Chapter 20 Abdominal and Gastrointestinal Emergencies.

Chapter 20Chapter 20

Abdominal and Gastrointestinal Emergencies

National EMS Education Standard CompetenciesNational 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.


Abdominal and Gastrointestinal Disorders

Anatomy, presentations, and management of shock associated with abdominal emergencies

− Gastrointestinal bleeding



Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of

− Acute and chronic gastrointestinal hemorrhage

− Liver disorders

− Peritonitis

− Ulcerative diseases

− Irritable bowel syndrome




− Inflammatory disorders

− Pancreatitis

− Bowel obstruction

− Hernias




− Infectious diseases

− Gallbladder and biliary tract disorders

− Rectal abscesses

− Rectal foreign body obstruction

− Mesenteric ischemia

IntroductionIntroduction

• GI problems are rarely life threatening.− Can lead to systemic problems if untreated


• The number of disorders causing abdominal pain, diarrhea, and nausea is high.− With the exception

of septicemia, most GI disorders are not deadly.


• Behaviors and characteristics may predispose some people to GI disorders.

Anatomy and PhysiologyAnatomy 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.


• 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


• The esophagus transports food using peristalsis.

• The portal vein is intertwined around the esophagus.− Transports venous blood to the liver.


• Food travels through the diaphragm to the cardiac sphincter.− Connects the esophagus and the stomach

− Controls amount of food that moves up the esophagus


• 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.


• 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.


• The liver: − Produces bile, which breaks down fats

− Promotes carbohydrate metabolism

− Detoxifies drugs

− Completes the breakdown of dead blood cells

− Stores vitamins and minerals


• The small intestine− Where 90% of

absorption occurs

− Divided into three sections:• Duodenum

• Jejunum

• Ileum


• Colon (large intestine)− Moves undigested

food (feces) to be eliminated from the body


• 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-UpScene Size-Up

• Ensure safety.

• Look for MOI or NOI.

• Take standard precautions.

• Always have equipment for hygiene.

Primary AssessmentPrimary Assessment

• Form a general impression.− Where was the patient found?

− What is the patient’s body posture?

− Is there an odor?


• Airway and breathing− Patient who is vomiting may aspirate.

− Open the airway with the appropriate method.

− Remove or suction obstructions.

− Check for unusual odors


• Circulation− Assess skin color, temperature, and moisture.

− Determine pulse rate.

− Ensure blood pressure reading is accurate.

− Take note of amount of blood.


• Transport decision− Based on primary assessment

− If positive orthostatic vital signs, carefully consider how to move the patient.

− Choose the mode of ambulance.

History TakingHistory 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

History TakingHistory Taking

Secondary AssessmentSecondary Assessment

• Detailed abdominal examination− Keep the muscles

from flexing.

− Check for skin irregularities.• Scars

• Striae© Medical-on-Line Alamy Images


• Asymmetric abdomen could mean:− Tumors

− Hernia

− Enlarged organs

− Pregnancy

• Check shape of the abdomen.


• Protuberance may be caused by:− Excessive weight

gain

− Ascites

− Pregnancy

− Organ enlargement

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• Auscultate for bowel sounds.


• Percuss the abdomen.− The abdomen should sound tympanic.

− The upper left and upper right quadrants will sound duller.


• Palpate the abdomen.− Begin farthest

away from the pain.

− Indent the abdomen wall about 2″ to 4″.

− Assess for discomfort, rigidity, and masses.


• Abdominal pain may indicate:− Trauma

− Hemorrhage

− Infection

− Obstruction

− Other serious problems

• Types of pain include:− Visceral pain

− Parietal pain (rebound)

− Somatic pain

− Referred pain


• 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.


• 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


• 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


• Many GI diseases affect electrolyte levels. − Use a handheld blood analyzer to test.

• Ultrasonography and intra-abdominal pressure testing may also be available.

ReassessmentReassessment

• Routine monitoring includes:− Pulse rate

− Electrocardiogram

− Blood pressure

− Respiratory rate

− Pulse oximetry


• Pain medication includes:− Meperidine hydrochloride

− Morphine

− Ketorolac

− Nalbuphine

− Fentanyl


• Nausea medications include:− Ondansetron

− Diphenhydramine

− Hydroxyzine

− Promethazine

Emergency Medical CareEmergency Medical Care

• Repeat assessment if patient’s condition suddenly changes dramatically.

• Do not let patients eat or drink anything.

Airway ManagementAirway 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.

