Pemicu Blok Kegawatdaruratan

SHOCK
• Shock is a life-threatening condition that
occurs when the body is not getting enough
blood flow. Lack of blood flow means that the
cells and organs do not get enough oxygen
and nutrients to function properly. Many
organs can be damaged as a result. Shock
requires immediate treatment and can get
worse very rapidly.

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

 Shock
• Low Cardiac Output  Inadequate perfusion
and oxygenation to tissues
• HR x SV = CO
• SV:
– Preload
– Afterload
– Contractility
 Classifications of Shock (from their
respective Etiologies)
• Cardiogenic shock (due to heart problems)
• Hypovolemic shock (caused by too little blood
volume)
• Anaphylactic shock (caused by allergic
reaction)
• Septic shock (due to infections)
• Neurogenic shock (caused by damage to the
nervous system)
US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm
 Main symptoms of shock
• Low Blood Pressure
• Anxiety or agitation/restlessness
• Bluish lips and fingernails
• Chest pain
• Confusion
• Dizziness, lightheadedness, or faintness
• Pale, cool, clammy skin
• Low or no urine output
• Profuse sweating, moist skin
• Rapid but weak pulse
• Shallow breathing
• Unconsciousness

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US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

• Call medical help. FIRST AID

• Check the person's [S]afety, [R]esponse, [Circulation], [A]irway, and
[B]reathing, [D]isability, [E]xposure. If necessary, begin rescue breathing
and CPR when there is no pulse.
• Even if the person is able to breathe on their own, continue to check rate
of breathing at least every 5 minutes until help arrives.
• If the person is conscious and does NOT have an injury to the head, leg,
neck, or spine, place the person in the shock position. Lay the person on
the back and elevate the legs about 12 inches. Do NOT elevate the head. If
raising the legs will cause pain or potential harm, leave the person lying
flat.
• Give appropriate first aid for any wounds, injuries, or illnesses.
• Keep the person warm and comfortable. Loosen tight clothing.
• IF THE PERSON VOMITS OR DROOLS
– Turn the head to one side to prevent choking. Do this as long as you do not
suspect an injury to the spine.
– If a spinal injury is suspected, "log roll" the person instead. To do this, keep the
person's head, neck, and back in line, and roll the body and head as a unit.
• In case of shock:
– Do NOT give the person anything by mouth, including anything to eat or drink.
– Do NOT move the person with a known or suspected spinal injury.
– Do NOT wait for milder shock symptoms to worsen before calling for
emergency medical help.
Hipovolemic shock
 HYPOVOLEMIC SHOCK (eg.
Hemorrhagic shock)
• Hypovolemic shock refers to a medical or
surgical condition in which rapid fluid loss
results in multiple organ failure due to
inadequate circulating volume and
subsequent inadequate perfusion. Most often,
hypovolemic shock is secondary to rapid blood
loss (hemorrhagic shock). (Preload)

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

http://emedicine.medscape.com/article/760145-overview#a5
 HYPOVOLEMIC SHOCK (eg.
Hemorrhagic shock)
• The human body responds to acute hemorrhage by
activating the following major physiologic systems:
– Hematologic: activating the coagulation cascade and
contracting the bleeding vessels.
– Cardiovascular: increasing the heart rate, increasing
myocardial contractility, and constricting peripheral blood
vessels (baroreceptors  releasing of norephinephrine
– Renal:increase in renin secretion from the juxtaglomerular
apparatus  vasoconstriction of arteriolar smooth muscle
and stimulation of aldosterone  active sodium
reabsorption and subsequent water conservation.
– Neuroendocrine systems: ADH  increased reabsorption
of water
http://emedicine.medscape.com/article/760145-overview#a5
 Etiology of Hypovolemic Shock
• Losing about a fifth or more of the normal amount of blood
in your body causes hypovolemic shock. (normal: 4,7-5,5L)
• Bleeding from cuts/bleeding from other injuries
• Internal bleeding, such as in the gastrointestinal tract

• The amount of circulating blood in your body may drop

when you lose too many other body fluids. This can be due
to:
– Burns
– Diarrhea
– Excessive perspiration
– Vomiting

