The Abdominal Catastrophe

This hot case usually circles the following issues:

  • Management of ongoing abdominal sepsis/SIRS
  • Source control, repeated surgical care, open abdomen
  • Nutrition without a working gut
  • Slow recovery afterwards

Previous hot cases with this sort of theme to them can be found below.

Examination of the Patient with an Abdominal Catastrophe

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

  • Rhythm
  • Rate
  • Morphology: QRS width,
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
  • Ancillary waveforms eg. the PA catheter waveform
  • Oxygen saturation measurement, and the quality of the waveform
  • End-tidal CO2 waveform and level

There is nothing special here that you wouldn't find in any horribly septic patient.

The Ventilator

One can ask the examiners the following questions:

  • How are we oxygenating this patient?
  • How are we ventilating this patient?
 

One should ask about the following parameters:

  • FIO2
  • PEEP
  • Peak pressure
  • Plateau pressure
  • Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

Think about ARDS.

Increased abdominal compartment pressure results in a reflex increase in PEEP, and the PEEP for this patient may be high. Tidal volumes may be low due to decreased compliance, resulting from compression by abdominal contents.

Urine catheter

  • Unusual colour
  • Anuria
  • Bilirubinuria

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

  • Which modality is being used?
  • What is the dose of dialysis?
  • What is the rate of fluid removal?
  • How is the circuit anticoagulated?
  • How long has this filter lasted?

These questions may go unanswered.

Infusions

This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.

One may encounter the following substances:

  • Vasopressors / inotropes
  • Antibiotics
  • Octreotide
  • Pantoprazole
  • Blood products
  • TPN

The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:

  • Skin colour, eg. jaundice or the discolouration of chronic renal failure
  • Muscle wasting, obesity
  • The evidence of trauma, wound dressings, etc
  • The pattern of breathing (eg. whether there is a characteristic chest flail)

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.

Now, time to look at them more closely.

First, one should spent a second assessing whether they are warm or cold.

Then, one can focus on the nails. Nail signs are numerous and deserve their own page. One should not get distracted with these.

Done with the nails, one may want to briefly consider (and maybe even comment upon) the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.

Next comes the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. It would be worthwhile to look up at the arterial line trace at this stage; abnormalities such as the widened pulse pressure of aortic regurgitation may not have been noticed until this stage.

Arms

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Asterixis

In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines
  • Evidence of multiple venepunctures
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines
  • Look again at the CVP

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

The cranial nerves may not yield a large amount of useful information in the examination of the abdominal catastrophe. One may wish to limit onself to the examination of the pupils, if the patient is unconscious.

Airway

One needs only to focus on the quality/volume of the secretions, and the duration of intubation.

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

Percussion:

One might wish to percuss the chest. If this is done in a slick fashion, it can be forgiven.

Changes in percussion resonance may be worth commenting on.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).
  • One should look for characteristic signs of pancreatitis:
  • Cullen’s sign: periumbilical oedema and bruising
  • Grey Turner's sign: flank bruising, suggestive of pancreatic necrosis and haemorrhage

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.
  • Examine any stoma, and comment on the mucosal health. Ask about the recent trends in output.
  • One should ask about the intra-abdominal pressure measurements. Instead of an answer, one might find oneself interrogated about how to perform such a measurement.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram?

Examination of the genitals and rectum

  • A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
  • One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles. Muscle wasting - especially of the quads- is an important feature of malnutrition. Additionally, one gets to appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular disease.
  • Pitting oedema should be palpated.

Leg muscle tone

The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend

Calf tenderness

In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.

This brings one to the feet, and to the beginning of the neurological examination.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the limbs

A detailed neurological examination is not usually called for.

Usually, it is enough to determine whether the patient is conscious or unconscious. Abdominal pain may prevent them from participating in leg raise exercises.

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.
  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output - very important!
    • One may even ask about the lipase content of the drain fluid
  • Urine output
  • Abdominal compartment pressure

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods
  • Urinalysis
  • Culture results
  • Case-specific bloods, eg. LFTs, pancreatic enzymes, inflammatory markers...

One definitely needs to ask about the laparotomy findings.

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR
  • CT or MRI results

Case presentation and discussion: when you have a good idea of what is going on

"Mr Bloggs is suffering from severe sepsis from an abdominal source."

"I have come to the conclusion that the source of sepsis [is well controlled / is not controlled] on the basis of the following findings: [insert clinical findings here]"

"I also note the following organ failures: [list organ problems]."

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"The current management issues are as follows: [a brief list of management priorities]"

"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

Number of previous hot cases in this topic: 6

2014, Paper 1

Princess Alexandra Hospital

  • 72-year-old male, day 14 ICU, post Ivor-Lewis oesophagectomy, complicated by anastamotic leak, multiple pneumothoraces, and atrial fibrillation. Clinical findings included bleeding from fresh tracheostomy with intermittent air leak, subcutaneous emphysema, left bronchopleural fistula, bile draining from right-sided chest drains and jejunostomy feeding tube. Candidates were directed to establish the nature of the post-operative complications.

Princess Alexandra Hospital

  • 42-year-old male, day 6 ICU, admitted following surgery for anastamotic leak and faecal peritonitis post anterior resection for metastatic colorectal carcinoma. Clinical signs included decreased breath sounds bilaterally, multiple abdominal drains and an ileostomy. Candidates were asked to examine him and identify the major clinical issues.
2013, paper 2

Westmead Hospital

  • 59-year-old male, day 5 ICU, following laparotomy for ischaemic bowel with decompensated liver cirrhosis. Clinical findings included reduced GCS, jaundice and the presence of an open abdomen with tension sutures and 2 drains and a heparin infusion. Candidates were asked to examine him, identify the issues and formulate a management plan. Other discussion points included interpretation of imaging, weaning plan, management of coagulation status and nutritional support.
2009, paper 1

Royal Brisbane Hospital

  • 65 year old lady presented with RIF pain and abdominal wall cellulitis. Assess her for ongoing management. Issues: Abdominal surgery, vac dressing, antibiotic cover, nutrition, ventilatory wean, tracheostomy

Royal Brisbane Hospital

  • A 36 year old lady who has had gastric bypass surgery, and follow up laparotomies for bleeding and failed to thrive. Candidates asked to assess patient, identify ongoing management issues.
  • Slow wean
  • Enterobacter in abd fluid
  • On TPN
  • Ongoing temperatures
    Areas of weakness identified by examiners:
    • Failure to identify multiplicity of problems
    • Lack of clear management plan
    • Lack of clear antibiotic plan
    • Candidates failed to clearly state how they would investigate new sepsis
2008, Paper 2

Unspecified hospital

  • A 58 yr old man – 4 days in ICU, following a perforated sigmoid diverticullum for which he had undergone a Hartmann's procedure. He was on chronic steroid therapy. Issues: AF, gastroparesis, absent BS, globally weak, ongoing temperatures and cushingoid features.