Rosen & Barkin's 5-Minute Emergency Medicine Consult (506 page)

• Adults:
  
  • Piperacillin/tazobactam 3.375 g IV
    OR
    
  • Cefotetan: 2 g IV + gentamicin 2 mg/kg IV
    OR
    
  • Cefoxitin: 2 g IV + gentamicin 2 mg/kg IV
    OR
    
  • Ceftriaxone: 1–2 g IV + Flagyl 15 mg/kg IV
    OR
    
  • Clindamycin: 600 mg IV + gentamicin 2 mg/kg IV
    
• Children:
  
  • Cefotetan: 20 mg/kg IV + gentamicin 2 mg/kg IV
    OR
    
  • Cefoxitin: 40 mg/kg IV + gentamicin 2 mg/kg IV
    OR
    
  • Ceftriaxone: 50 mg/kg per dose IV + Flagyl 15 mg/kg IV
    

Ceftriaxone and Flagyl or piperacillin/tazobactam or carbapenem:

• Goal is to choose broad-spectrum coverage with both aerobic and anaerobic coverage, particularly of enteric gram-negative organisms.
  

Addition of an aminoglycoside, as it has good activity in an alkaline environment:

• Particularly useful if patient is unstable for broader gram-negative coverage
  

There is no good evidence to support the use of octreotide as studies still conflict on the benefits and adverse effects.

FOLLOW-UP

• All patients with suspected pancreatic injuries must be admitted.
  
• Abdominal pain after blunt trauma requires serial exam and observation for 24–72 hr.
  
• Intoxicated trauma patient requires admission and serial exams for unidentified injury.
  

Only for very minor trauma and with no evidence of pancreatic or any other intra-abdominal injury with appropriate follow-up and return precautions

• Patient with surgical drains or complications such as fistula formation may need further surgical, GI, and wound care evaluations.
  
• Most patients need close monitoring and follow-up within 1 wk.
  

Delayed presentation of pancreatic injury is rare, but complications may arise and should be considered:

• Pancreatitis, pseudocysts, vascular aneurysms (such as splenic artery)
  
• Rare for exocrine or endocrine dysfunction to occur unless a majority of the pancreas is resected/destroyed:
  
  • Evaluate for glucose intolerance and digestive abnormalities
    

• Always consider pancreatic injury when evaluating abdominal or back trauma, both blunt and penetrating.
  
• Beware of nearby vascular injuries.
  
• Assess for related injuries.
  
• Choose the best imaging modality and obtain as rapidly as possible.
  
• Penetrating trauma or unstable patients should be rapidly prepared for surgical exploration.
  

• Ahmed N, Vernick JJ. Pancreatic injury.
  South Med J
  . 2009;102(12):1253–1256.
  
• Almaramhy HH, Guraya SY. Computed tomography for pancreatic injuries in pediatric blunt abdominal trauma.
  World J Gastrointest Surg
  . 2012;4(7):166–170.
  
• Beckingham IJ, Krige JE. ABC of diseases of liver, pancreas and biliary system: Liver and pancreatic trauma.
  BMJ
  . 2001;322:783–785.
  
• Rekhi S, Anderson SW, Rhea JT, et al. Imaging of blunt pancreatic trauma.
  Emerg Radiol
  . 2010;17(1):13–19.
  
• Vasquez JC, Coimbra R, Hoyt DB, et al. Management of penetrating pancreatic trauma: An 11-year experience of a level-1 trauma center.
  Injury
  . 2001;32(10):753–759.
  
• Wolf A, Bernhardt J, Patrzyk M, et al. The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma.
  Surg Endosc
  . 2005;19(5):665–669.
  

CODES

• 863.84 Injury to pancreas, multiple and unspecified sites, without mention of open wound into cavity
  
• 863.94 Injury to pancreas, multiple and unspecified sites, with open wound into cavity
  

BASICS

• Inflammation of pancreas due to activation, interstitial liberation, and digestion of gland by its ownenzymes
  
• Acute pancreatitis:
  
  • Exocrine and endocrine function of gland impaired for weeks to months
    
  • Glandular function will return to normal.
    