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

 SYMPTOMS of Hypovolemic Shock
• Symptoms may include:
• Anxiety or agitation
• Cool, clammy skin
• Confusion
• Decreased or no urine output
• General weakness
• Pale skin color (pallor)
• Rapid breathing
• Sweating, moist skin
• Unconsciousness

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

https://acls-algorithms.com/pediatric-advanced-life-support/pediatric-shock-
overview-part-1/pals-review-hypovolemic-shock/
 Exams and Test
• A physical exam will show signs of shock, including:
– Low blood pressure
– Low body temperature
– Rapid pulse, often weak and thready

• Tests that may be done include:

– Blood chemistry, including kidney function tests and those tests
looking for evidence of heart muscle damage
– Complete blood count (CBC)
– CT scan, ultrasound, or x-ray of suspected areas
– Echocardiogram: sound wave test of heart structure and function
– Endoscopy: tube placed in the mouth to the stomach (upper
endoscopy) or colonoscopy (tube placed through the anus to the large
bowel)
– Right heart (Swan-Ganz) catheterization
– Urinary catheterization (tube placed into the bladder to measure urine
output)
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 Treatment
• Get medical help right away. In the meantime, follow these steps:
• The goal of hospital treatment is to replace blood and fluids. An
intravenous (IV) line will be put into the person's arm to allow blood
or blood products to be given.
• Primary Survey: SRCABDE
• Keep the person comfortable and warm (to avoid hypothermia).
• Have the person lie flat with the feet lifted about 12 inches to increase circulation.
However, if the person has a head, neck, back, or leg injury, do not change the person's
position unless they are in immediate danger.
• DO NOT give fluids by mouth.
• If person is having an allergic reaction, treat the allergic reaction, if you know how.
• If the person must be carried, try to keep them flat, with the head down and feet lifted.
Stabilize the head and neck before moving a person with a suspected spinal injury.
• Medicines such as dopamine, dobutamine, epinephrine, and norepinephrine may be
needed to increase blood pressure and the amount of blood pumped out of the heart
(cardiac output).
• If there is a bleeder, stop it (eg. push the wounds with ripped cloth) and replace the
fluid loss
• In hemorrhagic shock vassopressor is contraindicated (reducement of organ perfusion)

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

 Treatment of Hypovolemic Shock
• 2 large bore of IVs or Central line
• Crystalloids: NS or RL up to 3L
• PRBC (O-Neg or cross matched)
Cardiogenic Shock
 Cardiogenic shock
Cardiogenic shock should be thought to present
whenever cardiac failure (ischemic, toxic, or
obstructive) causes syatemic hypoperfusion that
manifests as lactic asydosis with organ dysfunction.

Cardiogenic shock (myocardial pump failure) 

more than 40% of myocardium undergoes necrosis
from ischemia, inflammation, toxins, or imune
destruction.

Rosen’s Emergency Medicine Conceps and Clinical Practice

• Risk factors • Timing
– acute MI – 1/4 of MI patients develop
– older age CS rapidly (within 6 hour of
– female sex MI onset)
– prior MI – 3/4  later on the 1st day
– diabetes – Subsequent onset of CS 
• reinfarction,
– anterior MI location
• marked infarct expansion,
– reinfarction soon after MI • a mechanical complication

Harrison's principles of internal medicine,

18th
 Clinical Features
- Cardiac failure
- Clinical evidence of impaired forward flow of the heart,
including presence of dypsnea tachycardia, pulmonary edema,
or cyanosis.
- Cardiogenic shock
- Cardiac failure plus four criteria of empirical criteria from
diagnosis of circulatory shock:
- Ill appearance or altered mental status
- Heart rate > 100 beats/min
- Respiratory rate > 20 x/min or PaCo2 <32 mmHg
- Arterial base defisit < -4mEq/L or lactate > 4mM/L
- Urine output <0.5 mL/kg/hr
- Arterial hypotension > 20 minutes duration

