01Approach to the Critical Patient/attcp64

Immediate priorities

›Airway and breathing threats

›Distress from peritonitis or sepsis

›Tachypnea from metabolic acidosis

›Splinting from abdominal pain

›Oxygenation status

›SpO2 < 92% on room air

›Supplemental oxygen titration

›If altered mental status with sepsis, airway protection planning

›Aspiration risk with vomiting

›Rapid sequence intubation preparation

›Circulation and sepsis threats

›Shock physiology

›SBP < 90 mmHg

›MAP < 65 mmHg

›Sepsis screening from perforation or peritonitis

›Suspected intraabdominal infection with organ dysfunction

›Lactate >= 2 mmol/l

›If septic shock, broad spectrum antibiotics within 1 hour

›Class I recommendation

›Source control planning with surgery

›Key early branching

›Uncomplicated appendicitis pattern

›Localized right lower quadrant pain

›No free air or abscess on imaging

›Complicated appendicitis pattern

›Perforation with peritonitis

›Appendiceal abscess or phlegmon

02History/hx48

Presentation pattern

›Classic syndrome

›Periumbilical pain

›Initial vague visceral pain

›Radiating to right lower quadrant

›Pain migration to right lower quadrant

›Best single historical clue for ruling in

›Localization over 12 to 24 hours

›Anorexia

›Common early symptom

›Absence lowers but does not exclude

›Associated symptoms

›Nausea and vomiting

›Typically follows pain onset

›Vomiting before pain suggests alternative

›Low grade fever

›High fever suggests perforation

›Rigors as complication marker

›Anorexia and obstipation

›Reduced bowel function

›Diarrhea in pelvic appendix

Atypical presentations and pitfalls

›Atypical pain localization

›Retrocecal appendix

›Flank or back pain

›Minimal anterior tenderness

›Pelvic appendix

›Suprapubic pain

03Physical Exam/exam51

Vitals and general

›Stability snapshot

›Temperature

›Low grade fever common

›High fever >= 39 C as perforation marker

›Heart rate

›Tachycardia from pain or sepsis

›Rising trend as deterioration marker

›Blood pressure

›SBP < 90 mmHg as shock marker

›MAP < 65 mmHg as perfusion marker

›General appearance

›Patient lying still

›Movement worsens peritoneal pain

›Knees drawn up for comfort

›Toxic appearance

›Diaphoresis

›Pallor

Abdominal exam

›Localized findings

›Right lower quadrant tenderness

›McBurney point maximal tenderness

›Best ruling-in physical sign

›Guarding and rigidity

›Voluntary guarding early

›Involuntary rigidity as peritonitis

›Rebound tenderness

›Peritoneal irritation

04Differential Diagnosis/ddx40

Life threats and surgical mimics

›Immediate threats

›Perforated appendicitis with sepsis

›ICD-10 K35.32 association

›Diffuse peritonitis

›Ruptured ectopic pregnancy

›Positive pregnancy test

›Hemodynamic instability

›Mesenteric ischemia

›Pain out of proportion

›Lactic acidosis

›Common surgical mimics

›Acute diverticulitis

›Left lower quadrant in sigmoid disease

›Cecal diverticulitis right sided overlap

›Cholecystitis

›Right upper quadrant tenderness

›Murphy sign

›Small bowel obstruction

›Distension and vomiting

›Prior surgery history

Gynecologic and urologic differentials

›Gynecologic causes

›Ovarian torsion

›Sudden severe unilateral pain

›Adnexal mass on ultrasound

›Pelvic inflammatory disease

›Cervical motion tenderness

05Laboratory Tests/lt34

Core labs

›Infection and inflammation

›Complete blood count

›Leukocytosis supports diagnosis

›Normal count does not exclude

›CRP elevation

›Adds to inflammatory picture

›Combined with WBC improves accuracy

›Neutrophil predominance

›Left shift supports inflammation

›Used in inflammatory response scoring

›Metabolic and organ function

›Electrolytes and renal function

›Dehydration from vomiting

›Baseline before contrast imaging

›Liver and lipase

›Exclude biliary or pancreatic mimics

›Right upper quadrant overlap

Pregnancy and urinalysis

›Beta hCG

›All persons of childbearing potential

›Exclude ectopic pregnancy

›Guides radiation-sparing imaging

›Urinalysis

›Pyuria from adjacent appendiceal inflammation

›Exclude urinary tract infection

›Hematuria suggests ureteric colic

06Diagnostic Tests/dt72

Scoring Systems

›Risk stratification tools

›Alvarado score

›Migratory right iliac fossa pain 1 point

›Anorexia 1 point

›Nausea or vomiting 1 point

›Tenderness right lower quadrant 2 points

›Rebound tenderness 1 point

›Elevated temperature 1 point

›Leukocytosis 2 points

›Left shift of neutrophils 1 point

›Score <= 4 low risk

›Score 5 to 6 indeterminate

›Score >= 7 high probability

›Appendicitis Inflammatory Response score

›Incorporates CRP and WBC and neutrophil percentage

›Stratifies low intermediate high risk

›Pediatric Appendicitis Score

›Validated in children

›Guides imaging versus observation

›Limitations

›Scores stratify rather than confirm

›Imaging required in indeterminate range

›Clinical trajectory supersedes single score

MRI

›MRI abdomen and pelvis role

›Preferred when ultrasound equivocal in pregnancy

›Avoids ionizing radiation

07Disposition/dispo31

