular bacteria.
So if you have bacteria that have been gobbled up by the neutrophils, then, you know, you most likely have a surgical if that is an abdominal effusion. But you have to watch out. Some non-septic effusions can look suspiciously similar, but normally, They don't have so many degenerate neutrophils.
Now, they could have that. It's not a pathognomonic sign, but we're talking about trends and expected findings, but they shouldn't have obviously any bacteria. So a severe pancreatitis can look like that.
It could be quite an amount of fluid and some neutrophils that might look a little bit stressed. But I mean, most of us would agree that it's not a mainly surgical disease anymore. So, we just need to take your time at the microscope and really go through that fluid and analyse it properly.
And if you find bacteria, you probably have a surgical case. If you don't find bacteria, then you might not want to continue it and find out with further diagnostic and anything and so on what is going on. Oh, here we are.
So very degenerate neutrophils, you see the pynotic and, and the plasma is 4 is not the greatest picture, but if you see it a little bit. In the light of the abnormalities of the neutrophils, you see that that is absolutely, not normal. And then we have here, we have rods within the neutrophil here gobbled up.
We are starting to see quite a symptomatic, degeneration as well. But if you have intracellular bacteria like that, then this most likely will need, well, actually, in this case, it will need surgical exploration. We sometimes find cells that look suspiciously and also might fit, you know, very conveniently with the history.
They look suspiciously like cancer cells. I would just watch out and I always look at the second thing about, you know, some inflammatory mesothelial cells can look very, very suspicious like, neoplastic cells with some signs of, of, malignancy and so on. So just before you use it as real.
We don't want to use a single factor like that for the big decision maker anyway, but always be careful about some of the inflammatory cells, you might find that that fusion can suspiciously look like, yeah, nasty cells. So just be careful with that and diagnosis. Biochemistry, so what can you do?
Quite exciting stuff with that fluid. If you run it through your biochemistry, and it is actually straightforward if you think about it. In Europe, you would expect creatinine, and that should be roughly twice the amount.
So you always compare the abdominal fluid with the peripheral blood. You run both samples through the machine and you compare the levels. If your creatinine is over twice the amount in the blood, creatinine levels, and potassium is, that's dogs and cats numbers, so 1.4, 1.7 times higher than the serum.
Then you have a suspicion of the Euro abdomen. BUN, we normally don't use. I mean, it's, it doesn't mean that you can't use BUN as an other indicator, because in the initial very acute onset, UN will also be high, but UN is not an effective or small one.
It will very quickly subside and cross membranes, and therefore, the absence of high BUN levels doesn't rule out. A year. So perhaps for in the beginning, focus on your creatinine and potassium only, I wouldn't use you in much of an indicator at all.
Bille peritonitis, which can be very nasty, because the the bile acids are so aggressively causing inflammation within the abdominal cavity, we would expect that in that fluid bilirubin is higher than the serum bilirubin. Pancreatitis. Also, obviously, we check CPLI and so on, but if you have fluid, often the perinal fluid CBI is also really high.
Sometimes you have high serum levels as well. You can look at lipase, compared to, the serum lipase. And so, so that is all possible.
And, Kylo fusion, triglycerides, normally a pseudon 3 stain, I think. For the, for the lab, but you can also obviously have a look at that under the microscope, very typical shape of the, fat fat, bubbles, so to speak. But if you can measure triglycerides in the fluid, you can analyse it, and then Kyle can look like, sometimes like pyrothros.
Obviously, the cells are totally different, so always important as well to look under the microscope, not just using your machinery. Always inspect that fluid. And if we have a septic peritonitis, you would expect the glucose to go low in that fluid.
Right? So very low glucose levels. And the lactate levels will go up.
So what happens in that fluid and so glucose is very quickly gobbled up by all the substances have bacteria plus white blood cell, plus other cells are gobbling up the glucose, glucose drops down. And lactate goes up because of the lack of oxygen, so much more anaerobic and accumulation of lactate. So you have in that fluid.
Blood fluid, lactate difference of over 2 millimoles. And you will get to a blood to fluid glucose difference of over 1.1 millimoles or 20 milligrammes.
If you're in the states. And then, you have a pretty obvious suspicion of septic peritonitis and then obviously with the findings of the cells we have mentioned before, you're pretty much on. Route to diagnosis and potentially surgery.