BreathingBreathing

• Associated with decreased hemoglobin levels− Administer high-concentration oxygen.

− Prevent aspiration.

− Auscultate lung sounds.

CirculationCirculation

• Concerns: dehydration and hemorrhage− Fluids depend on circulatory perfusion status.

• Hypotonic solution for stable conditions

• Isotonic solution for profound dehydration

CirculationCirculation

• 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.



• Hypovolemia can be caused by:− Dehydration from

vomiting and/or diarrhea• Electrolyte levels

are affected during this process.



• 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 BleedingGastrointestinal Bleeding

• GI bleeding is a symptom, not the disease.− Determine onset and medical history.

− Treatment includes:• Fluid resuscitation

• Establish an IV line.

Gastrointestinal BleedingGastrointestinal Bleeding

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.



• 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



• 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



• Assessment− Bleeding may be light to severe.

− In extreme cases, patients will have: • Signs and symptoms of shock

• Epigastric abdominal pain

• Hematemesis

• Melena



• 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



• Assessment− Burning or gnawing pain in the stomach

• Disappears after eating, but returns hours later

− Other common symptoms may include:• Vomiting

• Belching

• Heartburn



• 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 DiseaseUpper 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.


• Assessment− Signs and symptoms

• Heartburn

• Coughing or difficulty swallowing

• Bleeding, resulting in hematemesis and melena


• Management− Treatment focuses on decreasing acidity.

• Antacids, proton pump inhibitors, H2 blockers

− Symptoms can be confused with myocardial infarction.

Lower Gastrointestinal Bleeding: HemorrhoidsLower Gastrointestinal Bleeding: Hemorrhoids

• Pathophysiology− Swelling and inflammation of blood vessels

around the rectum

− Caused by increased rectal pressure or irritation


• Assessment − Signs and symptoms:

• Hematochezia

• Rectal itching

• Small mass on rectum


• 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 FissuresLower Gastrointestinal Bleeding: Anal Fissures

• Pathophysiology− Linear tears in the

mucosal lining near and in the anus

Lower Gastrointestinal Bleeding: Anal FissuresLower Gastrointestinal Bleeding: Anal Fissures

• Assessment− Painful defecation

• Management− Place dressing over anus.

− Do NOT pack fissure or anus.

Acute Inflammatory ConditionsAcute Inflammatory Conditions

• Inflammation helps white blood cells destroy or seal off an invading agent.

• Localized inflammation will cause localized signs and symptoms.

Acute Inflammatory ConditionsAcute 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



• Pathophysiology (cont’d)− May arise from decreased flow of biliary

materials

− Patient may present with:• Murphy sign

• Nausea/vomiting

• Jaundice



• 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.

AppendicitisAppendicitis

• 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


• 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.


• Management− Assess for septicemia.

− Volume resuscitation • Use dopamine if crystalloids are not effective.

− Administer pain and antinausea medications.

DiverticulitisDiverticulitis

• Pathophysiology− Diverticulum: weak area in the colon that begins

to have pockets (diverticula)

− Diverticulosis: condition of having diverticula

− Diverticulitis: Inflammation of diverticuli


• 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


• Assessment− Signs and symptoms include:

• Abdominal pain, usually localized on the left lower abdomen

• Classic infection signs

• Constipation or diarrhea


• Management− Ensure severe infection is not present.

− Patients may need fluids and/or dopamine.

− In-hospital treatment includes:• Antibiotics

• Liquid diet

• Surgery

PancreatitisPancreatitis

• 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


• Assessment− Signs and symptoms may include:

• Sharp pain in the epigastric area or right upper abdomen

• Pain radiating to the back

• Muscle spasms


• Assessment (cont’d)− Internal

hemorrhage may be indicated by:• Cullen sign

• Grey-Turner sign

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• Management− Directed by general management guidelines

− Assess for signs of severe hemorrhage.

− Meperidine is the choice for pain management.

Ulcerative ColitisUlcerative 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



• Gradual onset of bloody diarrhea

• Hematochezia

• Mild to severe abdominal pain

• Skin lesions


• Management− Determine the degree of hemodynamic

instability.

− Administer fluids, if necessary.

− Follow the general management guideline.

Irritable Bowel Syndrome (IBS)Irritable Bowel Syndrome (IBS)

• Pathophysiology− Patients often show:

• Hypersensitivity of bowel pain receptors

• Hyperresponsiveness of the smooth muscle

• Psychiatric disorder connection


• Pathophysiology (cont’d)− Hyperresponsiveness can cause spasm.