Rosen’s Emergency Medicine Conceps and Clinical Practice

• Clinical findings
– Continuing chest pain & – Tachypnea, Cheyne-Stokes
dyspnea respirations
– Pale, apprehensive, – jugular venous distention
diaphoretic – S1 is usually soft, and an S3
– Altered consciousness gallop may be audible
– weak and rapid pulse – Acute, severe MR and VSR
• 90–110 beats/min  systolic murmurs
– Systolic BP <90 mmHg + – LV failure causing CS 
narrow pulse pressure (<30 rales
mmHg) – Oliguria
– quiet precordium + weak • urine output < 30 mL/h
apical pulse
Harrison's principles of internal medicine,
18th
• Laboratory findings • ECG
– WBC count > with left – acute MI with LV failure
shift • Q waves and/or >2-mm
– BUN & creatinin >> ST elevation in multiple
leads
– Hepatic transaminase >> • LBBB
– Lactic acid > – 1,5 of infarct  anterior
– Arterial blood gases – severe left main stenosis
• hypoxemia and metabolic  global ischemia
acidosis
• severe (e.g., >3 mm) ST
– creatine phosphokinase, depressions in multiple
troponin I & T > leads

Harrison's principles of internal medicine,

18th
• Chest X ray • Echocardiogram
– pulmonary vascular – left-to-right shunt in
congestion patients with VSR
– pulmonary edema – Pulmonary embolism 
– CS results from a first MI Proximal aortic
 heart’s size is normal dissection with aortic
regurgitation or
tamponade

Harrison's principles of internal medicine,

18th
 Rosens Emergency Medicine 8th edition.

Cardiogenic Shock
• Management
– Monitoring perfusion status : HR, BP, and
oxyhemoglobin saturation continuously
monitored.
– Quantitative resuscitation : ventilation, volume
replacement.
 Treatment
• Primary Survey: SRCABDE
• Airway stability and improving myocardial
pump function
• Cardiac monitor
• Oxygent and IV acess
• Intubation (Care for preload because of the
venous return resluting in hypotention, care
for trauma that could increas cathecolamine
and rising of BP, tach)
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Harrison's principles of internal medicine,
18th
Anaphylactic shock
• Life-threatening type of a whole body allergic
reaction. (Tissues in different parts of the body
release histamine and other substances. This
causes the airways to tighten and leads to other
symptoms.)

• Some drugs (morphine, x-ray dye, aspirin, and

others) may cause an anaphylactic-like reaction
(anaphylactoid reaction) when people are first
exposed to them. These reactions are not the
same as the immune system response that occurs
with true anaphylaxis. But, the symptoms, risk of
complications, and treatment are the same for
both types of reactions.
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 Etiologies of Anaphylactic Shock
• Drug allergies
• Food allergies
• Insect bites/stings
• Pollen and other inhaled allergens rarely cause
anaphylaxis. Some people have an
anaphylactic reaction with no known cause.

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

 Symptoms of Anaphylactic Shock
• Symptoms develop quickly, often within seconds or minutes. They may include any
of the following:

• Abdominal pain
• Feeling anxious
• Chest discomfort or tightness
• Diarrhea
• Difficulty breathing, coughing, wheezing, or high-pitched breathing sounds
• Difficulty swallowing
• Dizziness or lightheadedness
• Hives, itchiness, redness of the skin
• Nasal congestion
• Nausea or vomiting
• Palpitations
• Slurred speech
• Swelling of the face, eyes, or tongue
• Unconsciousness

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 Exams and Tests
• The health care provider will examine the
person and ask about what might have caused
the condition. (History of allergen contact,
bite or sting marks)

• Tests for the allergen that caused anaphylaxis

(if the cause is not obvious) may be done after
treatment.

