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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies Chapter 17 Gastrointestinal and Urologic Emergencies Unit Summary Students who complete this chapter presentation and the related course work will understand the concept of the following: anatomy and physiology of the gastrointestinal, genitourinary, and renal systems. Students should be able to assess and manage various patient populations with numerous related gastrointestinal/genitourinary complaints, some of which include but are not limited to, direct or referred abdominal pain, hypoglycemia, hyperglycemia, shock related to acute (medical versus trauma) or chronic gastrointestinal disorders, hemorrhage, peritonitis, and complications related to the renal system (renal dialysis). National EMS Education Standard Competencies Medicine Applies fundamental knowledge to provide basic and selected advanced emergency care and transportation based on assessment findings for an acutely ill patient. Abdominal and Gastrointestinal Disorders Anatomy, presentations, and management of shock associated with abdominal emergencies • Gastrointestinal bleeding (p 644) Anatomy, physiology, pathophysiology, assessment, and management of • Acute and chronic gastrointestinal hemorrhage (p 644) • Peritonitis (p 642) • Ulcerative diseases (p 644) Genitourinary/Renal • Blood pressure assessment in hemodialysis patients (p 654) Anatomy, physiology, pathophysiology, assessment, and management of © 2012 Jones & Bartlett Learning, LLC (www.jblearning.com) 1
Transcript
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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

Chapter 17Gastrointestinal and Urologic Emergencies

Unit Summary Students who complete this chapter presentation and the related course work will understand the concept of the following: anatomy and physiology of the gastrointestinal, genitourinary, and renal systems. Students should be able to assess and manage various patient populations with numerous related gastrointestinal/genitourinary complaints, some of which include but are not limited to, direct or referred abdominal pain, hypoglycemia, hyperglycemia, shock related to acute (medical versus trauma) or chronic gastrointestinal disorders, hemorrhage, peritonitis, and complications related to the renal system (renal dialysis).

National EMS Education Standard Competencies

MedicineApplies fundamental knowledge to provide basic and selected advanced emergency care and transportation based on assessment findings for an acutely ill patient.

Abdominal and Gastrointestinal DisordersAnatomy, presentations, and management of shock associated with abdominal emergencies

• Gastrointestinal bleeding (p 644)

Anatomy, physiology, pathophysiology, assessment, and management of

• Acute and chronic gastrointestinal hemorrhage (p 644)

• Peritonitis (p 642)

• Ulcerative diseases (p 644)

Genitourinary/Renal• Blood pressure assessment in hemodialysis patients (p 654)

Anatomy, physiology, pathophysiology, assessment, and management of

• Complications related to

○ Renal dialysis (p 654)

○ Urinary catheter management (not insertion) (p 654)

• Kidney stones (p 646)

Knowledge Objectives1. Understand the anatomy and physiology of the gastrointestinal system. (p 639)

2. Define the term acute abdomen. (p 642)

3. Explain the concept of referred pain. (pp 642-643)

4. Understand that abdominal pain can arise from other body systems. (pp 642-643)

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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

5. Discuss the various potential causes of acute abdomen, including diverticulitis, cholecystitis, appendicitis, perforated gastric ulcer, aortic aneurysm, hernia, cystitis, kidney infection, renal calculi (kidney stone), pancreatitis, urinary tract infection (UTI), and, in women, ectopic pregnancy and pelvic inflammation. (pp 643-644)

6. Define peritonitis and list its potential signs and symptoms. (pp 642-643)

7. Describe the assessment process for patients with acute abdomen. (pp 648, 651)

8. Discuss general management of a patient with acute abdomen. (pp 652-654)

9. Describe the procedures to follow in managing a patient with shock associated with abdominal emergencies. (p 649)

10. Understand the anatomy and physiology of the renal system. (p 646)

11. Discuss the various types of urologic pathophysiology, including UTIs, kidney stones, acute renal failure, and chronic renal failure. (pp 645-646)

12. Explain the purpose of renal dialysis. (p 654)

13. Describe potential complications of dialysis or a missed dialysis treatment. (p 654)

14. Describe the assessment process for patients with urologic emergencies. (pp 645-646)

15. Discuss general management of a patient with a urologic emergency. (pp 652-654)

16. Discuss assessment and management of specific urologic emergencies, including UTIs, kidney stones, acute renal failure, and chronic renal failure. (pp 645-646)

Skills Objectives1. Demonstrate the assessment of a patient’s abdomen. (pp 645-646)

Readings and Preparation• Review all instructional materials including Chapter 17 of Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition, and all related presentation support materials.

• Provide the AEMT student with evidence-based research articles relating to various gastrointestinal/genitourinary topics. This activity helps to validate the effectiveness and necessity of the basic assessment tools the AEMT is learning to master during his or her training program.

• Review any pertinent local protocols, especially those related to the testing of suspected hypoglycemia/hyperglycemia, abdominal pain, kidney stones, and the transport destinations for patients with medical or traumatic injuries involving the gastrointestinal/genitourinary system.

Support Materials• Lecture PowerPoint presentation

• Case Study PowerPoint presentation

Enhancements• Direct students to visit the companion website to Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition, at http://www.aemt.emszone.com for online activities.

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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

• If available, see the “You Are the EMT” DVD Series. The series includes five DVDs, and one of the DVDs is about preparing to be an AEMT. Available from http://www.jblearning.com, the ISBN for this product 978-0-7637-2981-3.

• Consider using the following websites for additional learning about renal failure and dialysis:

o http://www.kidney.org/atoz/atozTopic_Dialysis.cfm

o http://www.kidney.org/kidneydisease/ckd/index.cfm

• If at all possible, set up a short clinical observation in the emergency department or in the operating room during an abdominal surgery. The experience will immensely benefit the AEMT’s understanding of the vast range of gastrointestinal/genitourinary disorders that may occur in the prehospital setting. The AEMT provider should be adequately prepared to provide basic supportive care until an ALS crew arrives on scene or until reaching the receiving hospital facility.

• Students will benefit from visiting a local dialysis clinic or hospital unit to observe the renal dialysis procedure (hemodialysis). The experience will help them understand the importance of patients complying with their treatment regimen.

Content connections: The information in Chapter 9, Patient Assessment, relates to how the AEMT should approach a patient complaining of a gastrointestinal/genitourinary problem. Because these medical conditions present in a vague manner, it is best to approach the situation with no preconceived notions about the condition of the patient.

• Remind students that abdominal emergencies can be difficult to diagnose and treatment should always begin with the ABCs. Abdominal emergencies can cause a myriad of other medical emergencies including sepsis, hypovolemic shock, electrolyte imbalance, and cardiac dysrhythmias, all of which can be life threatening.

Cultural considerations: As with any physical assessment, assessing and palpating the abdomen may be a cause for distress for some cultures, particularly if the patient is of the opposite sex of the AEMT. Good communication is important between the patient, the family, and the AEMT.

Teaching Tips• Stress that abdominal emergencies can be vague and difficult to diagnose. Have students prepare presentations (see the Unit Activities section) to highlight signs and symptoms of worsening gastrointestinal and urologic emergencies.

• Be sure you set an example of professionalism and sensitivity in approaching a patient with either a gastrointestinal or genitourinary disorder/complaint, since it may cause some embarrassment during the physical examination. Adhere to patient privacy when caring for patients of any age.

• Although there are no Skill Drills specifically designated for this chapter, be sure your students understand and can use appropriate methods for obtaining an abdominal assessment. The assessment procedure must be taught in a clear, organized way, since abdominal complaints can present in a vague manner. The AEMT must maintain a high level of suspicion while assessing and treating a patient with gastrointestinal/genitourinary disorders/complaints. A simple chief complaint of a stomachache could be the result of an underlying severe disease.

