1. Chapter 4 Abdominal and Gastrointestinal Emergencies 2015 - 2016

2. Out lines 1.Introduction. 2.Physiology. 3.Function of GIT 4. Patient assessment. 5.Common gastrointestinal disease.

3. Introduction GI problems are rarely life threatening. Can lead to systemic problems if untreated. The number of disorders causing abdominal pain, diarrhea, and nausea. – May be caused by septicemia, most GI disorders are not deadly.

4. Pathophysiology of GIT System 1.Digestion begins in the mouth. – Enzymes in saliva begin the chemical breakdown of food for absorption by the body. 2.Food reaches the esophagus. – Typically collapsed, allowing air to flow into the lungs instead of the Stomach.

5. Physiology of GIT System 3.The esophagus transports food using peristalsis. 4. Food then enters the stomach. – Hydrochloric acid breaks down the food even more. – Water- and fat-soluble substances are absorbed.

6. Physiology of GI T system 5. To absorb the digested food. 1.The duodenum connects the liver, gallbladder, and pancreas to the digestive system. 2.The pancreas secretes enzymes to assist with digestion and neutralize gastric acid. 6. The liver: 1.Produces bile, which breaks down fats. 2.Promotes carbohydrate metabolism. 3.Stores vitamins and minerals.

7. Physiology of GIT System 5.The small intestine:- – Where 90% of absorption occurs – Divided into three sections: Duodenum Jejunum Ileum 6.Colon (large intestine):- – Moves undigested food (feces) to be eliminated from the body

8. Abdominal and Gastrointestinal Disorders  Acute and chronic gastrointestinal:- 1.Hemorrhage. 2.Liver disorders. 3.Peritonitis. 4. Ulcerative diseases. 5. Irritable bowel syndrome. 6. Inflammatory disorders. 7. Pancreatitis. 8. Bowel obstruction. 9. Hernias. 10. Gastrointestinal bleeding. 11. Infectious diseases, Gallbladder and biliary tract disorders. 12. Rectal abscesses. 13. Rectal foreign body obstruction.

9. Upper Gastrointestinal Bleeding (Esophagogastric) GI bleeding is a symptom, not the disease. Determine onset and medical history. Assessment Initial check ( signs and symptoms). Such as Fatigue, Jaundice, Anorexia, Abdominal pain. When blood vessels rupture: discomfort in the throat, Severe dysphagia ( difficult of swallowing), Vomiting bright red blood and Signs of shock. Caused  by pressure increases in blood vessels surrounding the esophagus and stomach.  Blood cannot easily flow through damaged liver. Blood backs up into the portal vessels

10. Upper Gastrointestinal Bleeding (Esophagogastric) Management 1. General management guidelines. Accurate assessment of blood loss 2. In-hospital treatment includes: a.Stopping the bleeding b.Establish an IV line. c.fluid resuscitation d.Possible endoscopy

11. Lower Gastrointestinal Bleeding (Anal Fissures) Assessment – Painful defecation Management – Place dressing over anus. – Do NOT pack fissure or anus.

12. Inflammation of appendix, Build-up of pressure will eventually cause the organ to rupture, resulting in: Peritonitis, Sepsis, Death. Assessment Signs and symptoms: A.Early: per umbilical pain, nausea,vomiting. B. Ripe: pain in lower right quadrant C. Rupture: decrease in pain (decrease in pressure) Evaluate for peritonitis Management Assess for septicemia. Volume resuscitation Administer pain and Ant nausea medications.

13. Early liver failure, which may be by:  Portal hypertension  Deficiencies with coagulation  decreased detoxification Assessment 1.First stage may include: Weakness and fatigue, Nausea and vomiting, Anorexia 2. 2nd stage may include: Alcoholic stools, Dark urine pallor conjunctiva, Ascites Enlarged liver.

14.  Common blood tests: 1.Alkaline phosphatase 2.Albumin 3.Bilirubin  Management I.Prehospital care should be supportive. II.Involves bleeding control and medication III.Use lower ends of medication dose range.

15. Large-Bowel Obstruction Caused by either mechanical obstruction or colon dilation. determine the location and extent of obstruction. Once located, can be easily treated. Assessment Signs and symptoms may include: Nausea and vomiting, Distended Abdomen,Absent bowel sounds, Peritonitis signs if bowel has rupture Management Same as for small bowel obstruction

16. – Most often caused by post-operative adhesions – Other causes include: Cancer Hernias Foreign bodies Assessment – Signs and symptoms may include: Cramp and intermittent abdominal pain Initial diarrhea, nausea, and vomiting Increased pressure and Constipation.

