Rosen & Barkin's 5-Minute Emergency Medicine Consult (505 page)

Disposition determined by medical condition and persistence of pain.

• Medical condition requiring admission.
  
• Uncontrolled pain.
  

• Medical condition(s) addressed
  
• Pain relief defined as a final evaluation of pain ≤3/10, or a decrease of pain ≥50% from the baseline, or if the acceptable level of pain is reached for an individual patient.
  
• Physicians may control pain well in the ED with IV titration, but risk poor pain control after discharge with oral opioids:
  
  • Be aware of conversion rates between opioids.
    
  • Be aware of conversion from IV to oral dosing.
    
  • Opioids should be prescribed at fixed intervals to control pain, with additional as-needed doses as required.
    

Recurrence of pain despite adequate analgesic treatment or new unexpected pain requires a reassessment of the diagnosis and consideration of alternative causes for the pain.

As appropriate for medical condition(s).

• In case of severe pain, initiate pain relief simultaneously with the primary assessment.
  
• Regular assessment of pain leads to improved pain management.
  
• Nonpharmacologic measures are effective in providing pain relief and should always be considered and used when possible.
  
• Titrating relatively high doses of opioid provides the best chance of delivering rapid and effective analgesia.
  

• Albrecht E, Taffe P, Yersin B, et al. Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: A 10 yr retrospective study.
  Br J Anaesth.
  2013;110(1):96–106.
  
• Guéant S, Taleb A, Borel-Kühner J, et al. Quality of pain management in the emergency department: Results of a multicentre prospective study.
  Eur J Anaesthesiol.
  2011;28(2):97–105.
  
• Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: Results of the pain and emergency medicine initiative (PEMI) multicenter study.
  J Pain.
  2007;8(6):460-466.
  

CODES

• 338.19 Other acute pain
  
• 338.29 Other chronic pain
  
• 780.96 Generalized pain
  

BASICS

• Direct epigastric blow compressing pancreas against vertebral column resulting in blunt trauma
  
• Injury to pancreas from penetrating object
  

• Trauma affects proportionately larger areas, leading to multisystem injuries.
  
• Children have less protective muscle and SC tissue.
  
• Malpositioned seat belts and child abuse need to be considered in small children.
  
• Children will less often present with hypotension.
  

• Penetrating trauma: Most common mechanism
  
• Blunt trauma: Deep location of pancreas requires significant force to cause injury:
  
  • Steering wheel, seat belts, or bicycle handlebars to abdomen
    
  • In children, evaluate for nonaccidental trauma
    

90% of pancreatic injuries associated with injuries to adjacent structures:

• Liver, stomach
  
• Major arteries and veins
  
• Spleen, kidney
  
• Duodenum, colon, small bowel
  
• Common bile duct, gallbladder
  
• Spine: Chance fracture
  

DIAGNOSIS

• Abdominal pain:
  
  • Diffuse or epigastric
    
  • Often out of proportion to physical exam and vital signs
    
• Soft-tissue contusion in upper abdomen
  
• Injury to lower ribs or costal cartilage
  
• Acute abdomen, often associated with other intra-abdominal injuries
  
• Concomitant splenic injury can present initially as dull back pain
  
• Hypotension
  
• Grey Turner sign:
  
  • Flank ecchymosis
    
• Cullen sign:
  
  • Periumbilical ecchymosis
    

Concise; details of incident especially important for blunt trauma

• Inspect for abrasions, contusions, penetrating wounds:
  
  • Must log roll patient for full inspection.
    
  • Look for seat belt–related injuries.
    
• Auscultate for presence or absence of bowel sounds.
  
• Palpate to determine location and severity of pain, presence of guarding, and rebound tenderness.
  
• Rectal exam for occult blood, vaginal exam, or penile exam
  
• Serial physical exams and vital signs for unidentified injuries
  

• Pace of workup is dictated by patient condition and other injuries.
  
• Abdominal CT with IV contrast is essential to evaluate for pancreatic trauma.
  
• MRCP is being used more frequently in trauma centers to better evaluate ductal injury.
  

• Blood type, screen, or cross-match
  
• Hematocrit, WBC with differential, complete metabolic profile
  
• Amylase:
  
  • Not a reliable indicator of pancreatic trauma
    
  • Serial levels may increase sensitivity, but specificity still poor.
    
  • Elevated amylase may be early indicator of potential pancreatic injury.
    
  • Normal amylase does not rule out pancreatic injury.
    
  • More sensitive and specific if detected in diagnostic peritoneal lavage (DPL) fluid
    
• Lipase:
  
  • No more specific for pancreatic injury
    
• Urinalysis
  
• Pregnancy test
  
• Alcohol and drug screening if indicated
  
• Prothrombin time/partial thromboplastin time, BUN, and creatinine
  

• Note that all imaging tests may miss pancreatic injury.
  
• Cervical spine, CXRs, and pelvis films as for all blunt trauma patients
  
• Bedside US/FAST scan
  
• CT scan with IV contrast, helical/MDCT if available:
  
  • Shows better contrast enhancement of pancreatic parenchyma than standard scanning
    
  • MDCT is particularly useful in pediatric populations
    
• Magnetic retrograde cholangiopancreatography:
  
  • Noninvasive evaluation of injury to ductal components
    
• Endoscopic retrograde cholangiopancreatography:
  
  • Useful for patients with persistent hyperamylasemia
    
  • Unexplained abdominal symptoms
    
  • Some advocating early use to minimize complications
    
• Operative exploration and intraoperative cholangiogram remains the ideal diagnostic modality, particularly if patient is unstable.
  

DPL to identify intraperitoneal injuries:

• Check fluid for amylase level.
  
• May still miss significant pancreatic injury
  

Other or associated abdominal traumatic injuries

TREATMENT

Transport to closest trauma center.

• Airway management, resuscitation as indicated with crystalloids, colloids, or blood products
  
• Nasogastric-tube suction may be especially helpful in the setting of pancreatic trauma.
  

Follow standard trauma treatment for blunt abdominal trauma:

• Penetrating trauma:
  
  • Tetanus prophylaxis and broad-spectrum antibiotic therapy
    
• Intra-abdominal injury requiring operative intervention:
  
  • Broad-spectrum antibiotic therapy
    
• Must cover for colonic bacteria:
  
  • Aerobic:
    Escherichia coli, Enterobacter, Klebsiella, Enterococcus
    
  • Anaerobic:
    Bacteroides fragilis, Clostridium, Peptostreptococcus
    

Follow ABCDE of trauma and resuscitate unstable patient with emergent surgical consultation or transfer to trauma center as indicated:

• Evaluate for associated abdominal injury.
  
• Choose imaging modality for rapid evaluation (CT and/or MRCP).
  
• Early identification of ductal injuries has been shown to reduce morbidity and mortality.
  
• Surgical: Pancreaticoduodenectomy, distal pancreatectomy, endoscopic stent (controversial), sump/closed suction drainage
  
• East Trauma Guidelines 2009
  
• Level III evidence: Grade I and II injuries: Drainage Grade III–V injuries: Resection and drainage