COVID-19 Pandemic Timeline

Dec 31,2019 China alerts WHO to several pneumonia cases

Jan 11,2020 China announces first death
Jan 30, 2020 WHO declares outbreak global health emergency
Feb 11, 2020 WHO names virus COVID 19
Mar 2, 2020 Indonesian first 2 cases
Mar 11, 2020 Indonesia announces first death
 Problems with COVID-19 Pandemic
• Social distancing during the COVID-19 pandemic has been
associated with a decrease in the search for medical care.
• High-risk patients have avoided hospital environments fearing
infection
• Fear of the Health Care worker
• Limitation of hospital activity
• Changed Hospital Protocol
 ABOUT THE THE
PATIENT
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01 02 DISCUSSION
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topic of the first section topic of the second section

FINAL PATIENT
DIAGNOSIS
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03 04 MONITORING
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topic of the third section topic of the fourth section
New Symptoms
 Acute Abdomen
• A clinical syndrome characterized by the sudden onset
of severe abdominal pain requiring emergency medical
or surgical treatment
• The most common cause of admission in emergency
departement (ED)
• Caused by various potentially life-threatening diseases
• Rapid and accurate diagnosis is essential to reduce
morbidity and mortality
De Simone, B., Ansaloni, L., Sartelli, M., Coccolini, F., Paolillo, C., Valentino, M., Ricci, G., & Catena, F. (2019). The Acute Abdomen Decision Making course
for the initial management of non traumatic acute abdomen: A proposition of the World Society of Emergency Surgeons. Emergency Care Journal, 15(1).
Acute Abdomen - Causes
Acute Abdomen - Causes
Acute Abdomen in COVID-19 Infection
 Acute Abdomen in COVID-19 Infection
Pathogenesis
 Key Point Evaluating Abdominal Pain
• Vital Parameters to be checked
• Pulse Rate
• Bood Pressure
• Temperature
• Oxygen Saturation
• Pain Score
• Thorough history taking and examination - half the
errors are eliminated
• Assessment of COVID 19 infection
 Acute Abdomen
• Obvious case
• Dubious case
• Benign presentation may
progress to life threatening
condition
5% diagnostic errors of 129,8 million annual ED visits
Dimension of error %
Problems with history 40,0
Problems with physical examination 5,7
Failure to review previous documentation 11,4
Problems ordering diagnostic tests for further
48,6
work up
Ordered test, not interpreted correctly 25,7
Problem initiating refferal 5,7
 Method of Diagnosis: The History
• Tell me more about your pain…
• Location and character
• Patterns of radiation and
referral of pain
• Onset
• Intensity
• Duration and progression
• Profocative and palliating
Mercury is the closest
factors planet to the Sun
• Previous episodes
Character of Abdominal Pain
 Character of Abdominal Pain
Refferal Pain Radiating pain

Result of a network of
Pain that starts in one area and
interconnecting sensory nerves,
spreads until a larger area hurt
that supplies many different tissues
Onset, Intensity, Duration and Progression of Abdominal Pain
Assessment of the Associated Symptoms
• Anorexia, body weight loss
• Nausea, vomiting, hematemesis
• Constipation, diarrhea, bloody stool
• Jaundice
• Hematuria
• The typical initial symptoms of COVID-19 include fever,
cough, and muscle pain or fatigue, anosmia and
dysgeusia
Past Medical/Surgical History
Method of Diagnosis: Physical Examination
 Examination of the Abdomen
Inspection:
• Scars/asymmetry/distention
• The exact point of maximal pain should be pointed out
• All the hernial orifices must be inspected as a routine and
special attention directed to the femoral canal, where, in an
obese patient, a small hernia is easy to overlook. Many lives
are lost from failure to do this.
• Motionless of the abdominal wall movement on respiration due
to peritoneal irritation
 Examination of the Abdomen
Palpation:
• Gentleness is essential to success in
palpation
• Rebound tenderness
• Percussion tenderness
• Guarding / Muscular rigidity
Guarding / Muscular rigidity, decreased in
• Mass • very fat and flabby abdominal wall and the
muscles are thin and weak
• severe toxemia and the reflexes are dulled
and diminished
• elderly, feeble patients
Examination of the Abdomen
• Percussion: shifting dullness/tympanic
• Auscultation: bowel sounds
- Bowel sound: absent / normal / hyperactive/ tinkling
- Of all the modalities of physical diagnosis of the
abdomen, auscultation is one of the least valuable
and most misleading (Z. Cope)
 Diagnostic Test
RADIOLOGY LAPAROSCOPY

LABORATORY ENDOSCOPY
Diagnostic Test-Laboratory
Diagnostic Test-Radiologic Studies
Plain Films-Facts
Plain Films-Facts
 USG- Facts
• Recommended as a screening test for acute
abdomen
�Lack of ionizing radiation
�Low cost
�Widespread availability

� Education for ER doctors?

 USG - Facts
• Acute appendicitis - sens, spec, acc
• US: 75–90 %, 95–100 %, 90–95 %
• CT: 90–100 %, 91–99 %, 94–98 %
• Recommended in children, pregnant
patients, and premenopausal women
with frequent gynecological
presentations resembling appendicitis
Abdominal CT - Facts
Initial Therapy
• A - Secure airway
• B - Oxygen 10L/m
• C - Fluid Balance: large bore,
IVF, catheter
• C - Blood Transfusion if
Hb<7g/dl
• D - Analgesia
• E - IV Antibiotics
• E - Thromboprophylaxis?
• Anti-emetics/ NG aspiration
• Re-assess
Emergency Department Disposition
Emergency Department Disposition
When to Call the Surgeon ?
• Unstable vital sign (hypotension,
sepsis)
• Obvious peritonitis on examination
(regardless of cause)
• Perforation (free air on BOF erect/LLD)
• Irreducible and tender hernia (risk of
strangulation)
• Work up complete in stable patient, but
still without a definitive diagnosis
Emergency Department Disposition
● When the diagnosis is
in question
 Emergency Department Disposition

• When the patient is

discharged home,
instruction to return if:
○ Pain worsen
○ New vomiting occurs
○ Fever
○ Pain persist beyond 8-12h
 CONCLUSIONS
• The key point in treatment of COVID-19 patients with abdominal
pain is to exclude acute surgical suffering.

• Besides physical examination, adequate imaging studies are

necessary in dubious case

• Abdominal pain may manifest before respiratory signs of SARS-

CoV-2 infection, and therefore, adequate imaging studies and
Covid19 Screening are required
THANKS