Unit Activities Writing activities: Using the links below, assign students (or pairs of students) to write a brief presentation on one aspect of gastrointestinal or urologic emergency. Alternate: Assign each

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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

student a research article based on gastrointestinal/genitourinary diseases in the infant, child, and adult populations. The article can be read and a short summary can be presented to the class during this topic discussion.

Student presentations: Assign students to research one aspect of dialysis complications or kidney failure. For a list of suggested links, refer to the Enhancements section. Have students prepare a brief (2 minute) presentation on this topic. Encourage discussion regarding the implications of this topic in prehospital management. Alternate: Ask students to create posters with information and drawings about certain gastrointestinal and genitourinary diseases. This may be the same disease they researched for the writing assignment. Posters can then be passed down from class to class.

Group activities: Student groups select one disease process from this chapter and create a diagram or other visual representation of the signs and symptoms of that disease or condition. The diagram should represent a worsening progression of signs and symptoms and highlight what the AEMT should be alert for in emergency care.

Medical terminology review: Prepare a matching activity focusing on the terminology used in the “Causes of Acute Abdomen” section within the chapter. For example:

1. Peptic Ulcer Disease _B__ A. Storage for digestive juice and waste.

2. Gallbladder _A__ B. The protective layer of mucus is eroded from the stomach and duodenum.

Visual thinking: Using a manikin, have each group attach color-coded paper shapes to the abdominal region affected by the disease, which they are presenting (either from Group Activities or Student Presentations). Alternate: Photocopy Figure 17-1 or Figure 17-2 from the text. Leave in the label lines, but leave out the labels and ask students to fill them in.

Pre-Lecture

You are the Provider“You are the Provider” is a progressive case study that encourages critical-thinking skills.

Instructor DirectionsDirect students to read the “You are the Provider” scenario found throughout Chapter 17.

• You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.

• You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper.

Lecture

I. IntroductionA. Abdominal pain is a common complaint.

1. The cause of abdominal pain is often difficult to identify, even for a physician.

B. As an AEMT:1. You do not need to determine the exact cause of abdominal pain.

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2. You should be able to recognize a life-threatening problem and act swiftly in response.3. You should remember that the patient in pain is probably anxious, requiring your skills of

rapid assessment and emotional support.

II. Anatomy and PhysiologyA. Gastrointestinal (GI) system

1. Also known as the digestive tract2. Consists of mouth and many organs

a. Abdomen has four quadrantsi. Abdominal organs can lie in more than one quadrant.

b. Solid organs i. Liverii. Spleeniii. Pancreasiv. Kidneysv. In women, ovaries

c. Hollow organsi. Gallbladderii. Stomachiii. Small and large intestineiv. Urinary bladder

3. Digestive process begins with saliva.

a. Saliva is secreted into the mouth to help lubricate food.

i. Combination of pulverizing and lubrication creates a substance that can be easily moved.

ii. Saliva also contains enzymes that begin the chemical breakdown of foods

b. Food is then swallowed and moves through the esophagus.

i. Esophagus is a muscular tube that is typically collapsed, which allows for air to easily flow into the lungs but not into the stomach

ii. Collapsed tube explains how gastric dilation and impairment of lung expansion can occur during ventilation(a) Given the choice between moving through a large tube into a large open

space (the stomach) or moving down a series of progressively smaller tubes, air will flow into the stomach.

4. Intertwined around the esophagus are veins that drain into an even more complex series of veins, which ultimately join together to form the portal vein.a. The portal vein transports venous blood from the GI tract directly to the liver for

processing of the nutrients that have been absorbed.b. If blood flow through the liver slows for any reason, the blood may back up

throughout the entire GI system.i. Pressure (even low amounts) may cause leaking or rupture of these vessels.

5. The esophagus does not absorb nutrients but rather pushes food along using peristalsis.

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a. Food travels through the diaphragm to the sphincter located at junction of esophagus and stomach.

b. Cardiac sphincter is designed to prevent food from backing up into the esophagus

6. Stomach a. Small when emptyb. Can stretch many times beyond its normal size to accommodate mealsc. Muscular organd. As food enters, stomach secrets hydrochloric acid to help break down food.e. To mix acid with food more evenly, stomach contracts.f. Material that exits the pyloric sphincter is called chyme.

7. Stomach absorbs some materialsa. Examples: water- and fat-soluble substances, such as alcohol

8. Duodenum reveals real purpose of digestive system.a. Absorb resources for use by other cells in the body

9. Duodenum a. First part of small intestine.b. Where pancreas, liver, and gallbladder connect to digestive systemc. Where active stage of absorption beginsd. Stomach releases small amounts of food into duodenum, which enables small

intestine to better manage digestion.e. Exocrine portion of pancreas secretes enzymes into duodenum that assist in digestion

of fats, proteins, and carbohydrates.f. Pancreatic juices also help neutralize gastric acids.

10. Liver a. Creates bile

i. Enzyme used by the body to help break down fats ii. Stored in the gallbladderiii. Released by duodenum where it helps emulsify fats

b. The liver affects the GI system indirectly, through carbohydrate metabolism.c. Dramatic drops in sugar glucose will cause the liver to convert fats and protein into

sugar.d. As blood flows through the liver, fat and protein metabolism continues. e. The liver also detoxifies drugs, completes the breakdown of dead red and white blood

cells, and stores vitamins and minerals. 8. Small Intestine

a. 90% of absorption occurs thereb. Three sections

i. Duodenum: Last part of upper GI systemii. Jejunum: First part of the lower GI systemiii. Ileum

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c. The small intestine produces enzymes that work with the pancreatic enzymes to turn chyme into substances that can be absorbed by the capillaries of the small intestine and move into the bloodstream.

d. Blood filled with nutrients exits the intestinal circulation and heads to the liver.i. Additional metabolism of fats and proteins takes place. ii. The blood then leaves the liver and enters the subclavian vessels. iii. Water-soluble vitamins are absorbed into the blood stream for use by the cells.

9. Large Intestinea. Substance that arrives here is no longer called chyme

i. Called feces b. The valve between the ileum and the first portion of the large intestine is called the

cecum.c. Located directly posterior to the ileocecal valve is the appendix.

i. The appendix is a blind pouch that holds small amounts of material.ii. If the feces contains too much bacteria, indigestible foreign bodies are present, or

the appendix becomes compressed or twisted, the appendix can become inflamed, resulting in appendicitis.

d. The ascending colon rises from the cecum. e. The ascending colon attaches to the transverse colon.f. The end of the colon is found near the lower left quadrant.g. The sigmoid colon aligns its most inferior portion in the center of the abdomen. h. The rectum is attached to the sigmoid colon.

i. The rectum is the last portion of the colon.i. The colon terminates at a sphincter called the anus where feces are expelled from the

body.j. The primary role of the large intestine is to complete the reabsorption of water.

i. Majority of water is reabsorbed in small intestineii. Also helps solidify digested material into formed stooliii. Failure of this portion can lead to diarrhea (soft, watery stool).

k. The colon is also the site of bacterial digestion.i. Help finish the breakdown of the chyme. ii. This produces gas as a by-product.

10. The entire digestive process takes 8-72 hours. a. Bowel movements normally range between one movement per day to one movement

every three days. b. This number varies based on types of food a person eats, amount of water consumed,

exercise level, and stress level.