17. Management 1.Monitor blood pressure. 2. perform I.V fluid resuscitation. 3.Administer dopamine medication as needed. 4.Consider using a nasogastric tube. 5.Antiemetics are indicated ( prevent vomiting).

18. – Organ/structure into adjacent cavity – To check for an inguinal hernia: Place fingers on lower abdomen. Instruct patient to cough. Weakness in abdominal wall will present as bulging. – Caused by any condition that causes intra- abdominal pressure: Obesity, Standing for long periods, Straining during bowel movements, and Chronic obstructive pulmonary disease.

19. Assessment – Four types Reducible Incarcerated Strangulated Incisional Management – Focus on supportive measures. – Pain management – Assess for sepsis

20. Patient assessment Apply patient assessment in ( EMS) 1.Scene size-up. 2.Primary assessment. 3.History taking. 4.Secondary assessment. 5.Reassessment.

21. 1. Scene Size-Up 1.Ensure safety. 2.Look for MOI or NOI. 3.Take standard precautions. 4.Always have equipment for hygiene.

22. 2. Primary Assessment 1.Form a general impression. A.Where was the patient found? B.What is the patient’s body posture? C.Is there an odor? 2.Airway and breathing A.Patient who is vomiting may aspirate. B.Open the airway with the appropriate method. C.Remove or suction obstructions. D.Check for unusual odors.

23. Primary Assessment 3. Circulation – Assess skin color, temperature, and moisture. – Determine pulse rate. – Ensure blood pressure reading is accurate. – Take note of amount of blood. 4. Transport decision – Based on primary assessment – According patient condition.. – Choose the mode of ambulance.

24. History Taking Patients may have a history of issues. – SAMPLE helps you gather information. Changes in bowel patterns or stool. Onset of diarrhea, constipation, nausea /vomiting. Recent weight loss. Patients last meal.

25. Secondary Assessment 1. Detailed abdominal examination – Keep the muscles from flexing. – Check for skin irregularities. 2. Scars abdomen could mean: – Tumors – Hernia – Enlarged organs – Pregnancy 3.Check shape of the abdomen

26. Secondary Assessment 1.Auscultate for bowel sounds. 2.Percuss the abdomen. The upper left and upper right quadrants will sound equal. 3.Palpate the abdomen. Assess for discomfort, rigidity, and masses. 4.Check tenderness occurs when the peritoneum is irritated.

27. Secondary Assessment  Abdominal pain may indicate: 1.Trauma 2.Hemorrhage 3.Infection 4.Obstruction 5.Other serious problems  Types of pain include: 1.Visceral pain 2.Parietal pain 3.Somatic pain, and Referred pain

28. Secondary Assessment 1. If there is pain in the right upper quadrant, assess for cholecystitis ( inflammation of gall bladder). – Ask the patient to breathe out. – Palpate deeply along the upper right quadrant. – Ask the patient to inhale deeply. 2. Obtain vital signs.  Determine the blood pressure and pulse rate. Have the patient change positions and retake.  Significant blood loss may be indicated by: 10-mm Hg drop in blood pressure 10-beat increase in pulse rate

29. Circulation 1. During dehydration:- ( Fluids administration). 2. During Hemorrhage: care should be directed at maintaining perfusion of vital organs. – Maintain a blood pressure of 90 to100 mm Hg. – If blood pressure cannot be maintained, vasoactive medications may be needed. 3. Many GI diseases affect electrolyte levels. – Use blood test. 4. Ultrasonography and intra-abdominal pressure testing may also be available.

30. Reassessment 1.Routine monitoring includes: – Pulse rate, Blood pressure, Respiratory rate – Electrocardiogram and Pulse oximetry 2.Pain medication includes: as – Morphine, and Fentanyl ( analgesic medication) 3.Nausea medications include: as ( prim prime) 4.Repeat assessment: if patient’s condition suddenly changes dramatically. 5.Do not let patients eat or drink anything.

31. Reassessment 1.Airway Management:- Airway include possible aspiration or obstruction due to blood or vomitus. Make sure suction equipment is available. You may need to use a nasogastric tube. 2.Breathing:- Associated with decreased hemoglobin levels – Administer high-concentration oxygen. – Prevent aspiration. – Auscultate lung sounds.