Presentation on theme: "Chapter 20 Abdominal and Gastrointestinal Emergencies."— Presentation transcript:
Chapter 20 Abdominal and Gastrointestinal Emergencies
National EMS Education Standard Competencies Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.
National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, presentations, and management of shock associated with abdominal emergencies −Gastrointestinal bleeding
National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of −Acute and chronic gastrointestinal hemorrhage −Liver disorders −Peritonitis −Ulcerative diseases −Irritable bowel syndrome
National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of −Inflammatory disorders −Pancreatitis −Bowel obstruction −Hernias
National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of −Infectious diseases −Gallbladder and biliary tract disorders −Rectal abscesses −Rectal foreign body obstruction −Mesenteric ischemia
Introduction GI problems are rarely life threatening. −Can lead to systemic problems if untreated
Introduction The number of disorders causing abdominal pain, diarrhea, and nausea is high. −With the exception of septicemia, most GI disorders are not deadly.
Introduction Behaviors and characteristics may predispose some people to GI disorders.
Anatomy and Physiology Digestion begins in the mouth. −The chewing process is called mastication. −Enzymes in saliva begin the chemical breakdown of food for absorption by the body.
Anatomy and Physiology Food reaches the esophagus. −Typically collapsed, allowing air to flow into the lungs instead of the stomach −Dilates when food or liquid travels through it Explains gastric distention during positive-pressure ventilation
Anatomy and Physiology The esophagus transports food using peristalsis. The portal vein is intertwined around the esophagus. −Transports venous blood to the liver.
Anatomy and Physiology Food travels through the diaphragm to the cardiac sphincter. −Connects the esophagus and the stomach −Controls amount of food that moves up the esophagus
Anatomy and Physiology Food then enters the stomach. −Hydrochloric acid breaks down the food even more. −Chyme exits the pyloric sphincter. −Water- and fat- soluble substances are absorbed.
Anatomy and Physiology The main function of the GI system is to absorb the digested food. −The duodenum connects the liver, gallbladder, and pancreas to the digestive system. −The pancreas secretes enzymes to assist with digestion and neutralize gastric acid.
Anatomy and Physiology The liver: −Produces bile, which breaks down fats −Promotes carbohydrate metabolism −Detoxifies drugs −Completes the breakdown of dead blood cells −Stores vitamins and minerals
Anatomy and Physiology The small intestine −Where 90% of absorption occurs −Divided into three sections: Duodenum Jejunum Ileum
Anatomy and Physiology Colon (large intestine) −Moves undigested food (feces) to be eliminated from the body
Anatomy and Physiology The main role of the large intestine is to complete the reabsorption of water. Bacterial digestion also occurs in the colon. The journey from mouth to anus takes 8 to 72 hours.
Scene Size-Up Ensure safety. Look for MOI or NOI. Take standard precautions. Always have equipment for hygiene.
Primary Assessment Form a general impression. −Where was the patient found? −What is the patient’s body posture? −Is there an odor?
Primary Assessment Airway and breathing −Patient who is vomiting may aspirate. −Open the airway with the appropriate method. −Remove or suction obstructions. −Check for unusual odors
Primary Assessment Circulation −Assess skin color, temperature, and moisture. −Determine pulse rate. −Ensure blood pressure reading is accurate. −Take note of amount of blood.
Primary Assessment Transport decision −Based on primary assessment −If positive orthostatic vital signs, carefully consider how to move the patient. −Choose the mode of ambulance.
History Taking Patients may have a history of issues. −SAMPLE helps you gather information. Changes in bowel patterns or stool Onset of diarrhea, constipation, or nausea/vomiting Recent weight loss Patient’s last meal
Secondary Assessment Rebound tenderness occurs when the peritoneum is irritated. −Once a tender area is found: Depress the skin with your fingertips 2" to 4". Quickly pull your fingers off the abdomen. −An alternative is the Markle heel drop test.
Secondary Assessment If there is pain in the right upper quadrant, use Murphy sign to assess for cholecystitis. −Ask the patient to breathe out. −Palpate deeply along the upper right quadrant. −Ask the patient to inhale deeply. −Sharp increase in pain: positive Murphy sign
Secondary Assessment Obtain orthostatic 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
Secondary Assessment Many GI diseases affect electrolyte levels. −Use a handheld blood analyzer to test. Ultrasonography and intra-abdominal pressure testing may also be available.