• Can cause constipation and bloating or diarrhea

− Typically begins during childhood

− Can be triggered by various stimuli


• 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 DiseaseCrohn 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



• Rectal bleeding

• Weight loss

• Skin disorders


• Management− Prehospital care should focus on general

management guidelines, including: • Volume resuscitation

• Control of nausea and pain

Acute Infectious ConditionsAcute 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 ConditionsAcute 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 GastroenteritisAcute 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


• Assessment− Symptoms may show anywhere from several

hours to several days from contact

− Can last two or three days, or several weeks


• Assessment (cont’d)− Signs and symptoms may include:

• Diarrhea of various types

• Nausea and vomiting

• Anorexia

− Assess for dehydration, hemodynamic instability, and electrolyte imbalance.


• Management− Determine the degree of fluid deficit.

− Obtain orthostatic vital signs.

− Analgesic and antiemetic medications

− Teach patients about safe food and water use.

Rectal AbscessRectal Abscess

• Pathophysiology− Caused when the ducts carrying mucus to the

rectal area become blocked• Allows bacteria to grow and spread to the anus

Rectal AbscessRectal Abscess

• Assessment− Symptoms may include:

• Rectal pain that increases with defecation

• Rectal drainage

• Constipation

• Management− Focus on keeping the patient comfortable.

Liver Disease: CirrhosisLiver Disease: Cirrhosis

• Pathophysiology− Early liver failure, which may be hallmarked by:

• Portal hypertension

• Deficiencies with coagulation

• Diminished detoxification


• Assessment− First stage may include:

• Weakness and fatigue


• Anorexia

• Pruritus


• 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


• Assessment (cont’d)− Common blood tests:

• Aminotransferases

• Alkaline phosphatase

• Albumin

• Bilirubin


• 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



• Assessment− Can range from mild memory loss to coma

− May be precipitated by:• Infection

• Renal failure

• GI bleeding

• Constipation



• 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 ConditionsObstructive Conditions

• Intestines are unable to move material through the digestive tract.− Two main reasons:

• Paralysis of the intestines

• Intestinal lumen diameter compromise

Small-Bowel ObstructionSmall-Bowel Obstruction

• Pathophysiology− Most often caused by post-operative adhesions

− Other causes include:• Cancer

• Crohn disease

• Hernias

• Foreign bodies



• Crampy and intermittent abdominal pain

• Initial diarrhea, nausea, and vomiting

• Increased pressure

• Constipation


• Management− Monitor blood pressure, and perform volume

resuscitation.

− Administer dopamine as needed.

− Consider using a nasogastric tube.

− Antiemetics are indicated.

Large-Bowel ObstructionLarge-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




• Distended abdomen

• Absent bowel sounds

• Peritonitis signs if bowel has ruptured


• Management− Same as for small bowel obstruction

HerniaHernia

• 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.

HerniaHernia

• 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

HerniaHernia

• Assessment− Four types

• Reducible

• Incarcerated

• Strangulated

• Incisional

HerniaHernia

• 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.



• 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 IschemiaMesenteric Ischemia

• Pathophysiology− Interruption of the blood supply to the

mesentery

− Can be caused by:• Arterial embolism

• Thrombosis

• Profound vasospasm


• Assessment− Gradual or sudden onset

− Symptoms include:• Severe pain with ill-defined location

• Nausea, vomiting, and diarrhea

• Possible blood in stool


• 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.



• Congenital GI anomalies− Gastrochisis:

portions of the GI system lie outside the abdominal wall

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• Congenital GI anomalies (cont’d)− Intestinal

malrotation: intestines rotated incorrectly during development



• Congenital GI anomalies (cont’d)− Pyloric stenosis:

hypertrophy of the pyloric sphincter of the stomach

• GI bleeding can occur in children.



• 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.



• 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

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 StrategiesPrevention Strategies

• Many behaviors can prevent or limit severity of GI diseases.

Prevention StrategiesPrevention Strategies

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• The four major conditions responsible for abdominal and GI emergencies are:− Hypovolemia

− Acute or chronic inflammation

− Infection

− Obstruction

SummarySummary

• 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.

CreditsCredits

• Chapter opener: © Wellcome Trust/Custom Medical Stock Photo

• Backgrounds: Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Red—© Margo Harrison/ShutterStock, Inc.; Green—Courtesy of Rhonda Beck

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

Chapter 20 Abdominal and Gastrointestinal Emergencies.

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Transcript of Chapter 20 Abdominal and Gastrointestinal Emergencies.