B. The genital system1. Abdominal space also holds reproductive organs.2. Male reproductive system consists of:

a. Testicles

b. Epididymis

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c. Vasa deferentia

d. Seminal vesicles

e. Prostate gland

f. Penis

3. Female reproductive system consists of:

a. Ovaries

b. Fallopian tubes

c. Uterus

d. Cervix

e. Vagina

C. The urinary system1. Two main functions:

a. Acts as the body’s accounting firmi. Keeps track of electrolytes, water content, and acids of the blood

b. Acts as the blood’s sewage treatment planti. Removes metabolic wastes, drug metabolites, and excess fluids

2. Kidneys perform these functions continuously.a. Filter 200 L of blood a day

3. Urinary system consists of:a. Kidneys, which filter blood and produce urineb. Urinary bladder, which stores urine until it is released from the bodyc. Ureters, which transport urine from the kidneys to the bladderd. Urethra, which transports urine from the bladder out of the body

4. Kidneysa. Bean-shaped organs found in the retroperitoneal spaceb. Medial side is concave, which forms a cleft called hilus

i. Hilus is where ureters, renal blood vessels, lymphatic vessels, and nerves enter and leave the kidney

c. A fibrous capsule covers the kidney and protects it against infection. i. A fatty mass of adipose tissue cushions the kidney and holds it in place in the

abdomen. ii. A layer of dense fibrous connective tissue called the renal fascia anchors the

kidney to the abdominal wall.d. Once the urine enters the collecting ducts, it passes through the minor calyx, into the

major calyx, and then into the renal pelvis. e. The urine moves through the ureter (one ureter from each kidney) and is stored in the

urinary bladder.i. Most of the bladder sits in the anterior abdominal cavity.ii. When empty, the bladder collapses, and the muscular walls fold over onto

themselves.

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iii. As urine accumulates, the bladder expands and becomes pear-shaped. f. The brain exerts control over the urge to void, keeping the external urinary sphincter

contracted until conditions are favorable for urination.g. The beginning of the urethra, through which urine is expelled, sits at the inferior

aspect of the bladder.

III. PathophysiologyA. General

1. Acute abdomen is a medical term referring to the sudden onset of abdominal pain that indicates an irritation of the peritoneum.a. Peritoneum: Thin membrane that lines the entire abdominal cavity b. This condition is called peritonitis.

i. Can be caused by infection, a penetrating abdominal wound, a blunt injury severe enough to damage abdominal organs, and many diseases.

ii. In all cases, severe pain is the major symptom.iii. The major clinical signs are abdominal tenderness and distension.

2. Peritoneuma. The peritoneum consists of two membranes.b. The parietal peritoneum lines the walls of the abdominal cavity.

i. Supplied by the same nerves from the spinal cord that supply the skin overlying the abdomen.

ii. It can perceive the sensations of pain, touch, pressure, heat, and cold.(a) These sensory nerves can easily identify and localize a point of irritation.

c. The visceral peritoneum covers the surface of each of the organs in the abdominal cavity.i. Supplied by the autonomic nervous system.

(a) Stimulated when distension or contraction of the hollow organs activates the stretch receptors.

(b) This sensation is usually interpreted as colic. (i) This can be referred pain felt in the shoulder or back.(ii) Referred pain is the result of connections between the body’s two

separate nervous systems. d. Peritonitis

i. Typically causes ileus, or paralysis of the muscular contractions that normally propel material through the intestine (peristalsis).(a) When this happens, the only way the stomach can empty itself is through

emesis (vomiting).ii. Peritonitis is associated with a loss of body fluids into the abdominal cavity and

usually results from abnormal shifts of fluid into the bloodstream into body tissues.

iii. This decreases the volume of circulating blood and may eventually cause hypovolemic shock.

iv. When peritonitis is accompanied by hemorrhage, the signs of shock are most apparent.

v. Fever may or may not be present.

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(a) Patients with diverticulitis (an inflammation of small pockets in the colon) or cholecystitis (inflammation of the gallbladder) may have substantial elevations in temperature.

(b) Patients with acute appendicitis may have normal temperature until the appendix ruptures and an abscess starts to form.

3. The more common abdominal emergencies, with most common locations of direct and referred pain, are listed in Table 17-1 in the text.

B. Causes of acute abdomen1. General

a. Many organs in the abdominal cavity are covered by visceral peritoneum.b. Parietal peritoneum covers the inside aspect of the abdominal wall that forms the

abdominal cavity.c. The entire abdominal cavity normally contains a very small amount of peritoneal

fluid to bathe the organs. d. Any condition that allows pus, blood, feces, urine, gastric juice, intestinal contents,

bile, pancreatic juice, intestinal contents, bile, pancreatic juice, amniotic fluid, or other foreign materials to lie within or adjacent to the abdominal cavity can result in peritonitis and acute abdomen.

e. Even though organs such as the kidneys, ovaries, and other genitourinary structures are retroperitoneal (behind the peritoneum) they can lead to acute abdomen because they lie next to the peritoneum.

f. Nearly every kind of abdominal problem can cause acute abdomen.2. Ulcers

a. The stomach and duodenum are subjected to high levels of acidity.

i. To prevent damage, protective layers of mucus line both organs.ii. In peptic ulcer disease, the protective layer erodes, allowing acid to eat into the

organ during a period of weeks, months, or yearsb. Peptic ulcers are usually the result of:

i. Helicobacter pylori infection to the stomach

ii. Chronic use of nonsteroidal anti-inflammatory drugs

iii. Alcohol and smoking can affect severity

c. Peptic ulcers affect men and women equally but occur more frequently in geriatric population.

d. Described as burning, gnawing pain usually in the upper abdomen that subsides or diminishes after eating and then reemerges 2 to 3 hours later.

i. Pain usually presents in upper part of the abdomen or below the sternumii. For some patients, pain occurs immediately after eating

e. Nausea, vomiting, belching, and heartburn are common symptoms.i. If the erosion is severe, it can lead to gastric bleeding resulting in hematemesis

and melena.f. Some ulcers heal without intervention.g. However, complications can often occur from bleeding or perforation

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i. More serious ulcerative conditions can cause severe peritonitis and an acute abdomen.

3. Gallstones

a. Gallbladder is storage pouch for digestive juices and waste from the liver.

b. Gallstones can form and block the outlet from the gallbladder, causing pain.

i. Sometimes blockage will pass.ii. If the blockage does not pass, it can lead to severe inflammation of the

gallbladder, called cholecystitis.(a) Condition in which the wall of the gallbladder is inflamed (b) Gallbladder can rupture in severe cases, causing inflammation to spread and

irritate surrounding structures such as the diaphragm and bowel.(c) Presents as a constant, severe pain in the right upper midabdominal region

and may refer to the right upper back, flank, or shoulder(d) Pain may steadily increase for hours or come and go.(e) Symptoms commonly appear 30 minutes after a particularly fatty meal and

usually at night.(f) Symptoms include general GI distress, nausea, vomiting, indigestion,

bloating, gas, and belching.4. Pancreatitis

a. The pancreas forms digestive juices and is also the source of insulin.

b. Inflammation of the pancreas is called pancreatitis.

i. Caused by obstructing gallstone, alcohol abuse, or other diseases

c. Signs and symptoms:

i. Severe pain in upper left and right quadrants, often radiating to the back

ii. Nausea

iii. Vomiting

iv. Abdominal distention

v. Tenderness

d. Complications like sepsis or hemorrhage may occur.

i. Look for fever or tachycardia.

5. Appendicitis

a. The appendix is a small recess in the large intestine.

b. Inflammation or infection in the appendix is called appendicitis.

i. Frequent cause of acute abdomen

ii. Can cause tissues to die and/or rupture, causing an abscess, peritonitis, or shock

iii. Pain is initially more generalized, dull, and diffuse.

(a) May center in umbilical area (b) Pain later localizes to the right lower quadrant. (c) May also cause referred pain

c. Patient may report:

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i. Nausea and vomiting

ii. Anorexia (lack of appetite for food)

iii. Fever

iv. Chills

c. Rebound tenderness is a classic symptomi. Result of peritoneal irritationii. Assessed by pressing down gently and firmly on abdomen

(a) Patient will feel pain when the pressure is released.(b) Women who are pregnant may not exhibit this symptom.

6. Gastrointestinal Hemorrhage

a. Bleeding within the GI tract

i. A symptom of another disease, not a disease itself

b. Can be acute

i. May be shorter term and more severe

c. Can be chronic

i. May be longer duration and less severe

d. All complaints of bleeding should be considered serious.

e. Can occur in upper or lower GI tract

i. Bleeding in upper gastrointestinal tract occurs from the esophagus to the upper part of the small intestine.