US National Library of Medicine: https://medlineplus.gov/ency/article/000039.htm

 Treatments of Anaphylactic Shock
• Call for help!
• Check the person's airway, breathing, and circulation, which are known as the ABC's of Basic
Life Support. A warning sign of dangerous throat swelling is a very hoarse or whispered
voice, or coarse sounds when the person is breathing in air. If necessary, begin rescue
breathing and CPR. If patient is unconcious use SRCABDE
• IVF and Oxygen
• Epinephrine or Corticosteroid/H1 and H2 blockers
• Calm and reassure the person.
• If the allergic reaction is from a bee sting, scrape the stinger off the skin with something firm
(such as a fingernail or plastic credit card). Do not use tweezers. Squeezing the stinger will
release more venom.
• If the person has emergency allergy medicine on hand, help the person take or inject it. Do
not give medicine through the mouth if the person is having difficulty breathing.
• Take steps to prevent shock.
– Have the person lie flat, raise the person's feet about 12 inches, and cover the
person with a coat or blanket. Do not place the person in this position if a head, neck,
back, or leg injury is suspected, or if it causes discomfort.
• Do not place a pillow under the person's head if they are having trouble breathing. This can block the airways.
• Place a tube through the nose or mouth into the airways. Or emergency surgery will be done to place a tube directly into the
trachea.

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Septic Shock
 Septic Shock
• Septic shock is a serious condition that occurs
when a body-wide infection leads to
dangerously low blood pressure (Afterload)

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 Etiologies of Septic Shock
• Any type of bacteria can cause septic shock. Fungi
and (rarely) viruses may also cause the condition.
Toxins released by the bacteria or fungi may
cause tissue damage. This may lead to low blood
pressure and poor organ function. Some
researchers think that blood clots in small
arteries cause the lack of blood flow and poor
organ function.
• The body has a strong inflammatory response to
the toxins that may contribute to organ damage

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• Hypotension, the cardinal manifestation of
sepsis, occurs via induction of nitric oxide
(NO). NO plays a major role in the
hemodynamic alterations of septic shock,
which is a hyperdynamic form of shock

http://emedicine.medscape.com/article/168402-overview#a4
http://emedicine.medscape.com/article/168402-overview#a4
 Risk Factor of Septic Shock
• Diabetes
• Diseases of the genitourinary system, biliary system, or intestinal
system
• Diseases that weaken the immune system, such as AIDS
• Indwelling catheters (those that remain in place for extended
periods, especially intravenous lines and urinary catheters, and
plastic and metal stents used for drainage)
• Leukemia
• Long-term use of antibiotics
• Lymphoma
• Recent infection
• Recent surgery or medical procedure
• Recent use of steroid medicines
• Solid organ or bone marrow transplantation

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 Symptoms of Septic Shock
• Septic shock can affect any part of the body, including the
heart, brain, kidneys, liver, and intestines. Symptoms may
include:
– Cool, pale arms and legs
– High or very low temperature, chills
– Light headedness
– Little or no urine
– Low blood pressure, especially when standing
– Palpitations
– Rapid heart rate
– Restlessness, agitation, lethargy, or confusion
– Shortness of breath
– Skin rash or discoloration
– Decreased mental status

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 Exams and Test for Septic Shock
• Blood tests may be done to check for:
• Infection around the body
• Complete blood count (CBC) and blood chemistry
• Presence of bacteria or other organisms
• Low blood oxygen level
• Disturbances in the body's acid-base balance
• Poor organ function or organ failure
• Other tests may include:
• A chest x-ray to look for pneumonia or fluid in the lungs (pulmonary
edema)
• A urine sample to look for infection
• Additional studies, such as blood cultures, may not become positive
for several days after the blood has been taken, or for several days
after the shock has developed.

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 Treatments of Septic Shock
• Septic shock is a medical emergency. In most cases, people are
admitted to the intensive care unit of the hospital.
• Treatment may include:
• Breathing machine (mechanical ventilation)
• Dialysis
• Drugs to treat low blood pressure, infection, or blood clotting
• Fluids given directly into a vein (intravenously)
• Oxygen
• Sedatives
• Surgery to drain infected areas, if needed
• Antibiotics
• The pressure in the heart and lungs may be checked. This is called
hemodynamic monitoring. This can only be done with special
equipment and intensive care nursing.