Emergency Medical Care Repeat assessment if patient’s condition suddenly changes dramatically. Do not let patients eat or drink anything.
Airway Management Airway concerns include possible aspiration or obstruction due to blood or vomitus. −Place patient so material can drain from mouth. Make sure suction equipment is available. You may need to use a nasogastric tube.
Circulation Concerns: dehydration and hemorrhage −Fluids depend on circulatory perfusion status. Hypotonic solution for stable conditions Isotonic solution for profound dehydration
Circulation Hemorrhaging care should be directed at maintaining perfusion of vital organs. −Titrate fluids to a blood pressure of 90 to 100 mm Hg. −If blood pressure cannot be maintained, vasoactive medications may be needed.
Specific Abdominal and Gastrointestinal Emergencies The paramedic must have an understanding of many conditions. −In the future, paramedics may be asked to help determine where a patient should be directed. −The more you understand, the more you can educate patients.
Specific Abdominal and Gastrointestinal Emergencies
Hypovolemia can be caused by: −Dehydration from vomiting and/or diarrhea Electrolyte levels are affected during this process.
Specific Abdominal and Gastrointestinal Emergencies Hypovolemia can be caused by (cont’d): −Hemorrhage Potential to be fatal Signs of shock are typically present. Drop in blood pressure indicates significant volume loss
Gastrointestinal Bleeding GI bleeding is a symptom, not the disease. −Determine onset and medical history. −Treatment includes: Fluid resuscitation Establish an IV line.
Upper Gastrointestinal Bleeding: Esophagogastric Varices Pathophysiology −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.
Upper Gastrointestinal Bleeding: Esophagogastric Varices Assessment −Initial presentation Fatigue Jaundice Anorexia Pruritus Abdominal pain −When the varices rupture: Abrupt discomfort in the throat Severe dysphagia Vomiting bright red blood Signs of shock
Upper Gastrointestinal Bleeding: Esophagogastric Varices Management −General management guidelines Accurate assessment of blood loss −In-hospital treatment includes: Stopping the bleeding Aggressive fluid resuscitation Possible endoscopy
Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome Pathophysiology −Junction between the esophagus and the stomach tears Generally due to severe vomiting
Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome Assessment −Bleeding may be light to severe. −In extreme cases, patients will have: Signs and symptoms of shock Epigastric abdominal pain Hematemesis Melena
Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome Management −Aimed at determining the extent of blood loss −In-hospital management may include: Volume resuscitation Endoscopy Attempt to repair the tear
Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) Pathophysiology −Erosion of the mucous that lines the stomach and duodenum −Typically occurs over weeks, months, or years −Variety of causes Infection with Helicobacter pylori Erosive gastritis
Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) Assessment −Burning or gnawing pain in the stomach Disappears after eating, but returns hours later −Other common symptoms may include: Vomiting Belching Heartburn
Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) Management −Assess blood loss and manage hypotension. −Monitor orthostatic vital signs. −In-hospital management includes: Acid neutralization Reduction therapies Endoscopy if needed
Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease Pathophysiology −Sphincter between the esophagus and stomach opens, allowing stomach acids to travel up −Can cause a burning sensation within the chest −Over time it can cause damage to the esophageal wall and possible bleeding.
Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease Assessment −Signs and symptoms Heartburn Coughing or difficulty swallowing Bleeding, resulting in hematemesis and melena
Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease Management −Treatment focuses on decreasing acidity. Antacids, proton pump inhibitors, H 2 blockers −Symptoms can be confused with myocardial infarction.
Lower Gastrointestinal Bleeding: Hemorrhoids Pathophysiology −Swelling and inflammation of blood vessels around the rectum −Caused by increased rectal pressure or irritation
Lower Gastrointestinal Bleeding: Hemorrhoids Assessment −Signs and symptoms: Hematochezia Rectal itching Small mass on rectum
Lower Gastrointestinal Bleeding: Hemorrhoids Management −Prehospital management is supportive. −Obtain orthostatic vital signs. −In-hospital management may include creams. −Prevention includes eating a high-fiber diet.
