Presentation on theme: "Abdominal and Gastrointestinal Emergencies"— Presentation transcript:
1 Abdominal and Gastrointestinal Emergencies Chapter 20Abdominal and Gastrointestinal Emergencies1
2 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.2
3 National EMS Education Standard Competencies Abdominal and Gastrointestinal DisordersAnatomy, presentations, and management of shock associated with abdominal emergenciesGastrointestinal bleeding3
4 National EMS Education Standard Competencies Abdominal and Gastrointestinal DisordersAnatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management ofAcute and chronic gastrointestinal hemorrhageLiver disordersPeritonitisUlcerative diseasesIrritable bowel syndrome4
5 National EMS Education Standard Competencies Abdominal and Gastrointestinal DisordersAnatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management ofInflammatory disordersPancreatitisBowel obstructionHernias5
6 National EMS Education Standard Competencies Abdominal and Gastrointestinal DisordersAnatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management ofInfectious diseasesGallbladder and biliary tract disordersRectal abscessesRectal foreign body obstructionMesenteric ischemia6
7 Introduction GI problems are rarely life threatening. Can lead to systemic problems if untreated7
8 IntroductionThe number of disorders causing abdominal pain, diarrhea, and nausea is high.With the exception of septicemia, most GI disorders are not deadly.8
9 IntroductionBehaviors and characteristics may predispose some people to GI disorders.9
10 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.10
11 Anatomy and Physiology Food reaches the esophagus.Typically collapsed, allowing air to flow into the lungs instead of the stomachDilates when food or liquid travels through itExplains gastric distention during positive-pressure ventilation11
12 Anatomy and Physiology The esophagus transports food using peristalsis.The portal vein is intertwined around the esophagus.Transports venous blood to the liver.12
13 Anatomy and Physiology Food travels through the diaphragm to the cardiac sphincter.Connects the esophagus and the stomachControls amount of food that moves up the esophagus13
14 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.14
15 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.15
16 Anatomy and Physiology The liver:Produces bile, which breaks down fatsPromotes carbohydrate metabolismDetoxifies drugsCompletes the breakdown of dead blood cellsStores vitamins and minerals16
17 Anatomy and Physiology The small intestineWhere 90% of absorption occursDivided into three sections:DuodenumJejunumIleum17
18 Anatomy and Physiology Colon (large intestine)Moves undigested food (feces) to be eliminated from the body18
19 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.19
20 Scene Size-Up Ensure safety. Look for MOI or NOI. Take standard precautions.Always have equipment for hygiene.20
21 Primary Assessment Form a general impression. Where was the patient found?What is the patient’s body posture?Is there an odor?21
22 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 odors22
23 Primary Assessment Circulation Assess skin color, temperature, and moisture.Determine pulse rate.Ensure blood pressure reading is accurate.Take note of amount of blood.23
24 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.24
25 History Taking Patients may have a history of issues. SAMPLE helps you gather information.Changes in bowel patterns or stoolOnset of diarrhea, constipation, or nausea/vomitingRecent weight lossPatient’s last meal25
30 Secondary AssessmentAuscultate for bowel sounds.
31 Secondary Assessment Percuss the abdomen. The abdomen should sound tympanic.The upper left and upper right quadrants will sound duller.
32 Secondary Assessment Palpate the abdomen. Begin farthest away from the pain.Indent the abdomen wall about 2″ to 4″.Assess for discomfort, rigidity, and masses.
33 Secondary Assessment Abdominal pain may indicate: TraumaHemorrhageInfectionObstructionOther serious problemsTypes of pain include:Visceral painParietal pain (rebound)Somatic painReferred pain
34 Secondary AssessmentRebound 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.
35 Secondary AssessmentIf 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
36 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 pressure10-beat increase in pulse rate
37 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.