(a) In the esophagus, problems might include esophagitis, esophageal varices, or Mallory-Weiss syndrome.

ii. Lower gastrointestinal bleeding occurs between the upper part of the small intestine and the anus.

(a) Common causes include: bowel inflammation, diverticulitis, and hemorrhoids

7. Esophagitis

a. Occurs when the lining of the esophagus becomes inflamed by infection or acids from the stomach (gastroesophageal reflux disease)

b. Patient may report pain in swallowing and complain of feeling like an object is stuck in his or her throat.

c. Additional symptoms include:

i. Heartburn

ii. Nausea

iii. Vomiting

iv. Sores in the mouth

d. In worst cases, bleeding can occur from the capillary vessels within the esophageal lining or the main blood vessels.

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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

8. Esophageal varices

a. Occur when the amount of pressure within blood vessels surrounding the esophagus increases

i. Esophageal blood vessels eventually deposit their blood into the portal system.

ii. When blood is blocked up in the portal vessels, vessels dilate, causing the capillary network of the esophagus to begin leaking.

iii. If pressure continues to build, the vessel walls may fail, causing bleeding.

b. In industrialized countries, alcohol is the main cause of portal hypertension.

c. Presentation takes two forms.

i. Initially, patient shows signs of liver disease:(a) Fatigue(b) Weight loss(c) Jaundice(d) Anorexia(e) Edema in the abdomen(f) Abdominal pain(g) Nausea(h) Vomiting

ii. This presentation is a gradual disease process, can take months to years before patient feels extreme discomfort

iii. The second presentation, rupture of varices, is far more sudden.(a) Sudden onset of discomfort in throat(b) Severe difficulty swallowing(c) Vomiting of bright red blood(d) Hypotension(e) Signs of shock(f) If the bleeding is less dramatic, hematemesis and melena are likely.

iv. Regardless of speed of bleeding, damage to these vessels can be life threatening.(a) Spontaneous rupture is often life threatening.(b) Significant blood loss at the scene may be evident.(c) Major ruptures can lead to death in a matter of minutes.

9. Mallory-Weiss Syndrome

a. Junction between esophagus and stomach tears

i. Causes severe bleeding and possibly death

b. Primary risk factors

i. Alcoholism

ii. Eating disorders

c. Affects men and women equally

i. Prevalent in older adults and older children

d. Vomiting is the principal symptom.

i. In women, this syndrome may be associated with severe vomiting related to pregnancy.

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e. Extent of bleeding can range from very minor to severe with extreme fluid loss.i. In extreme cases, patients may experience signs and symptoms of shock, upper

abdominal pain, hematemesis, and melena.10. Gastroenteritis

a. Acute infectious gastroenteritis comprises a family of conditions revolving around a central theme of infection combined with diarrhea, nausea, and vomiting.

b. Caused by bacterial or viral organisms

i. Typically enter the body through contaminated food or water

c. Patients may begin to experience an upset stomach and diarrhea as soon as several hours or several days after contact with the contaminated matter.

i. Disease can run its course in 2 to 3 days or continue for several weeks.

d. Other types of gastroenteritis are not infections.

i. However, still have hallmarks of acute infectious gastroenteritisii. Patients with this condition experience nausea, vomiting, and diarrhea.iii. Causes may include medications, toxins from shellfish, or chemotherapy.

e. Diarrhea is the principal symptom in both types.

f. Patients may experience:

i. Large dumping-type diarrhea or frequent small, liquid stools

ii. Diarrhea containing blood or pus

iii. Abdominal cramping

iv. Nausea

v. Vomiting

vi. Fever

vii. Anorexia

g. If diarrhea continues, dehydration will result.i. As fluid loss increases, so does likelihood of shock

11. Diverticulitis

a. First recognized around 1900 when the types of foods people ate change dramatically.

i. Fiber in US diet plummetedii. Amount of processed foods eaten increased

b. As amount of fiber consumed decreases, the consistency of stools became more solid, requiring more intestinal contractions, increasing pressure in colon.

c. Bulges in the colonic walls result from increased intestinal contractions.

i. These small outcroppings eventually turn into pouches called diverticula

ii. Fecal matter is caught in bulges, and bacteria form, causing localized inflammation and infection.

d. Main symptom is abdominal pain, usually on the left side if the lower abdomen.

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e. Classic signs include:

i. Fever

ii. Malaise

iii. Body aches

iv. Chills

v. Nausea

vi. Vomiting

f. Bleeding is rare.g. Adhesions may develop

i. Narrowing diameter of colonii. Results in constipation and bowel obstruction

12. Hemorrhoids

a. Created by swelling and inflammation of blood vessels surrounding rectum

i. Common problemii. Half of people have at least one by age 50

b. May result from conditions that increase pressure on the rectum or irritation of the rectum

i. Increased pressure may be caused by pregnancy, straining a stool, and chronic constipation.

ii. Diarrhea can cause irritation.

c. Often result in bright red blood during defecation

i. Minimal bleeding and easy to control

d. Patients may also experience itching and a small mass on the rectum.

i. Typically, this mass is a clot formed in response to the mild bleeding.

C. Urinary system1. Diseases and problems of the renal and urologic system can cause acute abdominal pain.

a. Conditions range from mild (urinary tract infections) to true emergencies (acute renal failure).

2. Prehospital care is usually supportive.a. Your ability to recognize signs and symptoms of true emergencies is critical.

3. Urinary tract infections (UTIs) a. Usually develop in the lower urinary tract (urethra and bladder) when bacteria enter

the urethra and growb. More common in womenc. UTI occurs in upper urinary tract (ureters and kidneys) most often when a lower UTI

goes untreated.i. Upper UTIs can lead to pyelonephritis and abscesses,ii. This eventually reduces kidney functioniii. In severe cases, untreated UTIs can lead to sepsis.

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d. Common symptoms with a lower UTI include:i. Painful urinationii. Frequent urges to urinateiii. Difficulty in urination

e. Pain usually begins as visceral discomforti. Converts to extreme burning pain, especially during urinationii. Pain remains localized in the pelvisiii. Often perceived as bladder pain in women and as prostate pain in meniv. Sometimes pain is referred to shoulder or neck

f. Additionally, urine will have a foul odor and may appear cloudy.

D. Renal system1. Kidney stones originate in the renal pelvis and result when an excess of insoluble salts or

uric acid crystallizes in the urine. a. The excess of salts is usually due to water intake that is insufficient to dissolve the

salts.b. The most common stones, calcium stones, occur more frequently in men than in

women and may have a hereditary component. i. These stones also occur in patients with metabolic disorders such as gout or with

hormonal disorders.c. People with kidney stones are almost always in severe pain.

i. The pain usually starts as a vague discomfort in the flank but becomes very intense within 30 to 60 minutes.

ii. It may migrate forward and toward the groin as the stone passes through the system.

d. Some patients will be agitated and restless as they walk and move in an attempt to relieve the pain.i. Others will attempt to remain motionless and guard the abdomen.ii. Either behavior makes palpitation of the abdomen difficult.iii. Vital signs vary depending on severity of pain

(a) Greater the pain, higher the blood pressure and pulsee. If a stone has become dislodged in the lower part of the ureter, signs and symptoms

of UTI may be present, but the patient will not have a fever.f. If a kidney stone is suspected, obtain a patient and family history.

2. Acute Renal Failure (ARF)a. A sudden decrease in kidney filtration.b. It is accompanied by an increase in toxins in the blood.c. Patients with ARF have a 50% mortality but the disease is reversible if diagnosed and

treated early.d. If the urine output drops to less than 500 mL/d, the condition is known as oliguria.e. If urine production stops completely, the condition is called anuria.f. Whenever ARF occurs, the patient may experience generalized edema, acid buildup,

and high levels of waste products in the blood.g. If left untreated, ARF can lead to heart failure, hypertension, and metabolic acidosis.