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• 2 Large bores IVs
– NS IVF bolus 1-2 L wide open if no cons
• Supplemental Oxygen
• AB covering – and + grams
– Zosyn 3-375 grams IV and Ceftriaxone 1 gram IV
– Or Imipenem 1 gr IV
• Pseudomonas Gentamicin or Cefepime
• MRSA  Vancomycin
• Anaerobic  Clindamicin or Metronidazole
• Asplenic – Ceftriaxone  N. Meningitidis, H. Influenzae
• Neutropenic  Cefepime or Imipenem

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 Presistent?
• After 2-3 L of IVF still no response 
Vasopressors (norepinephrine, dopamine) and
titrate to effect
• Goal MAP >60
• Adrenal Insufficiency  100 mg IV
 Acute abdomen
• ~Acute abdominal pain
– Since proper therapy may require urgent action
– The unhurried approach suitable for the study of other
conditions is sometimes denied
– A meticulously executed, detailed history and physical
examination are of great importance

• The most obvious of "acute abdomens" may not require

operative intervention
• The mildest of abdominal pains may herald an urgently
correctable lesion
• Patient with abdominal pain of recent onset requires early
and thorough evaluation and accurate diagnosis
Acute Abdominal Pain
Etiology
 Some mechanisms of pain originating
in abdomen
• Inflammation of the parietal peritoneum
– Pain of parietal peritoneal inflammation is steady and aching in
character and is located directly over the inflamed area 
transmitted by somatic nerves supplying the parietal
peritoneum
– Pain intensity  type and amount of material to which the
peritoneal surfaces are exposed in a given time period
– The pain of peritoneal inflammation is invariably accentuated by
pressure or changes in tension of the peritoneum
• Produced by palpation or by movement, as in coughing or sneezing
• Lies quietly in bed, preferring to avoid motion,
• In contrast to the patient with colic, who may writhe incessantly
– Tonic reflex spasm of the abdominal musculature, localized to
the involved body segment
• Obstruction of hollow viscera
– Intermittent, or colicky
• Distention of a hollow viscus  steady pain + very occasional
exacerbations
• The colicky pain of obstruction of the small intestine 
periumbilical or supraumbilical, poorly localized
• Acute distention of the gallbladder  pain in the right upper
quadrant with radiation to right posterior region of the
thorax / to the tip of the right scapula
• Distention of the common bile duct  pain in the
epigastrium radiating to the upper part of the lumbar region
• Obstruction of the urinary bladder  dull suprapubic pain,
usually low in intensity
– In contrast, acute obstruction of the intravesicular portion of the
ureter  severe suprapubic and flank pain radiates to penis,
scrotum, or inner aspect of the upper thigh
• Vascular Disturbances
– Pain associated with intraabdominal vascular disturbances
is sudden and catastrophic in nature
• Embolism or thrombosis of the superior mesenteric artery
– Severe & diffuse; only mild continuous diffuse pain for 2 or 3 days before
vascular collapse or findings of peritoneal inflammation appear
• Impending rupture of an abdominal aortic aneurysm
– Abdominal pain with radiation to the sacral region, flank, or genitalia;
persist over a period of several days before rupture and collapse occur
• Abdominal wall
– Pain from the abdominal wall  constant & aching
– e/ Movement, prolonged standing, and pressure
accentuate the discomfort and muscle spasm
• Ex: hematoma of the rectus sheath
 Approach to the patient
• Only those patients with exsanguinating
intraabdominal hemorrhage (e.g., ruptured
aneurysm)  operate
• But in such instances only a few minutes are
required to assess the critical nature of the
problem

• Orderly, painstakingly detailed history

• Even though a reasonably accurate diagnosis can
be made on the basis of the history alone in the
majority of cases
Differential diagnose
 Examination
• Simple critical inspection of the patient
– facies, position in bed, and respiratory activity

• Gentle percussion of the abdomen (rebound tenderness on a miniature

scale), a maneuver that can be far more precise and localizing
• Abdominal signs may be virtually or totally absent in cases of pelvic
peritonitis