Hemo abdomen, if you see, after trauma hema abdomen and you see that, you know, you, you, you scan, and you know there's blood. We, we, and, and, you know, believe it or not, an acute urodomen, the, the fluid can look relatively, suspicious for as blood, but there is, although there is blood in, in, in that fluid doesn't mean it's. Blood.
It could, it is mixed sometimes with urine and it looks on a spectrum. If you look at it, you would, you would bet it is blood. But when you analyse it, the PCV is relatively low until you find out creatinine is up, potassium is up and so on.
So just make sure that you're, looking at it like entirely with, you know, looking at all the factors. If you have a hemo abdomen, obviously, ultrasound is not number one, imaging to, to, to keep track of it and the focus technique of four quadrants and then looking into the development of it is it getting worse or not is absolutely helpful. But you can also compare the PCV of the of the blood of the peripheral blood and the PCV of the abdominal fluid.
You would expect with fluid therapy, most, most patients will get fluid therapy for resuscitation. You would expect the peripheral PCV to drop. And if the bleeding is ongoing, the PCV of the abdominal abdominal fluid with time should also then drop accordingly.
Now, if the peripheral, PCV drops and the PCV and the abdominal fluid remains relatively stable, you could have a suspicion with other vitals hopefully pointing in the same direction. You could have the suspicion that That initial bleed is subsiding because the fluid you're putting into the peripheral vascular system is not necessarily, leaking into the abdomen anymore because the bleeding has stopped. But this is just one factor you can look at.
We also look at patient stabilisation, of course, resuscitation endpoints, how is he reacting. The patient was in lateral redundancy and non-responsive, but is not responsive due to after resuscitation. Blood pressure is coming up, refill time is getting better, because my brain colour is getting better, temperatures coming up, and so on and so on.
And during the scan, there's no more increase in, you know, positive, quadrants for free fluid. So this is how we approach these kind of, cases initially. And Yeah, make sure you have some products in your practise as well you can use for that.
Or you need a very, very, very big staff dog, but at the end of the day, start, if you haven't done that so far in the UK, start speaking towards the with the bank about products and so on and so on and try to incorporate that more into your practise. It will, it's really helpful if you need it. We will be glad you have it when you need it.
We don't, or I, I wouldn't personally look at blood pressure as an indicator of how the patient is doing, you know, obviously we, we, well, no, let me rephrase that. Of course, we use blood pressure as an indicator of what the patient is doing, but We do not spring into action when the blood pressure goes down or falls very low. And so we want to, it's a very late sign of hypovolemia.
So the, the body keeps that up for quite a while. If you lose blood, the body has compensatory mechanisms to cope with that. So, blood pressure is maintained for quite a while.
If blood pressure drops to an extent that you can't feel the femoral pulse anymore. And the patient is in severe dire straits and might be difficult to retrieve back to a better state. So we just need to be alert, feel the peripheral pulse, look at all the other parameters we've mentioned already for assessment, and make sure that you intervene before blood pressure drops to, a ridiculous amount.
And, and the resuscitation endpoints, and that depend a little bit on, What you want to achieve. So, for example, in a huge abdomen that has a haemorrhage, a hemoabdomen, we try to keep the blood pressure and to an extent that is maintaining perfusion through all the organs, but it's not supernatural. So we don't want to pop up the blood pressure to 160, Doppler or 100.
In that area, we, we just want to keep it into an area that is actually perfusing the organs. Probably, if you haven't got a blood pressure machine, feel the peripheral pulses, you want, kind of, not ice cold, peripheral, you know, pulse. And so you want to have a, a peripheral, pulse that is at least fair.
And if you have perfusion into the periphery to that extent, then hopefully other organs will get perfusion as well. But if you haven't got a blood pressure, monitor it or blood pressure machine and so on, try to think to get one because it's really difficult sometimes to, and in some situations, most situations impossible to guesstimate. So it would be helpful for the emergency patients.
I couldn't see a scenario where we wanted to do that properly, could do that without blood pressure management of some sort. So, if you haven't got one, think about it and try to do that. Then it becomes important for us to, because we cannot, we cannot accept low blood pressure where there is diminished organ perfusion for a prolonged period of time.
So, yes, fluid polos is to perhaps go to first comfort blanket we do, and that makes sense with the caveat of hemoabdomen we just mentioned. But if push comes to shove, and we have to do that quite frequently in the septic patient, we have to support the blood pressure with vasopressors. And in septic patients, often there's norepinephrine.