Lower Gastrointestinal Bleeding: Anal Fissures Pathophysiology −Linear tears in the mucosal lining near and in the anus
Lower Gastrointestinal Bleeding: Anal Fissures Assessment −Painful defecation Management −Place dressing over anus. −Do NOT pack fissure or anus.
Acute Inflammatory Conditions Inflammation helps white blood cells destroy or seal off an invading agent. Localized inflammation will cause localized signs and symptoms.
Acute Inflammatory Conditions If bacteria moves into the bloodstream, sepsis occurs. −The body responds with a generalized inflammatory response. −Autoimmune condition: the body attacks and kills its own cells for no defined reason.
Cholecystitis and Biliary Tract Disorders Pathophysiology −Inflammation of the gallbladder Choleangitis—inflammation of bile duct Cholelithiasis—stones in the gallbladder Cholecystitis—inflammation of the gallbladder Acalculus cholecystitis—inflammation without gallstones
Cholecystitis and Biliary Tract Disorders Pathophysiology (cont’d) −May arise from decreased flow of biliary materials −Patient may present with: Murphy sign Nausea/vomiting Jaundice
Cholecystitis and Biliary Tract Disorders Assessment −After eating a fatty meal, severe upper right quadrant abdominal pain develops. Management −Pain medications: meperidine and morphine −Medication for nausea is often necessary.
Appendicitis Pathophysiology −Fecal and other matter builds up in appendix. −Build-up of pressure will eventually cause the organ to rupture, resulting in: Peritonitis Sepsis Death
Appendicitis Assessment −Stages of presentation Early—periumbilical pain, nausea, vomiting Ripe—pain in lower right quadrant Rupture—decrease in pain (decrease in pressure) −Evaluate for peritonitis with Dunphy sign.
Appendicitis Management −Assess for septicemia. −Volume resuscitation Use dopamine if crystalloids are not effective. −Administer pain and antinausea medications.
Diverticulitis Pathophysiology −Diverticulum: weak area in the colon that begins to have pockets (diverticula) −Diverticulosis: condition of having diverticula −Diverticulitis: Inflammation of diverticuli
Diverticulitis Pathophysiology −A diet low in fiber creates more solid stool. −If feces gets trapped in diverticula, inflammation and infection occur and may cause: Scarring Adhesions Fistula
Diverticulitis Assessment −Signs and symptoms include: Abdominal pain, usually localized on the left lower abdomen Classic infection signs Constipation or diarrhea
Diverticulitis Management −Ensure severe infection is not present. −Patients may need fluids and/or dopamine. −In-hospital treatment includes: Antibiotics Liquid diet Surgery
Pancreatitis Pathophysiology −Inflammation of the pancreas −Occurs when the tube carrying enzymes becomes blocked, leading to autodigestion −Can occur suddenly or over many months −May be single or episodic attacks
Pancreatitis Assessment −Signs and symptoms may include: Sharp pain in the epigastric area or right upper abdomen Pain radiating to the back Muscle spasms
Pancreatitis Management −Directed by general management guidelines −Assess for signs of severe hemorrhage. −Meperidine is the choice for pain management.
Ulcerative Colitis Pathophysiology −Generalized inflammation of the colon −Causes a thinning of the intestinal wall and a weakened rectum −Peaks between ages 15 and 25 years and 55 and 65 years
Ulcerative Colitis Assessment −Signs and symptoms may include: Gradual onset of bloody diarrhea Hematochezia Mild to severe abdominal pain Skin lesions
Ulcerative Colitis Management −Determine the degree of hemodynamic instability. −Administer fluids, if necessary. −Follow the general management guideline.
Irritable Bowel Syndrome (IBS) Pathophysiology −Patients often show: Hypersensitivity of bowel pain receptors Hyperresponsiveness of the smooth muscle Psychiatric disorder connection
Irritable Bowel Syndrome (IBS) Pathophysiology (cont’d) −Hyperresponsiveness can cause spasm. Can cause constipation and bloating or diarrhea −Typically begins during childhood −Can be triggered by various stimuli
Irritable Bowel Syndrome (IBS) Assessment −You will typically be called when the patient is having a flare-up of symptoms. Management −Mainly supportive −Assessment should include the patient’s mood.