41 Emergency Medical Care Repeat assessment if patient’s condition suddenly changes dramatically.Do not let patients eat or drink anything.41
42 Airway ManagementAirway 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.42
43 Breathing Associated with decreased hemoglobin levels Administer high-concentration oxygen.Prevent aspiration.Auscultate lung sounds.43
44 Circulation Concerns: dehydration and hemorrhage Fluids depend on circulatory perfusion status.Hypotonic solution for stable conditionsIsotonic solution for profound dehydration44
45 CirculationHemorrhaging 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.45
46 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.46
47 Specific Abdominal and Gastrointestinal Emergencies 47
48 Specific Abdominal and Gastrointestinal Emergencies Hypovolemia can be caused by:Dehydration from vomiting and/or diarrheaElectrolyte levels are affected during this process.48
49 Specific Abdominal and Gastrointestinal Emergencies Hypovolemia can be caused by (cont’d):HemorrhagePotential to be fatalSigns of shock are typically present.Drop in blood pressure indicates significant volume loss49
50 Gastrointestinal Bleeding GI bleeding is a symptom, not the disease.Determine onset and medical history.Treatment includes:Fluid resuscitationEstablish an IV line.50
52 Upper Gastrointestinal Bleeding: Esophagogastric Varices PathophysiologyCaused by pressure increases in blood vessels surrounding the esophagus and stomachBlood cannot easily flow through damaged liver.Blood backs up into the portal vessels.52
53 Upper Gastrointestinal Bleeding: Esophagogastric Varices AssessmentInitial presentationFatigueJaundiceAnorexiaPruritusAbdominal painWhen the varices rupture:Abrupt discomfort in the throatSevere dysphagiaVomiting bright red bloodSigns of shock53
54 Upper Gastrointestinal Bleeding: Esophagogastric Varices ManagementGeneral management guidelinesAccurate assessment of blood lossIn-hospital treatment includes:Stopping the bleedingAggressive fluid resuscitationPossible endoscopy54
55 Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome PathophysiologyJunction between the esophagus and the stomach tearsGenerally due to severe vomiting55
56 Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome AssessmentBleeding may be light to severe.In extreme cases, patients will have:Signs and symptoms of shockEpigastric abdominal painHematemesisMelena56
57 Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome ManagementAimed at determining the extent of blood lossIn-hospital management may include:Volume resuscitationEndoscopyAttempt to repair the tear57
58 Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) PathophysiologyErosion of the mucous that lines the stomach and duodenumTypically occurs over weeks, months, or yearsVariety of causesInfection with Helicobacter pyloriErosive gastritis
59 Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) AssessmentBurning or gnawing pain in the stomachDisappears after eating, but returns hours laterOther common symptoms may include:VomitingBelchingHeartburn
60 Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) ManagementAssess blood loss and manage hypotension.Monitor orthostatic vital signs.In-hospital management includes:Acid neutralizationReduction therapiesEndoscopy if needed
61 Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease PathophysiologySphincter between the esophagus and stomach opens, allowing stomach acids to travel upCan cause a burning sensation within the chestOver time it can cause damage to the esophageal wall and possible bleeding.
62 Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease AssessmentSigns and symptomsHeartburnCoughing or difficulty swallowingBleeding, resulting in hematemesis and melena
63 Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease ManagementTreatment focuses on decreasing acidity.Antacids, proton pump inhibitors, H2 blockersSymptoms can be confused with myocardial infarction.
64 Lower Gastrointestinal Bleeding: Hemorrhoids PathophysiologySwelling and inflammation of blood vessels around the rectumCaused by increased rectal pressure or irritation
65 Lower Gastrointestinal Bleeding: Hemorrhoids AssessmentSigns and symptoms:HematocheziaRectal itchingSmall mass on rectum
66 Lower Gastrointestinal Bleeding: Hemorrhoids ManagementPrehospital management is supportive.Obtain orthostatic vital signs.In-hospital management may include creams.Prevention includes eating a high-fiber diet.
67 Lower Gastrointestinal Bleeding: Anal Fissures PathophysiologyLinear tears in the mucosal lining near and in the anus
68 Lower Gastrointestinal Bleeding: Anal Fissures AssessmentPainful defecationManagementPlace dressing over anus.Do NOT pack fissure or anus.
69 Acute Inflammatory Conditions Inflammation helps white blood cells destroy or seal off an invading agent.Localized inflammation will cause localized signs and symptoms.
70 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.
71 Cholecystitis and Biliary Tract Disorders PathophysiologyInflammation of the gallbladderCholeangitis—inflammation of bile ductCholelithiasis—stones in the gallbladderCholecystitis—inflammation of the gallbladderAcalculus cholecystitis—inflammation without gallstones
72 Cholecystitis and Biliary Tract Disorders Pathophysiology (cont’d)May arise from decreased flow of biliary materialsPatient may present with:Murphy signNausea/vomitingJaundice72
73 Cholecystitis and Biliary Tract Disorders AssessmentAfter eating a fatty meal, severe upper right quadrant abdominal pain develops.ManagementPain medications: meperidine and morphineMedication for nausea is often necessary.