There are other things to be considered, but obviously, some are more vasoconstrictive and some increase more, you know, heart contractility due to better receptors. But at the end of the day, norepinephrine, is a very good no adrenaline is a very good drug to go to for beginners, I would say. And it is not, it sounds funky if you haven't used it before and so on, but it's not difficult to administer and do.
But like I said, it is, there's no alternative. If blood pressure drops to a certain extent and fluid bonuses have not, you know, given you the, the effect, you know, at some point, you know, once the process. And this is a long discussion and a whole different webinar and the critical list, you know, community regarding when.
If we have all sepsis, you know, surviving sepsis guidelines, and so it's relatively clear, but, but there's still a lot of, you know, challenges ahead to really determine exactly, you know, when, how much, how to give that. But for sure, we cannot accept. Very low blood pressures in these patients that are critically ill for a long period of time, so that needs to be remedied.
Then we talk antibiotics, but at the end of the day, again, would be a whole webinar. And we have the guidelines from the, there's a lot of, you know, guidelines regarding, the avoidance of overuse, jumping around too much, changing stuff, and so on. So that needs to be taken very, very serious.
I can't go into that. I mean not today, but often in, so I think I can summarise it in a way of, if we have some slightest suspicion of sepsis and so on, then antibiotics need to be given in a very, very quick time frame. It's very time dependent.
So we then have no luxury of time or, or see, see how he is tomorrow. We give it then and so on if there's any suspicion of septic, you know, upcoming, for example, in, in these patients, you need to start antibiotics straight away. And obviously, we can talk about 4 quadrant, .
Coverage robes on a robes, it helps when you know who's involved, you suspects, what the location is, you know, is this infection coming from the prostate, prosthetic abscess that burst, or is it coming from, somewhere else that might play a role. But, you know, we often don't have the luxury of being able to wait for the fluid analysis regarding culture from the external lab. So in the meantime, we need to do something.
And these drugs mentioned here are very reasonable. Again, we need to think about what drugs to give. We definitely want broad spectrum.
And it depends also, I guess what you have available, but, but I think the main take home message is if you suspect deceptive folk enzyme, do not hesitate with antibiotics. That's one of the situations where, you know, where it's definitely indicated. Then we support off the gastrointestinal that will come sooner or later, the question of support of gastrointestinal symptoms, if it's just ileus or vomiting, or, ulceration and so on, so the usual suspects, just as a reminder to everybody, ranitidine doesn't do much regarding pH but it might, if you believe it, still do something regarding.
Increasing peritosis. So if you have to severe, often after surgery, septic peritonitis surgery, and then massive ileus, we sometimes use prokinetics as we can, also use all the tactics we can to increase mobility, that, that means diminishing opioids as quickly as if it's safe as possible and start moving the patient more, feeding. Big topic which I also didn't include in this webinar for today, but it's another topic in a week or before we mask, but anyway, early feeding.
Will help parental feeding will especially help regarding peristalsis and so on. . And yeah, erythromycin is one of the antibiotics that might cover.
If that is an antibiotic that you think has a spectrum against something you're fighting on top of that, you might be able to kill two birds with one stone there. Alin I just mentioned it because there's still so much confusion and it's not 100% clear cut. I think I personally would say that it's not recommended as a so therapy when you have hyperhybominemia and you see that sometimes in these, acute, septic patients, abdominal peritonitis patients that are so leaky from the musculature.
Not recommended as soul therapy to, focus on hypoalbuinemia, where we put a way of increasing the levels. So we need vast amounts to actually have a reasonable approach to increasing it. And obviously, you haven't turned off the reason for the loss, which is the leaky vessels.
And then the question is, you know, is it reasonable to transfuse so, so many, so large volumes? Plasma transfusion normally very, very safe, but when we get to these areas and big dogs and so on, then it might become problematic. Transient plasma transfusion, I just, one of the studies, our friend, Andy Brown was involved as well.
They looked at 308 patients and they looked at how do we use plasma now actually in practise, and this was an oldest look at 1960 to 1. What was it? For coopathy, 31% got it.
But 2006 to 2008, 80% got it. So it's a big shift. And for hypoalbuminemia, as we stated, 96 to 98, 53% in a hospital got that and 308 patients.
So, but now, you know, around 10 years later, only 15% got it. So that shows a little bit that the trend has changed and that the reasons for giving it is a little bit different. How much to give, depends, obviously.
Otherwise, the job would be too easy. We can have a look at clotting times, but we also, as a rule of thumb, let's say, I think that's not a mistake to start with. It's very, crude number, but, if you give roughly 20 mL per kilo, that is the minimum you most often need.