Crohn Disease Pathophysiology −Involves the entire GI tract −A series of attacks leaves a scarred, narrowed, and weakened portion of the small intestine. Can cause bowel obstruction
Crohn Disease Assessment −Signs and symptoms may include: Rectal bleeding Weight loss Skin disorders
Crohn Disease Management −Prehospital care should focus on general management guidelines, including: Volume resuscitation Control of nausea and pain
Acute Infectious Conditions GI infection occurs when contaminated food is ingested or when the GI tract ruptures. −People that have a difficulty combating infection: Immunocompromised Very old Very young
Acute Infectious Conditions Damage may allow contents to be released into surrounding tissues. −The body will begin to defend itself. −If the infection continues, it may leave the GI system and enter the bloodstream. This is known as sepsis.
Acute Gastroenteritis Pathophysiology −Conditions involving infection with fever, abdominal pain, diarrhea, nausea, and vomiting −Can be caused by various organisms Typically enter via the fecal-oral route
Acute Gastroenteritis Assessment −Symptoms may show anywhere from several hours to several days from contact −Can last two or three days, or several weeks
Acute Gastroenteritis Assessment (cont’d) −Signs and symptoms may include: Diarrhea of various types Nausea and vomiting Anorexia −Assess for dehydration, hemodynamic instability, and electrolyte imbalance.
Acute Gastroenteritis Management −Determine the degree of fluid deficit. −Obtain orthostatic vital signs. −Analgesic and antiemetic medications −Teach patients about safe food and water use.
Rectal Abscess Pathophysiology −Caused when the ducts carrying mucus to the rectal area become blocked Allows bacteria to grow and spread to the anus
Rectal Abscess Assessment −Symptoms may include: Rectal pain that increases with defecation Rectal drainage Constipation Management −Focus on keeping the patient comfortable.
Liver Disease: Cirrhosis Pathophysiology −Early liver failure, which may be hallmarked by: Portal hypertension Deficiencies with coagulation Diminished detoxification
Liver Disease: Cirrhosis Assessment −First stage may include: Weakness and fatigue Nausea and vomiting Anorexia Pruritus
Liver Disease: Cirrhosis Assessment (cont’d) −2nd stage may include: Alcoholic stools Dark urine Icteric conjunctiva Ascites Enlarged liver Courtesy of Dr. Thomas F. Sellers/Emory University/CDC
Liver Disease: Cirrhosis Management −Prehospital care should be supportive. −Involves bleeding control and medication −Use lower ends of medication dose range.
Liver Disease: Hepatic Encephalopathy Pathophysiology −Brain impairment due to diminished liver function −Underlying causes: Increased levels of ammonia Diminished cellular energy supplies Change in blood-brain barrier permeability
Liver Disease: Hepatic Encephalopathy Assessment −Can range from mild memory loss to coma −May be precipitated by: Infection Renal failure GI bleeding Constipation
Liver Disease: Hepatic Encephalopathy Management −Mainly supportive −Ensure that LOC status is not from other cause. Check blood glucose levels. Assess for trauma and overdose. Take a medical history.
Obstructive Conditions Intestines are unable to move material through the digestive tract. −Two main reasons: Paralysis of the intestines Intestinal lumen diameter compromise
Small-Bowel Obstruction Pathophysiology −Most often caused by post-operative adhesions −Other causes include: Cancer Crohn disease Hernias Foreign bodies
Small-Bowel Obstruction Assessment −Signs and symptoms may include: Crampy and intermittent abdominal pain Initial diarrhea, nausea, and vomiting Increased pressure Constipation
Small-Bowel Obstruction Management −Monitor blood pressure, and perform volume resuscitation. −Administer dopamine as needed. −Consider using a nasogastric tube. −Antiemetics are indicated.
Large-Bowel Obstruction Pathophysiology −Caused by either mechanical obstruction or colon dilation −Imaging studies determine the location and extent of obstruction. Once located, can be easily treated
Large-Bowel Obstruction Assessment −Signs and symptoms may include: Nausea and vomiting Distended abdomen Absent bowel sounds Peritonitis signs if bowel has ruptured
Large-Bowel Obstruction Management −Same as for small bowel obstruction
Hernia Pathophysiology −Organ/structure protrusion 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.
