Pain can produce unstable hemodynamics
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- Elvin Bryan
- 5 years ago
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27 30-year-old male came to emergency department for severe epigastric pain for 6 hours as well as nausea and vomiting. 1)BP: 130/70mmHg 2)HR: 130 beats/min 3)RR: 18 cycles/min 4)Temp: 98.4 F 5)Pain-80% on VAS Scale
28 a. Airway: speaks full sentences b. Breathing: no apparent respiratory distress; no cyanosis, O2 Sat: 97% on RA c. Circulation: slightly diaphoretic; normal capillary refill In SEVERE distress due to pain; does not want to lie down on the stretcher
29 1) 2 large-bore peripheral IV line placed 2) Labs CBC, LFT, coagulation studies, blood type Serum amylase, serum lipase ECG, USG- abdomen Urine Analysis 3) 1 L NS 20ml/kg iv over 20 min
30 A 30-year-old male with heavy alcohol consumption Presents with severe epigastric pain for past 4 days but aggravated since last 6 hours associated with nausea and vomiting. Patient describes the pain as sharp and stabbing, radiating to his back. Pain aggravated on lying down position and on food consumption. Relieved by sitting or bending position
31 He reports four episodes of non bilious, non bloody vomitings since the pain started; no diarrhea; no blood per rectum; denies fever or chills; denies any urinary symptoms or flank pain Past Medical History: history of similar complaints twice previously last episode being- 2 months back, No h/o DM, HTN, TB, ASTHMA Past Surgical History: no surgical history Allergies: none Social: drinks alcohol regularly
32 General: alert, oriented, appears in severe distress due to pain Head: atraumatic Eyes: extra ocular movement intact, pupils equal, reactive to light Ears: normal tympanic membranes Nose: no discharge Neck: full range of motion, no jugular vein distension, no stridor Pharynx: normal dentition, no lesions, no swelling
33 Chest: nontender Lungs: clear bilaterally Heart: tachycardic rate, rhythm regular, no murmurs, rubs, or gallops Abdomen: bowel sounds active, tenderness in epigastric area with guarding; no rebound tenderness; no rigidity Urogenital: normal, no discharge
34 Extremities: no deformity, normal pulses Back: nontender Neuro: cranial nerves II to XII intact; normal sensation, strength; normal reflexes and gait Skin: warm and dry Lymph: no lymphadenopathy
35 Complete blood count: HB- 16 gm % WBC /ul Hct -38% Platelet- 1.4 lakhs/cumm RBS mg/dl
36 Blood urea -29 mg/dl Sr.Cr mg/dl Na -138 meq/l K- 3.8 meq/l Cl -100 meq/l Ca -8 mg/dl
37 PT- 16 sec aptt sec INR -1.14
38 S.Amylase- 259 U/L S.Lipase -188 U/L AST- 56 U/L ALT -68 U/L Alk Phos -77 U/L T bili -1.0 mg/dl D bili -0.3 mg/dl Albumin- 4 g/dl
39 SG ph 5 8 Prot- Neg Gluc- Neg Ketones Neg Bilirubin -Neg Blood Neg Color Yellow
40 PH-7.36 PCO2-38mmHg PO2-97 mmhg HCO3-22meq/l O2 Sat-99%
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42 CHEST XRAY
43 Bulky pancreas with peripancreatic inflammatory changes. Fatty liver grade -II
44 1. ACUTE PANCREATITS 2. Severe Pain 3. Dehydration 4. Vomitings Analgesics Inj PARACETAMOL 1g infusion. Inj TRAMADOL 50 mg slow IV Inj DICLOFENAC 75 mg IM Fluid resuscitation IV Fluids NS 20 ml/kg IV followed by urine output + 75 ml/ hr for maintenance. Nill per oral Inj ONDONSETRON 4mg iv Inj PANTOP 80 mg in 500 NS
45 Octreotride infusion Epidural analgesia Trans dermal patch(fentanyl patch) Celiac plexus block Neurolysis
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47 PAIN MANAGEMENT OF PANCREATITIS IN EMERGENCY DEPARTMENT
48 ACUTE
49 PAIN BY
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52 CELIAC PLEXUS BLOCK EMERGENCY PAIN MANAGEMENT FOR PANCREATITIS
53 CASE SCENAREO Pain score of 80% -VAS
54 COELIAC PLEXUS BLOCK
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56 RETROCRURAL APPROACH
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59 Very effective block % pain relief for nearly 14 to 16 hrs is observed. On Follow up- pain relief, increased quality of life for nearly 6 months.
60 TECHNICAL PHYSIOLOGICAL Damage to somatc nerves -Parathesia /Defecit of lumbar somatic nerves Penetration of intervertebral foramin (if the needle is inserted too posterior) -Dural drip -Epidural injection -Paraplegia COMPLICATIONS -Hypotension (ORTHOSTATIC) -Coeliac plexus ablation by neurolsis. -Urinary incontinance -Failure of ejaculation -Impotence -Diorrhea(unopposed parasympathetic activity)
61 TECHNICAL PHYSIOLOGICAL Trauma to closely related great vessels -Intravascular injection (venous / arterial) -Vascular wall trauma -Vascular thrombosis / embolism -Necrosis of intervening tissue -Aorto-duodenal fistula Others Shoulder tip pain / back pain, Groin numbness / seizures/loss of consciousness
62 TECHNICAL -Needle injury -Intradiscal injection -Renal injury -Pneumothorax / chylothorax -Perforation of cyst / tumors -Injection of psoas muscle -Retroperitoneal haematoma PHYSIOLOGICL Infection, Abscess, Peritonitis
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