• Auscultation of the abdomen

– strangulating small intestinal obstruction or perforated appendicitis  normal
peristaltic sounds
– proximal part of the intestine above an obstruction becomes markedly
distended and edematous  weak or absent even when peritonitis is not
present
– Severe chemical peritonitis  truly silent abdomen
 Laboratory examination
• White blood cell count
– >20,000/L may be observed  perforation of a viscus, but
pancreatitis, acute cholecystitis, pelvic inflammatory disease, and
intestinal infarction
– Normal count is not rare in cases of perforation of abdominal viscera
• Urinalysis
– state of hydration or rule out severe renal disease, diabetes, or urinary
infection
– Serum amylase levels may be increased by many diseases other than
pancreatitis, e.g., perforated ulcer, strangulating intestinal obstruction,
and acute cholecystitis
• Plain & upright or lateral decubitus radiographs of the abdomen
– Intestinal obstruction, perforated ulcer, and a variety of other
conditions
 Peritonitis
•  life-threatening event that is often
accompanied by bacteremia and sepsis syndrome
– Pancreas, duodenum, and ascending and descending
colon are located in the anterior retroperitoneal space
– Kidneys, ureters, and adrenals are found in the
posterior retroperitoneal space
– Other organs, including liver, stomach, gallbladder,
spleen, jejunum, ileum, transverse and sigmoid colon,
cecum, and appendix, are within the peritoneal cavity
• Cavity is lined with a serous membrane that can
serve as a conduit for fluids
 Primary (spontaneous) bacterial
peritonitis
• Usually caused by single organism
• Etiology
– Occurs most commonly in conjunction with cirrhosis
of the liver (frequently the result of alcoholism)
– Metastatic malignant disease
– postnecrotic cirrhosis
– chronic active hepatitis & acute viral hepatitis
– congestive heart failure
– systemic lupus erythematosus
– lymphedema
• Clinical manifestation
– Fever (80%)
– Acites  predates infection
– Abdominal pain, an acute onset of symptoms, and peritoneal irritation
(physical examination)
– Nonlocalizing symptoms  malaise, fatigue, or encephalopathy

• Other examination
– >250 PMNs/L is diagnostic for PBP
– Blood culture
• enteric gram-negative bacilli (Escherichia coli)  most commonly encountered
• gram-positive organisms (streptococci, enterococci, or even pneumococci)  sometimes
found
• Aerobic bacteria
– Contrast-enhanced CT  intraabdominal source for infection
– Chest & abdominal radiography  to exclude free air
• Treatment
– Third-generation cephalosporins (cefotaxime 2 g q8h,
administered IV)  initial coverage in moderately ill patients
– Broad-spectrum antibiotics, such as penicillin/β-lactamase
inhibitor combinations (piperacillin/tazobactam 3.375 g q6h IV
for adults with normal renal function); ceftriaxone (2 g q24h IV)
• Prevention
– Up to 70% of patients experience a recurrence within 1 year
– Antibiotic prophylaxis reduces this rate to <20%
– Prophylaxis agents
• fluoroquinolones (ciprofloxacin, 750 mg weekly; norfloxacin, 400
mg/d)
• trimethoprim-sulfamethoxazole (one double-strength tablet daily)
 Secondary peritonitis
• Develops when bacteria contaminate the peritoneum
as a result of spillage from an intraabdominal viscus 
chemical irritation and/or bacterial contamination
• Found almost always constitute a mixed flora in which
– facultative gram-negative bacilli
– anaerobes predominate, especially when the
contaminating source is colonic
• Early death in this  gram-negative bacillary sepsis
and to potent endotoxins circulating in the
bloodstream
– E. coli, are common bloodstream isolates, but Bacteroides
fragilis bacteremia also occurs
• Clinical manifestation
– local symptoms may occur in secondary peritonitis, ex:
• Epigastric pain from a ruptured gastric ulcer
• Appendicitis  vague, with periumbilical discomfort and nausea;
number of hours  pain localized right lower quadrant
– lie motionless
– knees drawn up to avoid stretching the nerve fibers of the
peritoneal cavity
– Coughing and sneezing  increase pressure within the
peritoneal cavity  sharp pain
• Physical examination
– voluntary and involuntary guarding of the anterior abdominal
musculature
– tenderness, especially rebound tenderness
• Treatment
– antibiotics aimed particularly at aerobic gram-negative
bacilli and anaerobes
– penicillin/β-lactamase inhibitor combinations
(ticarcillin/clavulanate, 3.1 g q4–6h IV); cefoxitin (2 g q4–6h
IV)
– Patients in the intensive care unit  imipenem (500 mg
q6h IV), meropenem (1 g q8h IV), or combinations of
drugs, such as ampicillin plus metronidazole plus
ciprofloxacin
– Surgical intervention + antibiotics (bacteremia) 
decrease incidence of abscess formation & wound
infection; prevent distant spread of infection
 Peritonitis in Patients Undergoing
CAPD
• CAPD (continuous ambulatory peritoneal
dialysis)
• CAPD-associated peritonitis usually involves
skin organisms
• Pathogenesis
– skin organisms migrate along the catheter 
serves as an entry point and exerts the effects of a
foreign body
• usually caused by a single organism
• Clinical presentation
– diffuse pain and peritoneal signs are common