To resolve coagulation coagulation disturbances again, by no means is that an accurate number and so on, but as as a rough guideline and I don't think it helps beginners, especially to have a rough idea of what that all means and volumes and how to give it and so on. And then monitor the neurological status. I'm sure we all do that now more and more and so on.
But that is really a helpful tool as well to get on top of the neurological status of the patient. Just wanted to remind everybody as well, even if it's the abdomen we're dealing with, to still have a look, because some of These patients are actually optunded and, you know, and recumbent and so on. So just double check their neurological sessions, a reminder that if we do that more frequently and, and, you know, give some numbers to that assessment, we can be a little bit more objective.
And, and I think that is helpful altogether in the assessment. And then the big question is, of course, surgery, right? And we talked about that already.
You know, is it surgical? If you find, you know, bacteria, you know, intracellular bacteria, my answer would be yes, it is surgical, right? And then also the next question is, when should we cut it?
So, that depends often on the Patient status. Also sometimes really, really, depends on how the hospital works and how the clinic works and so on, who's going home when, how is, who is here overnight? Can we cut it tomorrow morning?
Can we cut it late at night? Is there somebody still here? And so on and so on.
So. But at the end of the day, obviously, the decision needs to be made on the patient's status, basis. And I think sometimes you might get into a A pressure of saying, hmm, best time would be now to cut it because later on it's more difficult, but if the patient is not stable, you'll most likely do better and the patient will do better, which is the main thing.
If you would stabilise him first. So if you have troubles to control the blood pressure, if you have a hemoabdomen that has bled out to an extent that is not resuscitated yet and so on, obviously, if the hemodoma needs to go to emergency surgery, you need to be quick and you need to resuscitate as we speak. But we have sometimes hemodos that need a little bit more stabilisation.
It will come to into. The equation potentially the question when you have a splenic, you know, mass that has bled, and then it stops bleeding and at some point it needs to be removed, but you have the patient under control and so on. In the meantime, when he's not under control and not stable, it's probably not the best time to take him to surgery.
So. If, and one tip I think for, for beginners when you start your surgical career and practise and so on, so. There's a lot of, and I spoke to a surgeon at some point and he said, if all your X labs are positive, then you might miss some, then you don't do enough because, you know, some X labs or seulotomy, explorative sebiotomies.
Will probably be negative because if you have a, you often have a suspicion that there's something going on or obstructive pattern, not sure if there's something in there, I think, you know, we want to go in, we go in, we don't find anything. I think often, not a problem at all, except you having the owner prepared for it. So just a practical tip of saying for before every soliotomy, make sure that you also tell the owner as an informed consent that.
You know, if you're not 100% sure that this is an explorative, explorative surgery and That it could be that it's negative and you don't find anything. And then if you really don't find anything, the owner is prepared for that and it's potentially relieved. But if you go with a clear indication of, I think there's something, and I'll take it out now, and then you open up and there's nothing in there and you have to tell the owner there was nothing in there, they might think we shouldn't have gone in in the first place.
So just be clear with the communication, and, then that is much, much easier to deal with whatever you found. And, and, obviously, all the previous things we have talked about of trying to pinpoint the diagnosis, trying to localise it, trying to deal with it, and then going in for surgery, necessary to avoid what we call a peak and shriek. So you will open up and then you find something that you're not prepared for.
Let's say, for example, a famous example is any gallbladder issues that normally needs more sophisticated surgery, most, most, including the, general practitioners, that would probably be uncomfortable tackling. So just make sure the workout is done properly and the oral communication is 100% and then you can deal with that. And then any doubt of areas when you're in there and so on, please take biopsies because at the end of the day.
It is super annoying and problematic if then you close and after 2 or 3 days, we have another issue and we wondered if they, if that and that was normal and we haven't taken biopsies. You don't want to go back in and take some or get some done by needle or to cut and so on. So just also, if in doubt, you know, and you think the patient will benefit from that if you have areas especially that look abnormal and so, and again, I'm not a surgeon, so that would be the best.
Let's discussed exactly via via er regarding when and how to take biopsies, but as a general rule, from my experience within the emergency setting that often when we wish . Well, often, when you don't take bise afterwards you wish you would have taken. I say so much.
OK, I want to say thank you to everybody. That's no family, obviously, and no, and of course no brother and parent and friend or organisation IVC Edencia. Some people have helped with pictures and content and so, and that's all from me.
Thank you so much.