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3. Chronic Renal Failurea. A progressive and irreversible inadequate kidney function.b. Develops over months or years.c. More than half of all cases are caused by systemic diseases, such as diabetes or

hypertensioni. CRF can also be caused by congenital disorders or prolonged pyelonephritis or

can be the secondary effect of some infections, including strep throat.d. As the nephrons of the kidney become damaged and cease to function, scarring

occurs.e. As kidney function diminishes, waste products and fluid build up in the blood. f. Systemic complications can develop, such as hypertension, congestive heart failure,

anemia, and electrolyte imbalances. g. Patients with CRF exhibit several signs and systems beginning with an altered level

of consciousness. Seizures and coma are also possible.h. Patients may also present with lethargy, nausea, headaches, cramps, and signs of

anemia.i. A patient with CRF may have skin that is pale, cool, and moist.

i. Patient may appear jaundicedj. Patients may have a powdery accumulation of uric acid called uremic frost,

especially on the face. The skin may be bruised, and muscle twitching may be present.

l. Patients with CRF exhibit edema in the extremities and face because of fluid imbalances. They may also be hypotensive and have tachycardia.

m. Pericarditis and pulmonary edema are also common and should be considered during auscultation of the chest.

E. Female reproductive system1. Gynecologic problems are a common cause of acute abdominal pain.

a. Always consider that a woman with lower abdominal pain and tenderness may have a problem related to her ovaries, fallopian tubes, or uterus.

2. Pain may also be related to the normal menstrual cycle.a. Mittelschmerz is associated with the release of the egg from the ovary, but it is often

mistaken for appendicitis.i. Short-livedii. Characteristically occurs in the middle of the menstrual cycleiii. May be associated with abdominal tenderness

b. Some women experience painful cramps at the time of their menstrual periods.i. In some, the discomfort may be crippling and the menstrual flow severe.

3. A common cause of an acute abdomen in women is pelvic inflammatory disease (PID).a. PID is an infection of the fallopian tubes and surrounding tissues of the pelvis.b. Acute pain and tenderness in the lower part of the abdomen may be intense and

accompanied by a high fever.4. Ectopic Pregnancy

a. 1-2% of all pregnancies are ectopic.

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b. The fertilized egg implants outside of the uterus, usually in a fallopian tube.c. Fallopian tube can only support growth of fetus and placenta for about 6-8 weeks.d. These usually rupture, which can produce a massive internal hemorrhage and acute

abdominal pain, generally on one side.e. Acute abdomen may be associated with the onset of hypovolemic shock.

F. Other organ systems1. The aorta lies immediately behind the peritoneum on the spinal column.

a. In older people, the wall of the aorta sometimes develops weak areas that swell to form an aneurysm.

i. Aneurysm: A swelling or enlargement of a part of an artery, resulting from weakening of the arterial wall.

ii. Difficult to detect unless acutely dissecting

iii. Rarely associated with symptoms because development is slow

iv. If an aneurysm tears or ruptures, massive hemorrhage may occur with signs of acute peritoneal irritation(a) Patient may also experience severe back pain(b) Bleeding usually leads to profound shock

2. Hernias can occur.

a. A hernia is a protrusion of an organ or tissue through a hole in the body wall covering its normal site.

i. Can happen to virtually any organ or tissue in the body in certain circumstances

b. Hernias can occur as a result of:

i. A congenital defect, as around the umbilicusii. A surgical wound that has failed to heal properlyiii. Some natural weakness in an area such as in the groin

c. Hernias always produce a noticeable mass or lump that is usually easy to detect.

i. Extreme obesity may interfere with the ability to detect the mass.

d. Reducible hernias pose little risk and can be pushed back into the body cavity.

e. Incarcerated hernias cannot be pushed back in and may become seriously compressed by surrounding body tissue, eventually compromising the blood supply.

i. Strangulation of an incarcerated hernia is a serious medical emergency.a. Immediate surgery is require to remove dead tissue and repair the hernia

f. Serious hernia signs and symptoms:

i. The existence of the hernia itself

ii. A previously reducible mass that can no longer be pushed back inside the body

iii. Pain at the hernia site

iv. Tenderness when the hernia is palpated

v. Red or blue skin discoloration over the hernia

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IV. Patient AssessmentA. Scene size-up

1. Scene safety

a. Ensure scene safety.

b. Use standard precautionary gloves and eye protection.

c. Consider donning a gown and covering your shoes with disposable protective covers.

2. Mechanism of injury/nature of illness

a. Acute abdomen can be the result of violence, such as blunt or penetrating trauma.

i. Always be vigilant.

ii. If several patients complain about GI symptoms, suspect a release of a biologic or chemical agent.

3. Chapter 29, Abdominal and Genitourinary Injuries, discusses abdominal traumatic injuries.

B. Primary assessment1. Form a general impression

a. Look for these signs of acute abdomen:i. Local or diffuse abdominal pain and/or tendernessii. A quiet patient who is guarding the abdomeniii. Rapid and shallow breathingiv. Referred (distant) painv. Anorexia, nausea, and vomitingvi. Hematemesis (bright red or coffee ground emesis)vii. Tense, often distended abdomenviii.Sudden constipation or bloody diarrheaix. Dark, tarry stools (melena)x. Painful or frequent urinationxi. Discolored urine accompanied by a strong odorxii. Tachycardiaxiii.Hypotensionxiv.Fever

b. A patient with urologic or renal problems may exhibit extremes of activity. i. Observe the patient’s movement and position.ii. If you find any life-threatening conditions, take immediate steps to correct them.

c. It is not critical for you to determine the cause of acute abdomen but to recognize potential causes and provide the correct supportive care.

d. Closely examine the location where the patient is found because it can provide hints about what happened.

e. One aspect of the general impression that is different for GI patients is odor. i. Upper GI bleeding produces a very foul odor.

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ii. AEMTs are advised to hold their ground. iii. After 2 to 5 minutes, the smell may be barely noticeable.

2. Airway and breathinga. Airway patency becomes a pertinent concern with a GI patient.b. A patient who is vomiting has a greater chance of aspirating.c. For patients who are awake and responsive, positioning is the key to maintaining a

patent airway.d. In patients who have an altered mental status, open the airway using the appropriate

maneuvers and inspect it for foreign bodies. i. Remove or suction any obstructions that are found.

e. Evaluate any odors coming from the mouth.i. Patients with advanced bowel obstructions can have feculent breath.

f. GI problems rarely affect breathing directly.i. Breathing problems typically stem from severe complications.

g. Ensure the airway is clear.i. If the patient has aspirated, it can affect his or her ability to oxygenate and

ventilate. ii. Patient may show shallow or inadequate respirations because deep breaths often

intensify pain.3. Circulation

a. The assessment of the circulatory system is essential in understanding how the GI issue is affecting the body.

b. Assess skin color, temperature, and condition.c. Determine the heart rate.d. Evaluate the peripheral pulses, and compare them with the central pulse.e. Assess for major bleeding.

i. Pulse rate and quality, as well as skin condition, may indicate shock.f. Many GI diseases involve pain and/or hemorrhage.

i. As blood volume begins to drop, the body tries to compensate by releasing epinephrine and norepinephrine.(a) These agents attempt to stabilize blood pressure through vasoconstriction,

increased heart rate, and increased force of left ventricular contraction. ii. Pain triggers similar responses.iii. Either problem can leave the patient with tachycardia; diminished peripheral

pulses; diaphoresis; and pale, cool, clammy skin.g. Evaluate for shock.

i. Shock may be caused by hypovolemia or may be the result of a severe infection (sepsis).

ii. If evidence of shock is present, interventions should include high-flow oxygen, keeping the patient warm, and placing the patient in a position dictated by local protocol.

h. Ensure that you provide prompt treatment for life threats, and do not delay in providing transport.

i. Check the patient’s blood pressure.