– dialysate is usually cloudy and contains >100 WBCs/L,

>50% of which are neutrophils
– Organisms:
• most common organisms are Staphylococcus spp
• Gram-negative bacilli and fungi such as Candida spp. are also
found
• Vancomycin-resistant enterococci and vancomycin-
intermediate S. Aureus
• Treatment
– should be directed at S. aureus, coagulase-negative
Staphylococcus, and gram-negative bacilli until the results of
cultures are available
– first-generation cephalosporin such as cefazolin (for gram-
positive bacteria)
– fluoroquinolone or a third-generation cephalosporin such as
ceftazidime (for gram-negative bacteria)
– MRSA  vancomysin
– If the patient is severely ill, IV antibiotics should be added at
doses appropriate for the patient's degree of renal failure
– if the patient has not responded after 48 h of treatment,
catheter removal should be considered
 Acute appendicitis
• Incidence & epidemiology
– The peak incidence of acute appendicitis is in the
second and third decades of life
– perforation is more common in infancy and in the
elderly, during which periods mortality rates are
highest
– Males and females are equally affected, except
between puberty and age 25, when males
predominate in a 3:2 ratio
• Pathogenesis
– occur as a result of appendiceal luminal obstruction
• Obstruction is most commonly caused by a fecalith
• Enlarged lymphoid follicles associated with viral infections (e.g.,
measles)
• inspissated barium
• worms (e.g., pinworms, Ascaris, and Taenia)
• tumors (e.g., carcinoid or carcinoma)
– appendiceal ulceration
– Infection with Yersinia organisms may cause the disease
• Luminal bacteria multiply and invade the appendiceal wall  venous
engorgement and subsequent arterial compromise  gangrene and
perforation occur 
– slow: terminal ileum, cecum, and omentum (localized abscess); rapid:
perforation with free access to the peritoneal cavity
• Clinical manifestations
– abdominal discomfort and anorexia
– The pain is described as being located in the periumbilical
region initially and then migrating to the right lower
quadrant
• resulting from distention of the appendiceal lumen; pain is carried
on slow-conducting C fibers and is usually poorly localized in the
periumbilical or epigastric region
– In general, this visceral pain is mild, often cramping and
usually lasting 4–6 h
– As inflammation spreads to the parietal peritoneal
surfaces  pain becomes somatic, steady, and more
severe and aggravated by motion or cough
– Nausea and vomiting occur in 50–60% of cases
• Differential diagnosis
• Physical findings
– tenderness to palpation will often occur at McBurney's point
– Abdominal tenderness may be completely absent if a retrocecal or
pelvic appendix is present  tenderness in the flank or on rectal or
pelvic examination
• Referred rebound tenderness is often present and is most likely to be absent
early in the illness
– Flexion of the right hip and guarded movement by the patient are due
to parietal peritoneal involvement
– The temperature is usually normal or slightly elevated [37.2°–38°C
(99°–100.5°F)], >38.3°C (101°F)  perforation
– Rigidity and tenderness  more marked as the disease progresses to
perforation and localized or diffuse peritonitis
– Perforation is rare before 24 h after onset of symptoms, but the rate
may be as high as 80% after 48 h
– Any infant or child with diarrhea, vomiting, and
abdominal pain is highly suspect
– Fever is much more common in this age group
– abdominal distention is often the only physical finding