74 Appendicitis Pathophysiology Fecal and other matter builds up in appendix.Build-up of pressure will eventually cause the organ to rupture, resulting in:PeritonitisSepsisDeath
75 Appendicitis Assessment Stages of presentation Early—periumbilical pain, nausea, vomitingRipe—pain in lower right quadrantRupture—decrease in pain (decrease in pressure)Evaluate for peritonitis with Dunphy sign.
76 Appendicitis Management Assess for septicemia. Volume resuscitation Use dopamine if crystalloids are not effective.Administer pain and antinausea medications.
77 Diverticulitis Pathophysiology Diverticulum: weak area in the colon that begins to have pockets (diverticula)Diverticulosis: condition of having diverticulaDiverticulitis: Inflammation of diverticuli
78 Diverticulitis Pathophysiology A diet low in fiber creates more solid stool.If feces gets trapped in diverticula, inflammation and infection occur and may cause:ScarringAdhesionsFistula
79 Diverticulitis Assessment Signs and symptoms include: Abdominal pain, usually localized on the left lower abdomenClassic infection signsConstipation or diarrhea
80 Diverticulitis Management Ensure severe infection is not present. Patients may need fluids and/or dopamine.In-hospital treatment includes:AntibioticsLiquid dietSurgery
81 Pancreatitis Pathophysiology Inflammation of the pancreas Occurs when the tube carrying enzymes becomes blocked, leading to autodigestionCan occur suddenly or over many monthsMay be single or episodic attacks
82 Pancreatitis Assessment Signs and symptoms may include: Sharp pain in the epigastric area or right upper abdomenPain radiating to the backMuscle spasms
84 Pancreatitis Management Directed by general management guidelines Assess for signs of severe hemorrhage.Meperidine is the choice for pain management.
85 Ulcerative Colitis Pathophysiology Generalized inflammation of the colonCauses a thinning of the intestinal wall and a weakened rectumPeaks between ages 15 and 25 years and 55 and 65 years85
86 Ulcerative Colitis Assessment Signs and symptoms may include: Gradual onset of bloody diarrheaHematocheziaMild to severe abdominal painSkin lesions86
87 Ulcerative Colitis Management Determine the degree of hemodynamic instability.Administer fluids, if necessary.Follow the general management guideline.87
88 Irritable Bowel Syndrome (IBS) PathophysiologyPatients often show:Hypersensitivity of bowel pain receptorsHyperresponsiveness of the smooth musclePsychiatric disorder connection88
89 Irritable Bowel Syndrome (IBS) Pathophysiology (cont’d)Hyperresponsiveness can cause spasm.Can cause constipation and bloating or diarrheaTypically begins during childhoodCan be triggered by various stimuli89
90 Irritable Bowel Syndrome (IBS) AssessmentYou will typically be called when the patient is having a flare-up of symptoms.ManagementMainly supportiveAssessment should include the patient’s mood.90
91 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 obstruction91
92 Crohn Disease Assessment Signs and symptoms may include: Rectal bleedingWeight lossSkin disorders92
93 Crohn Disease Management Prehospital care should focus on general management guidelines, including:Volume resuscitationControl of nausea and pain
94 Acute Infectious Conditions GI infection occurs when contaminated food is ingested or when the GI tract ruptures.People that have a difficulty combating infection:ImmunocompromisedVery oldVery young
95 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.
96 Acute Gastroenteritis PathophysiologyConditions involving infection with fever, abdominal pain, diarrhea, nausea, and vomitingCan be caused by various organismsTypically enter via the fecal-oral route
97 Acute Gastroenteritis AssessmentSymptoms may show anywhere from several hours to several days from contactCan last two or three days, or several weeks
98 Acute Gastroenteritis Assessment (cont’d)Signs and symptoms may include:Diarrhea of various typesNausea and vomitingAnorexiaAssess for dehydration, hemodynamic instability, and electrolyte imbalance.
99 Acute Gastroenteritis ManagementDetermine the degree of fluid deficit.Obtain orthostatic vital signs.Analgesic and antiemetic medicationsTeach patients about safe food and water use.
100 Rectal Abscess Pathophysiology Caused when the ducts carrying mucus to the rectal area become blockedAllows bacteria to grow and spread to the anus
101 Rectal Abscess Assessment Management Symptoms may include: Rectal pain that increases with defecationRectal drainageConstipationManagementFocus on keeping the patient comfortable.