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i. Obtain a manual pressure before you use one of the automated blood pressure machines.

j. Orthostatic vital signsi. Help determine the extent of breathing that has occurred.

(a) Have the patient assume a position of comfort (usually seating or lying down).

(b) Take an accurate blood pressure and heart rate.(c) Using caution to avoid loss of consciousness, have the patient change

positions and repeat measurements after a minute or two.(d) Normal patients will show little change in measurements with positional

changes. (e) When a patient has a significant loss of fluid within the vascular space, there

may be a 10-beat increase in the heart rate and/or a 10–mm Hg drop in blood pressure.

(f) A decrease in a patient’s blood pressure while sitting up from a lying position or when standing up from a sitting position is called orthostatic hypotension.

k. When you examine a patient with a GI problem for gross bleeding, it is not unusual to find large amounts of blood. i. Take note of the amount of blood loss, focusing on being accurate.ii. Emotional reactions to blood loss could lead people to overestimate volume lost.iii. Amount of blood in a toilet is difficult to estimate owing to dilution.iv. Practice volume estimation by pouring amounts of water you have measured onto

various surfaces, noting the size of the puddle.4. Transport decision

a. When making transport decision, integrate information from primary assessment.

b. Certain patients should be packaged quickly transported rapidly, including:

i. Patients with ABC problems, including problems with pulse and perfusion.ii. Patients with suspected internal bleeding.iii. Patients with a poor general impression, especially pediatric and geriatric

patients.iv. Patients showing other signs of significant illness

(a) Pale, cool, diaphoretic skin(b) Tachycardia(c) Hypotension(d) Altered level of consciousness

c. Ensure that the ride is as gentle as possible.i. Drive smoothly and steadily.

C. History taking1. Investigate chief complaint

a. Pain is often an important finding in patients with GI problems, because it can indicate trauma, hemorrhage, infection, or obstruction.

b. Use OPQRST (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Timing of pain) to elaborate on the chief complaint.

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c. In patients with a urologic problem, the patient history and physical examination will provide the information needed to manage the patient.

2. SAMPLE Historya. The SAMPLE history will help elicit the relevant current and past medical history.b. You often need to discuss subjects that are not commonly described with everyday

language.i. Make sure you and your patient have a common frame of reference.

c. Ask the following questions specific to the signs and symptoms of a GI or urologic emergency: i. Nausea and vomiting.ii. Changes in bowel habits.iii. Urinationiv. Weight lossv. Belching or flatulencevi. Painvii. Other signs and symptoms related to this complaint, such as “Are there any

changes you have noted recently that may be contributing to your pain?”viii.Concurrent chest pain

(a) If chest pain is reported, use OPQRST,d. Very important to ask female patients about their last menstrual period.e. All patients should be asked about their last oral intake.

i. Do not give the patient anything by mouth.f. All patients should be asked about the events leading up to the injury/illness.

i. Determine whether this is a medical emergency or related to trauma.g. Even if the SAMPLE history does not affect the interventions you perform, it is very

helpful to the physician in the emergency department.

D. Secondary assessment1. Performed at the scene for patient in stable condition with isolated complaint or in the

back of the ambulance en route to the hospital.

a. Time may not permit a secondary assessment if you have to manage life threats identified during the primary assessment.

b. Positioning of the patient may give clues to the nature of illness.

i. Example: A patient with appendicitis may draw up the right knee.

ii. Example: A patient with pancreatitis may lie curled up on one side.

2. Physical examinations

a. Normal abdomen is soft and not tender to the touch.

b. Pain and tenderness are most common symptoms of an acute abdomen.

i. Pain may be sharply localized or diffuse and will vary in severity.

ii. Localized pain may give clues to problem organ or area causing it.

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iii. In some cases, muscles of the abdominal wall may become rigid involuntarily to prevent abdomen from further irritation.

(a) This boardlike muscle spasm is called guarding.(b) Can be seen with major problems such as a perforated peptic ulcer or

pancreatitis

c. Patient with peritonitis usually has abdominal pain, even when lying quietly.

i. Patient can be quiet but have difficulty breathing and may take rapid, shallow breaths

ii. Usually, you will find tenderness on palpation of the abdomen or when the patient moves.

iii. Degree of pain and tenderness is usually related directly to the severity of peritoneal inflammation

d. The following steps will help in the abdominal assessment:

i. Explain assessment procedures to patient.

ii. Place patient in supine position with legs drawn up and flexed at the knees, unless trauma is involved.

(a) Trauma patient should remain supine and stabilized.(b) Determine if patient is restless or quiet and whether motion causes pain.

iii. Expose and visually assess abdomen.

iv. Ask the patient where the pain is most intense.

(a) Palpate in a clockwise direction beginning with the quadrant after the one the patient indicates is tender or painful

(b) End with quadrant patient indicates is tender or painful (c) If you palpate the most painful area fist, patient may guard against further

examination

v. Palpate the abdomen very gently.

(a) If you see a pulsating mass, do not touch it.

vi. Gently palpate all four regions of the abdomen to determine softness or guarding.

vii. Note whether the pain is localized or widespread.

viii.Look for patient response after palpating.

(a) Do not ask “Does it hurt here?” as you palpate.

ix. Determine whether the patient exhibits rebound tenderness.

(a) Indicator of peritonitis(b) Use extreme caution

x. Determine whether the patient can relax the abdominal wall on command.xi. Guarding and rigidity may be detected.

3. Vital signs

a. High respiratory rate with a normal pulse rate and blood pressure may indicate improper ventilations.

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b. High respiratory rate and pulse rate with signs of shock (such as pallor and diaphoresis) may indicate septic or hypovolemic shock.

4. Monitoring Devicesa. When available, use pulse oximetry and noninvasive blood pressure devicesb. Always assess the patient’s first blood pressure manually with a sphygmomanometer

(blood pressure cuff) and stethoscope.

E. Reassessment1. Because it is often difficult to determine the cause of an acute abdominal emergency,

frequent reassessment is extremely important.a. Condition can change rapidly from stable to unstable.

2. Vital signs must be reassessed and compared with patient’s baseline vital signsa. If anything changes en route, manage the problem and document changes or

additional treatment.3. Reassess the patient and then ask and answer the following questions (as appropriate):

a. Has the patient’s level of consciousness changed?

b. Has the patient become more anxious?

c. Have the skin signs begun to change?

d. Has the pain gotten better or worse?

e. Has bleeding become worse or better?

f. Is current treatment improving the patient’s condition?

g. Has an already identified problem gotten better?

h. Has an already identified problem gotten worse?

i. What is the nature of any newly identified problems?

2. Interventionsa. The goal of reassessment is to monitor the patient for changes en route to the

hospital.b. Routine monitoring should include heart rate, blood pressure, respiratory rate, and

pulse oximetry.c. If the patient has GI bleeding, continue to assess for signs of shock.d. If patient had signs of GI bleeding, continue to assess for signs for shock. e. Determine what effect your treatment is having.f. Before giving additional fluid boluses, listen to the patient’s lung sounds to determine

whether adult pulmonary edema is developing.g. If the patient wants to lie on his or her side, try to make that possible. h. Be sure to observe and maintain the patient’s airway. i. Be sure to call for paramedic backup if the patient’s condition becomes unstable.j. If rapid transport is needed, consider air medical transport if available.k. Patients with urologic emergencies, especially those with signs and symptoms of

renal failure, need reassessment.