Level of care selection

›Admission indications

›Confirmed appendicitis

›Surgical admission for appendectomy

›NPO and IV antibiotics

›Complicated disease

›Perforation or abscess

›Need for drainage or operation

›Sepsis or hemodynamic instability

›SBP < 90 mmHg

›Lactate >= 2 mmol/l with infection

›ICU indications

›Septic shock

›Vasopressor requirement

›Rising lactate despite resuscitation

›Severe peritonitis with organ dysfunction

›Acute kidney injury

›Respiratory compromise

Discharge and observation criteria

›Observation candidates

›Equivocal imaging with low risk score

›Serial abdominal exams

›Repeat labs and imaging if worsening

›Nonoperative management candidate

›Uncomplicated appendicitis without appendicolith

›Reliable follow up

›Follow up plan

›Surgical follow up after discharge

08Treatment/t81

Resuscitation and supportive care

›Immediate measures

›NPO status

›Pending operative decision

›Aspiration risk reduction

›Intravenous fluids

›Balanced crystalloid resuscitation

›Correct dehydration from vomiting

›Antiemetics

›Ondansetron 4 mg IV for nausea

›Reduces aspiration risk

›Pain management

›Multimodal analgesia priority

›Does not delay diagnosis or mask peritonitis

›AAFP supported approach

›Acetaminophen

›1 g IV or PO every 6 hours

›Maximum 4 g per 24 hours

›Opioids as needed

›Morphine 0.1 mg/kg IV titrated

›Reassess pain after dosing

Preoperative antibiotics

›Timing and rationale

›Administer as soon as diagnosis made

›Reduces surgical site infection

›Class I recommendation

›Single preoperative dose for uncomplicated disease

›Postoperative antibiotics not required

09Special Populations/sp40

Pregnancy

›Pregnancy considerations

›Most common nonobstetric surgical emergency

›Diagnosis challenged by displaced appendix

›Right upper quadrant pain in later gestation

›Imaging approach

›Ultrasound as initial study

›MRI when ultrasound equivocal

›CT only when benefits outweigh risks

›Antibiotic selection

›Beta lactams generally preferred

›Avoid tetracyclines and fluoroquinolones when possible

›Surgical approach

›Laparoscopic appendectomy feasible in pregnancy

›Obstetric involvement for fetal monitoring

Geriatric

›Older adult features

›Atypical presentation

›Blunted fever and leukocytosis

›Delayed presentation common

›Higher perforation rate

›Diagnostic delay contribution

›Higher morbidity and mortality

›Malignancy consideration

›Appendiceal or cecal tumor mimic

›Interval colonoscopy after nonoperative care

›Comorbidity impact

›Renal dosing adjustment

10Background/b40

Epidemiology

›Frequency and burden

›Most common reason for emergency abdominal surgery worldwide

›Annual incidence 96.5 to 100 per 100,000 adults

›Lifetime risk 7 to 8 percent

›Age distribution

›Peak incidence ages 10 to 30 years

›Occurs across all ages

›Diagnostic accuracy

›Over 90 percent with history exam labs and imaging

›Appendicolith present in approximately 25 percent

Pathophysiology

›Mechanisms

›Luminal obstruction

›Fecalith or appendicolith

›Lymphoid hyperplasia

›Progressive inflammation

›Increased intraluminal pressure

›Venous congestion and ischemia

›Bacterial proliferation

›Wall invasion

›Transmural inflammation

›Complication pathways

›Perforation with peritonitis

›Abscess and phlegmon formation

Therapeutic Considerations

›Management strategy principles

›Operative versus nonoperative decision

11Patient Discharge Instructions/pdi20

copy discharge instructions

›Appendicitis home care after treatment

›Take all antibiotics exactly as prescribed until finished

›Rest and gradually increase activity as tolerated

›Keep surgical incisions clean and dry

›Use prescribed pain medication as directed

›Warning signs to return to the ER

›Worsening or spreading abdominal pain

›Fever above 38.5 C or shaking chills

›Persistent vomiting or inability to keep fluids down

›Redness pus or swelling at the incision

›Abdominal swelling or hardness

›Fainting or feeling lightheaded

›Follow up

›Surgical follow up appointment as scheduled

›Wound check and suture or staple removal if needed

›Return promptly if symptoms recur after antibiotic-only treatment

›Recovery tips

›Avoid heavy lifting until cleared by your surgeon

›Stay hydrated and eat as tolerated

›Walk regularly to reduce clot risk

12References/r12

Guidelines and key sources

›Guideline sources

›WSES Jerusalem Guidelines 2025 diagnosis and treatment of acute appendicitis

›AAST emergency general surgery guideline summaries acute appendicitis

›American College of Surgeons gastrointestinal surgical emergencies guidance

›Key reviews and trials

›JAMA review diagnosis and management of acute appendicitis in adults 2021

›NEJM treatment of acute uncomplicated appendicitis 2021

›AAFP acute appendicitis efficient diagnosis and management 2018

›Decision tools and coding

›Alvarado score and Appendicitis Inflammatory Response score

›Pediatric Appendicitis Score

›ICD-10 K35 acute appendicitis coding family

Evidence & Review

Evidence & Review