102 Liver Disease: Cirrhosis PathophysiologyEarly liver failure, which may be hallmarked by:Portal hypertensionDeficiencies with coagulationDiminished detoxification
103 Liver Disease: Cirrhosis AssessmentFirst stage may include:Weakness and fatigueNausea and vomitingAnorexiaPruritus
104 Liver Disease: Cirrhosis Assessment (cont’d)2nd stage may include:Alcoholic stoolsDark urineIcteric conjunctivaAscitesEnlarged liverCourtesy of Dr. Thomas F. Sellers/Emory University/CDC
106 Liver Disease: Cirrhosis ManagementPrehospital care should be supportive.Involves bleeding control and medicationUse lower ends of medication dose range.
107 Liver Disease: Hepatic Encephalopathy PathophysiologyBrain impairment due to diminished liver functionUnderlying causes:Increased levels of ammoniaDiminished cellular energy suppliesChange in blood-brain barrier permeability
108 Liver Disease: Hepatic Encephalopathy AssessmentCan range from mild memory loss to comaMay be precipitated by:InfectionRenal failureGI bleedingConstipation
109 Liver Disease: Hepatic Encephalopathy ManagementMainly supportiveEnsure that LOC status is not from other cause.Check blood glucose levels.Assess for trauma and overdose.Take a medical history.
110 Obstructive Conditions Intestines are unable to move material through the digestive tract.Two main reasons:Paralysis of the intestinesIntestinal lumen diameter compromise
111 Small-Bowel Obstruction PathophysiologyMost often caused by post-operative adhesionsOther causes include:CancerCrohn diseaseHerniasForeign bodies
112 Small-Bowel Obstruction AssessmentSigns and symptoms may include:Crampy and intermittent abdominal painInitial diarrhea, nausea, and vomitingIncreased pressureConstipation
113 Small-Bowel Obstruction ManagementMonitor blood pressure, and perform volume resuscitation.Administer dopamine as needed.Consider using a nasogastric tube.Antiemetics are indicated.
114 Large-Bowel Obstruction PathophysiologyCaused by either mechanical obstruction or colon dilationImaging studies determine the location and extent of obstruction.Once located, can be easily treated
115 Large-Bowel Obstruction AssessmentSigns and symptoms may include:Nausea and vomitingDistended abdomenAbsent bowel soundsPeritonitis signs if bowel has ruptured
116 Large-Bowel Obstruction ManagementSame as for small bowel obstruction
117 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.117
118 Hernia Pathophysiology (cont’d) Caused by any condition that causes intra-abdominal pressure:ObesityStanding for long periodsStraining during bowel movementsChronic obstructive pulmonary disease118
119 Hernia Assessment Four types Reducible Incarcerated Strangulated Incisional119
120 Hernia Management Focus on supportive measures. Pain management Assess for sepsis
121 Rectal Foreign Body Obstruction PathophysiologyOriginates from upper GI tract or anal insertionAssessmentPresents with sudden rectal pain with defecationDetermine if the rectum has been perforated.121
122 Rectal Foreign Body Obstruction ManagementDo NOT attempt to remove object.Prehospital management should be limited to patient comfort.Treat with analgesia if indicated.Closely monitor vital signs.
123 Mesenteric Ischemia Pathophysiology Interruption of the blood supply to the mesenteryCan be caused by:Arterial embolismThrombosisProfound vasospasm123
124 Mesenteric Ischemia Assessment Gradual or sudden onset Symptoms include:Severe pain with ill-defined locationNausea, vomiting, and diarrheaPossible blood in stool124
125 Mesenteric Ischemia Management Patients require rapid transportation. Monitor closely.Check vitals for signs of sepsis.Fluid resuscitation in cases of shockGive analgesics as needed.
126 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.
128 Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies (cont’d)Intestinal malrotation: intestines rotated incorrectly during development
129 Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies (cont’d)Pyloric stenosis: hypertrophy of the pyloric sphincter of the stomachGI bleeding can occur in children.
130 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 fluidGet a detailed medical history from the parent.
131 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.
132 Gastrointestinal Conditions in Older Adults GI diseases more prevalent in older adultsAbdominal 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.
133 Prevention Strategies Many behaviors can prevent or limit severity of GI diseases.
135 SummaryGI 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.135
136 SummaryObserve 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.136
137 SummaryThe 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.
138 SummaryPain 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.
139 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.
140 SummaryThe four major conditions responsible for abdominal and GI emergencies are:HypovolemiaAcute or chronic inflammationInfectionObstruction
141 SummaryGI 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.