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i. Electrolyte imbalances can cause major, rapid changes in the functioning of the body’s organs.

ii. Serial vital signs should be obtained and documented on the prehospital care report, at least every five minutes in cases of possible renal failure.

iii. Note any trends in the vital signs and level of consciousness because they can be indicators of disease progression.

iv. Patients with suspected urologic diseases should not be given anything by mouth. l. If the patient’s condition undergoes a sudden, dramatic change, repeat the rapid and

detailed assessments as if it were a new patient. 3. Communication and documentation

a. Communicate with the receiving hospital early to allow the hospital staff to recruit the resources necessary to treat your patient upon arrival.

b. Carefully document your findings in your patient care report.

c. Relay all relevant information to the receiving physician or nurse, including:

i. Updated vital signsii. Changes in the patient’s LOCiii. Any new or worsening complaints

V. Emergency Medical CareA. The signs and symptoms of an acute abdomen signal a serious medical or

surgical emergency.

B. Provide prompt, gentle transport; do not delay transport.

C. Carry out these steps as quickly as possible before transport:1. Do not attempt to diagnose the cause of acute abdomen.2. Clear and maintain the airway.3. Anticipate vomiting; place the patient in the recovery position or position of comfort.4. Administer 100% supplemental oxygen, and be prepared to assist ventilation if the

patient has reduced tidal volume.5. Do not give the patient anything by mouth.6. Document all pertinent information. Use OPQRST.7. Anticipate the development of hypovolemic shock.

a. Monitor blood pressureb. Treat the patient for shock when it is evident.

8. Establish IV access. Give a 20-mL bolus of an isotonic crystalloid if the patient presents with signs of hypovolemia. Otherwise, maintain fluid at a keep-vein-open rate. If patient has a UTI or kidney stone and kidney function is present, administer a bolus of fluid.

9. For transport, place the patient in a position of comfort, usually with the legs bent. Conserve body heat with blankets, as needed. Provide gentle but rapid transport and constant psychological support.

10. Monitor vital signs; these may change quickly.11. Consider calling for paramedic backup.

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B. PID1. With PID, acute pain and tenderness in the lower part of the abdomen may be intense and

accompanied by a high fever. 2. If you suspect PID, transport patient to the emergency department immediately.

C. Combination of acute abdominal pain and hypovolemic shock1. Consider an ectopic pregnancy in any female of childbearing age who presents with acute

abdominal distress, especially in the presence of hypotension.

D. Pneumonia1. May cause both ileus and abdominal pain. 2. Problem lies in the adjacent body cavity, but the inflammatory response affects the

abdomen. 3. Treat and transport as you would any other patient with abdominal pain.

E. Acute signs and symptoms with shock1. Could signify an aneurism and requires prompt transportation.2. Avoid unnecessary and vigorous palpation of the abdomen. 3. Administer fluid only if patient is hypotensive and symptomatic.

F. Hernia1. With any signs and symptoms of a hernia, transport promptly to the emergency

department.

G. ARF and CRF1. Can lead to life-threatening emergencies.2. Support of ABCs is imperative3. Be alert for possibility of hypotension or pulmonary edema.

a. Medications to regulate acidosis and electrolyte imbalance and fluids for volume regulation may be required.

4. Emergency transport and supportive care are preferred over aggressive management.

VI. Renal DialysisA. In chronic cases of CRF, renal dialysis is the only definitive treatment.

1. Dialysis is a technique for “filtering” toxic wastes from the blood, removing excess fluid, and restoring the normal balance of electrolytes. a. Renal dialysis and problems associated with it may require prehospital interventions.

2. There are two types of dialysis: peritoneal dialysis and hemodialysis.a. In peritoneal dialysis, large amounts of specially formulated dialysis fluid are infused

into (and back out of) the abdominal cavity. i. Fluid stays in cavity for 1 to 2 hoursii. Very effective, but high risk of peritonitisiii. With proper training, can be performed in the home

b. In hemodialysis, the patient’s blood circulates through a dialysis machine that functions much like normal kidneys.

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i. Most patients undergoing long-term hemodialysis have some sort of shunt.ii. Shunt: A surgically created connection between a vein and an artery that is

usually located in the forearm or upper armiii. Patient connected to dialysis machine through this shunt.

3. Patients requiring long-term dialysis usually go “on the machine” every 2 or 3 days for a period of 3 to 5 hours.a. If a problem with the machine occurs, the patient may know a lot more about it than

you do, so always ask what the patient has done before your arrival.4. Adverse effects and complications of dialysis include:

a. Hypotension

b. Muscle cramps

c. Nausea and vomiting

d. Hemorrhage from the access site

e. Infection at the access site

f. Altered mentation, loss of consciousness

g. Air embolism

h. Electrolyte imbalance

i. Myocardial ischemia

5. Sudden drop in blood pressure is not uncommon during or immediately after dialysisa. Can lead to cardiac arrest if not promptly detected and treatedb. Patient may feel lightheaded or become confused, and may yawn more than usual.c. Electrolyte imbalance may develop

i. Consider possibility of cardiac arrhythmias and the need for ALS backup.d. Shock secondary to bleeding is also possible from any number of causes.

6. If a patient misses a dialysis treatment, weakness, pulmonary edema, or excesses of electrolytes may develop.

7. If your call involves a patient receiving dialysis, start with the ABCs.a. Provide high-flow oxygen, and manage any bleeding from the access site. b. Position the patient sitting up in cases of pulmonary edema or supine if the patient is

in shock.c. Transport promptly.

8. When you find a shunt leaking during the dialysis cycle, see if you can tighten the connection. a. If it has become disconnected at the vein, clamp the cannula and disconnect the

patient from the machine. b. In a suicide attempt, the patient may open up the cannula. c. If you encounter this situation, immediately clamp off the cannula and apply direct

pressure.9. Many dialysis patients also have urinary catheters.

a. Catheter is placed in the bladder so the urine can run into a bag.

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b. Catheters can often be a source of infection.

i. Patient may report fever and general malaise in addition to symptoms specific to kidney failure.

ii. Leave device in place.iii. Treat signs and symptoms and transport for further evaluation.

10. During transport, unless there is a life-threatening event, make all attempts to deliver the patient to a hospital with dialysis capability.

IX. Summary A. The gastrointestinal (GI) system is also known as the digestive tract. It consists

of the mouth and many organs and is divided into four quadrants.

B. The main function of the GI system is to absorb resources for use by other cells in the body.

C. The digestive process begins with saliva to lubricate food. Once food is swallowed, it moves through the esophagus via rhythmic contractions called peristalsis.

D. Veins intertwine around the esophagus and join together to form the portal vein, which transports blood from the GI tract to the liver. If blood flow through the liver slows, blood may back up throughout the entire GI system.

E. The stomach can stretch many times beyond its normal size. The stomach secretes hydrochloric acid to help break down food. The material then moves into the duodenum, the first part of the small intestine.

F. The duodenum is where the active stage of absorption begins. The pancreas and liver secrete enzymes and bile, respectively, which ultimately assist digestion in the small intestine.

G. The liver also converts glycogen into glucose, the essential and only fuel source for brain cells. The liver also detoxifies drugs, completes the breakdown of dead red and white blood cells, and stores vitamins and minerals.

H. The small intestine is divided into the duodenum (mentioned earlier), the jejunum, and the ileum. The small intestine produces enzymes that turn digested food into substances that can be moved into the bloodstream.

I. The large intestine, or colon, is the next step in the digestive process. The primary role of the large intestine is to complete the reabsorption of water. The colon is also the site of digestion by bacteria, which helps to finish the breakdown of chyme.

J. The genitourinary system includes the kidneys, urinary bladder, ureters, urethra, male and female reproductive organs, and specific structures within the kidneys.

K. Many abdominal organs are covered by a membrane called the peritoneum. Any condition that allows pus, blood, feces, urine, gastric juice, intestinal contents, bile, pancreatic juice, amniotic fluid, or other foreign material to lie within or

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adjacent to this membrane in the abdominal cavity can cause peritonitis and, thus, an acute abdomen.

L. Nearly every kind of abdominal problem can cause an acute abdomen.

M. Acute abdomen can be caused by GI or renal sources, diverticulitis, cholecystitis, appendicitis, perforated gastric ulcer, aortic aneurysm, hernia, cystitis, kidney infection, kidney stone, pancreatitis, urinary tract infection, and, in women, ectopic pregnancy and pelvic inflammation.