Hernia Pathophysiology (cont’d) −Caused by any condition that causes intra- abdominal pressure: Obesity Standing for long periods Straining during bowel movements Chronic obstructive pulmonary disease
Hernia Management −Focus on supportive measures. −Pain management −Assess for sepsis
Rectal Foreign Body Obstruction Pathophysiology −Originates from upper GI tract or anal insertion Assessment −Presents with sudden rectal pain with defecation −Determine if the rectum has been perforated.
Rectal Foreign Body Obstruction Management −Do NOT attempt to remove object. −Prehospital management should be limited to patient comfort. Treat with analgesia if indicated. Closely monitor vital signs.
Mesenteric Ischemia Pathophysiology −Interruption of the blood supply to the mesentery −Can be caused by: Arterial embolism Thrombosis Profound vasospasm
Mesenteric Ischemia Assessment −Gradual or sudden onset −Symptoms include: Severe pain with ill-defined location Nausea, vomiting, and diarrhea Possible blood in stool
Mesenteric Ischemia Management −Patients require rapid transportation. −Monitor closely. −Check vitals for signs of sepsis. −Fluid resuscitation in cases of shock −Give analgesics as needed.
Gastrointestinal Conditions in Pediatric Patients GI complaints are common in children. −Prolonged vomiting, diarrhea, or bleeding can lead to severe changes in sodium and potassium levels.
Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies (cont’d) −Intestinal malrotation: intestines rotated incorrectly during development
Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies (cont’d) −Pyloric stenosis: hypertrophy of the pyloric sphincter of the stomach GI bleeding can occur in children.
Gastrointestinal Conditions in Pediatric Patients Careful assessment is critical. −Check skin turgor, pulse rate, and peripheral pulse status. −Severe fluid loss may cause diminished LOC. Standard fluid resuscitation: 20 mL/kg isotonic fluid −Get a detailed medical history from the parent.
Gastrointestinal Conditions in Pediatric Patients Patients may have a gastrostomy tube. −If dislodged, place a sterile dressing over it. −If clogged, talk about ways to clear the tube. −If the blockage cannot be easily managed, turn off the feeding, clamp the tube, and transport.
Gastrointestinal Conditions in Older Adults GI diseases more prevalent in older adults Abdominal pain can also be a symptom of a cardiac condition. −Obtain a thorough history and physical exam. −Consider a 12-lead ECG. −Monitor vital signs.
Prevention Strategies Many behaviors can prevent or limit severity of GI diseases.
Summary GI illnesses are rarely life threatening, but systemic illnesses can occur if left untreated or undertreated. The structures and functions of the GI system perform digestion, which begins in the mouth and ends in the anus. It is likely you will come in contact with blood or other body fluids. A complete scene size-up requires a survey of PPE.
Summary Observe a patient presenting with GI symptoms to form a general impression. Maintain airway and circulation; determine extent of bleeding. Weigh patient stability and risk of injury when deciding on rapid transport. The field impression and gathered information can determine cause of complaint.
Summary The secondary assessment should include a physical examination. Orthostatic vital sign changes of 10-beat pulse rate increase and 10-mm Hg drop in blood pressure is a likely sign of significant volume loss. Reassess the patient by monitoring changes in condition.
Summary Pain and nausea management can be given to most patients with GI emergencies. Compassionate care and clear documentation are essential parts of delivering excellent patient care. Perform new assessments and examinations if patient condition changes.
Summary Perform airway management if necessary. If circulation is compromised by dehydration or hemorrhage, fluid resuscitation is essential. Paramedics must understand GI diseases to educate patients and to perform an increasing level of responsibilities.
Summary The four major conditions responsible for abdominal and GI emergencies are: −Hypovolemia −Acute or chronic inflammation −Infection −Obstruction
Summary GI tract bleeding is a symptom and can reflect many GI diseases. Pediatric patients face special challenges because of their size, physiology, and possible GI congenital anomalies. Treating older adults with GI emergencies is complicated by comorbidities, multiple medications, and other factors.