• Chronic pancreatitis:
  
  • Exocrine and endocrine function progressively deteriorates with resultant steatorrhea and malabsorption.
    
  • Dysfunction progressive and irreversible
    
• Pancreatic pseudocyst:
  
  • Cystic collection of fluid with high content of pancreatic enzymes surrounded by a wall of fibrous tissue lacking a true epithelial lining
    
  • Localized in parenchyma of pancreas or adjacent abdominal spaces (lesser peritoneal sac)
    
  • Requires 4–6 wk to form from onset of acute pancreatitis
    

• Gallstones and alcohol abuse most common causes of
  acute pancreatitis
  (75–80%)
  
• Alcohol abuse accounts for 70–80% of
  chronic pancreatitis.
  
• Acute:
  
  • Biliary tract disease
    
  • Chronic alcoholism
    
  • Obstruction of pancreatic duct
    
  • Ischemia
    
  • Medications
    
  • Infectious
    
  • Postoperative
    
  • Post-ERCP
    
  • Metabolic diseases
    
  • Trauma
    
  • Scorpion venom
    
  • Penetrating peptic ulcer
    
  • Hereditary
    
• Chronic:
  
  • Chronic alcoholism
    
  • Obstruction pancreatic duct
    
  • Tropical
    
  • Hereditary
    
  • Shwachman disease
    
  • Enzyme deficiency
    
  • Idiopathic
    
  • Hyperlipedemia
    
  • Hypercalcemia
    
• Pancreatic pseudocyst:
  
  • Complication in 5–16% of acute pancreatitis; 20–40% of chronic pancreatitis
    

Causes mainly viral, trauma, and medications

DIAGNOSIS

• Frequency:
  
  • Abdominal pain: 95–100%
    
  • Epigastric tenderness: 95–100%
    
  • Nausea and vomiting: 70–90%
    
  • Low-grade fever: 70–85%
    
  • Hypotension: 20–40%
    
  • Jaundice: 30%
    
  • Grey Turner/Cullen sign: <5%
    
  • Subcutaneous or SQ
    
• GI:
  
  • Severe, persistent epigastric pain radiating to back:
    
    • Colicky or rebound tenderness suggests nonpancreatic source.
      
    • Worse when supine
      
  • Nausea, vomiting, and anorexia
    
  • Bowel sounds usually decreased or absent
    
  • Significant GI bleed in patients with acute severe pancreatitis is uncommon.
    
  • Cullen sign:
    
    • Bluish discoloration at umbilicus secondary to hemorrhagic pancreatitis
      
  • Grey Turner sign:
    
    • Bluish discoloration at flank secondary to hemorrhagic pancreatitis
      
• Respiratory:
  
  • Pleuritic chest pain
    
  • Dyspnea
    
  • Lung exam:
    
    • Left pleural effusion (most common)
      
    • Atelectasis
      
    • Pulmonary edema
      
  • Hypoxemia (30%)
    
• Cardiac:
  
  • Tachycardia
    
  • Hypotension
    
  • Shock
    
• Neurologic:
  
  • Irritability
    
  • Confusion
    
  • Coma
    
  • Chvostek and Trousseau signs are rare despite lab evidence of hypocalcemia.
    

• Indicators of morbidity and mortality:
  
  • 0–2 criteria: 2% mortality
    
  • 3 or 4 criteria: 15% mortality
    
  • 5 or 6 criteria: 40% mortality
    
  • 7 or 8 criteria: 100% mortality
    
• Criteria on admission:
  
  • Age >55 yr
    
  • WBC count >16,000 mm
    ³
    
  • Blood glucose >200 mg/dL
    
  • Serum lactate dehydrogenase >350 IU/L
    
  • AST >250 IU/L
    
• Criteria during 1st 48 hr:
  
  • Hematocrit fall >10%
    
  • BUN increase >5 mg/dL
    
  • Serum calcium <8 mg/dL
    
  • Arterial PO
    ₂
    <60 mm Hg
    
  • Base deficit >4 mEq/L
    
  • Estimated fluid sequestration >6 L
    

Lab tests to confirm physical diagnosis