N. Peritonitis typically causes ileus—paralysis of peristalsis—and ultimately abdominal distention. In this situation, nothing that is eaten can pass normally out of the stomach or through the bowel. The only way the stomach can empty itself, then, is by emesis, or vomiting. Therefore, peritonitis is almost always associated with nausea and vomiting.

O. Peritonitis can lead to hypovolemic shock.

P. Symptoms of urinary tract infection include painful urination, frequent urges to urinate, difficulty urinating, and possibly referred pain to the shoulder or neck. The urine may have a foul odor and be cloudy.

Q. Kidney stones result when an excess of insoluble salts or uric acid crystallizes in the urine. Symptoms include severe pain in the flank that may migrate forward to the groin.

R. Acute renal failure is a sudden decrease in kidney filtration, resulting in a release of toxins into the blood. Chronic renal failure is progressive and irreversible inadequate kidney function.

S. Gynecologic problems are a common cause of acute abdominal pain. Always consider that a woman with lower abdominal pain and tenderness may have a problem related to her ovaries, fallopian tubes, or uterus.

T. Abdominal pain may stem from other organ systems. If an abdominal aortic aneurysm ruptures, massive hemorrhage may occur and signs of acute peritoneal irritation will present. A hernia (protrusion of an organ or tissue through a hole in the body) may eventually compromise blood supply, causing a serious emergency.

U. Transport patients with an acute abdomen promptly but gently.

V. Remember that GI complaints often involve body substances. Take extra gloves, masks, gowns, and other protective equipment and supplies with you to the scene.

W. In a patient with an acute abdomen, the first priorities are to assess airway, breathing, and circulation and then apply oxygen.

X. When taking the patient’s history, ask when the symptoms began, how they have changed, the exact location of the pain, and how it feels. Also ask if there has been vomiting or diarrhea.

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Y. Remember airway concerns with a patient who is vomiting. Open the airway using the appropriate maneuvers, and closely inspect it for foreign bodies. Remove or suction any obstructions that are found.

Z. Abnormal abdominal assessment findings include excessive nausea/vomiting or hematemesis, changes in bowel habits/stool, painful or frequent urination that is discolored or has a strong odor, weight loss, belching/flatulence, concurrent chest pain, and abdominal pain, tenderness, guarding, or distention.

AA. Pain is commonly located directly over the inflamed area of the peritoneum, or it may be referred to another part of the body. Referred pain occurs because of the connections between the two different nervous systems supplying the parietal peritoneum and the visceral peritoneum.

BB. A healthy or normal abdomen should be soft and not tender. The pain in an acute abdomen may be sharply localized or diffuse and will vary in severity. Localized pain gives a clue to the problem organ or area causing it. The abdominal muscles may have become rigid, called guarding.

CC. Take vital signs, and gently palpate the abdomen. If the abdomen is tender, the patient needs to be transported urgently.

DD. Note the degree of abdominal distention; this can also provide clues to the severity of the patient’s condition.

EE. Patients with acute abdomen may be comfortable only when lying in one particular position, for example curled up on one side or with the right knee drawn up. Note the patient’s position.

FF. Do not give the patient with an acute abdomen anything by mouth.

GG. Establish IV access. Consult with medical control to administer pain medication.

HH. Renal dialysis is a procedure for removing toxic wastes and excess fluids from the blood. Patients receiving dialysis usually have a shunt through which they are connected to the dialysis machine. They are vulnerable to problems such as hypotension, potassium imbalance, disequilibrium syndrome, and air embolism.

Post-LectureThis section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities.

Assessment in ActionThis activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of AEMT knowledge.

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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

Instructor Directions1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the

end of Chapter 17.

2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity.

3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper.

Answers to Assessment in Action Questions1. Answer: A. acute cholecystitis.

Rationale: Acute cholecystitis is the medical term for an inflammation of the gallbladder.

2. Answer: D. right shoulder.Rationale: Acute cholecystitis may cause referred pain to the right shoulder because the autonomic nerves serving the gallbladder lie near the spinal cord at the same anatomic level as the spinal sensory nerves that supply the skin of the shoulder.

3. Answer: A. VisceralRationale: Visceral pain originates in the hollow organs because of the organ contracting too forcefully or becoming distended.

4. Answer: B. Renal calculiRationale: Renal calculi (kidney stones) originate in the renal pelvis and result when an excess of insoluble salts or uric acid crystallizes in the urine. This excess of salts is typically due to water intake that is insufficient to dissolve the salts. The calculi consist of different types of chemicals, depending on the precise imbalance in the urine.

5. Answer: C. Decreased frequency of urinationRationale: Patients with a UTI typically present with painful urination and difficulty in urination. In addition, patients with UTIs typically have an increase in the frequency of urination.

6. Answer: B. FalseRationale: False. The quadrant in which the patient is experiencing pain should be palpated last. If the painful quadrant is palpated first, the patient may reflexively guard the remaining quadrants and have increased anxiety.

Additional Questions7. Answer: B. Parietal peritoneum

Rationale: The parietal peritoneum lines the walls of the abdominal cavity; the visceral peritoneum covers the surface of each of the organs in the abdominal cavity.

8. Answer: B. Right lower quadrantRationale: When a patient is experiencing a ruptured or dissecting abdominal aortic aneurysm, pain is typically felt in the right lower quadrant, and there is often referred pain into the lower back.

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AssignmentsA. Review all materials from this lesson and be prepared for a lesson quiz to be

administered (date to be determined by instructor).

B. Read Chapter 18, Endocrine and Hematologic Emergencies, for the next class session.

Unit Assessment Keyed for Instructors1. Rhythmic contractions that push food along the esophagus are called?

Answer: Peristalsis

p 639

2. A severe, intermittant cramping pain occuring in the abdominal cavity is called?

Answer: Colic

p 642

3. A hernia is a protrusion of an organ or tissue through a hole in what?

Answer: Body wall covering

p 647

4. Why might a patient with abdominal pain have a high respiratory rate and a normal pulse rate?

Answer: This may indicate that the patient is unable to ventilate proprerly because deep breathing causes pain.

p 651

5. What are some complications and adverse effects of dialysis?

Answer: Hypotension, muscle cramps, nausea and vomiting, hemorrhage, infection, altered mentation, air embolism, electrolyte imbalance, and myocardial ischemia.

p 654

6. In pediatric patients, the intra-abdominal organs are relatively large, making them vulnerable to which type of trauma?

Answer: Blunt trauma

p 652

7. When palpating the abdomen, which side should the AEMT begin with?

Answer: The AEMT should begin with the side opposite from the site of pain.

p 650

8. Between 1% and 2% of all pregnancies are __________.

Answer: Ectopic

p 647

9. The primary risk factors for Mallory-Weiss syndrome are?

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Answer: Alcoholism and eating disorders

p 645

10. Pain from acute pancreatitis often refers to which part of the body?

Answer: Back

p 644

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Advanced Emergency Care and Transportation of the Sick and Injured, Second Edition Chapter 17: Gastrointestinal and Urologic Emergencies

Unit Assessment 1. Rhythmic contractions that push food along the esophagus are called?

2. A severe, intermittant cramping pain occuring in the abdominal cavity is called?

3. A hernia is a protrusion of an organ or tissue through a hole in what?

4. Why might a patient with abdominal pain have a high respiratory rate and a normal pulse rate?

5. What are some complications and adverse effects of dialysis?

6. In pediatric patients, the intra-abdominal organs are relatively large, making them vulnerable to which type of trauma?

7. When palpating the abdomen, which side should the AEMT begin with?

8. Between 1% and 2% of all pregnancies are __________.

9. The primary risk factors for Mallory-Weiss syndrome are?

10. Pain from acute pancreatitis often refers to which part of the body?

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