– In the elderly, pain and tenderness are often blunted

– the diagnosis is also frequently delayed and leads to a
30% incidence of perforation in patients over 70
– often present initially with a slightly painful mass (a
primary appendiceal abscess) or with adhesive
intestinal obstruction 5 or 6 days after a previously
undetected perforated appendix
• Laboratorium findings
– moderate leukocytosis of 10,000–18,000 cells/microL
is frequent
– Leukocytosis of >20,000 cells/microL  perforation
– Anemia and blood in the stool suggest a primary
diagnosis of carcinoma of the cecum, especially in
elderly individuals
– urine may contain a few white or red blood cells
without bacteria if the appendix lies close to the right
ureter or bladder
– Urinalysis is most useful in excluding genitourinary
conditions that may mimic acute appendicitis
• Radiographs
– opaque fecalith (5% of patients) is observed in the
right lower quadrant (especially in children)
– intestinal obstruction or ureteral calculus may be
present
– Ultrasound  an enlarged and thick-walled
appendix
– CT will include a thickened appendix with
periappendiceal stranding and often the presence
of a fecalith
• Treatment
– early operation and appendectomy as soon as the patient can be
prepared
– A different approach is indicated if a palpable mass is found 3–5 days
after the onset of symptoms  phlegmon / abscess
• broad-spectrum antibiotics, drainage of abscesses >3 cm, parenteral
fluids, and bowel rest usually show resolution of symptoms within 1 week
• Interval appendectomy can be performed safely 6–12 weeks later
– antibiotics alone can effectively treat acute, nonperforated
appendicitis in 86% of male patients (higher recurrence rate)
 Hernia
•  protursion of an organ or part of an organ
through a defect wall of the cavity containing
it, into an abnormal position
• Abdominal wall hernia
– Inguinal (direct or indirect)
– Femoral
– Umbilical & para-umbilical
– Incisional
– Ventral & epigastric
Etiology
– Weakness in the abdominal wall
– Occur at the site of penetration of structures through the
abdominal wall
– The layers of the abdominal wall may be weakened
following a surgical incision
– Poor healing as a result of infection, hematoma formation
– Damage to the nerve  paralysis of abdominal muscles
– Increase of intra-abdominal pressure
• Chronic cough
• Constipation
• Urinary obstruction
• Pregnancy
• Abdominal distention with ascites
• Weak abdominal muscles
Varieties
– Reducible hernia
• Can be replaced completely into the peritoneal cavity
• Presents as a lump that may disappear on lying down, not
painful
• Examination: reveals a reducible lump with cough impulse
– Irreducible hernia
• Adhesions of its contents to the inner wall of the sac
• Painless, absence of cough impulse
– Strangulated hernia
• The hernia constricted on the neck of the sac  circulation
is cut off  perforation & gangrene
• Severe pain of sudden onset, colicky pain, vomitting,
distention, absolute constipation
• Examination: tender, tense hernia, overlying skin become
inflamed, noisy bowel sound
• (femoral, indirect inguinal, umbilical)
 Abdominal Abscess
• Clinical Symptoms
a. Abdomen pain, fever & tachycardia – is
related to history of abdomen or pelvis
surgery
b. There’s an effect of surgery or trauma and
inflammatory bowel disease at the peritoneal
cavity
• Diagnosis
a. Complete blood count (CBC)
b. Electrolyte test
c. Urinalysis
d. Kidney function test
e. Blood culture – sepsis
f. CT Scan abdomen (oral,intravena)
g. Plain x ray – perforated viscus
• Complications
a. Sepsis
b. Multiple Organ Dysfunction Syndrome
• Managements & Medication
a. Fluid resuscitation
b. Broad spectrum antibiotics
c. Indication of surgery – abscess intra
abdominal
 Refference
• US National Library of Medicine:
https://medlineplus.gov/ency/article/000039.
htm
• Rosen - Emergency Medicine, 8’th
• Harrison's principles of internal medicine,
18th