Chapter 20 Abdominal and Gastrointestinal Emergencies.
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Transcript of Chapter 20 Abdominal and Gastrointestinal Emergencies.
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Chapter 20Chapter 20
Abdominal and Gastrointestinal Emergencies
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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.
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Abdominal and Gastrointestinal Disorders
Anatomy, presentations, and management of shock associated with abdominal emergencies
− Gastrointestinal bleeding
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National EMS Education Standard CompetenciesNational 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
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National EMS Education Standard CompetenciesNational 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
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National EMS Education Standard CompetenciesNational 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
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IntroductionIntroduction
• GI problems are rarely life threatening.− Can lead to systemic problems if untreated
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IntroductionIntroduction
• The number of disorders causing abdominal pain, diarrhea, and nausea is high.− With the exception
of septicemia, most GI disorders are not deadly.
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IntroductionIntroduction
• Behaviors and characteristics may predispose some people to GI disorders.
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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.
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Anatomy and PhysiologyAnatomy 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
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Anatomy and PhysiologyAnatomy and Physiology
• The esophagus transports food using peristalsis.
• The portal vein is intertwined around the esophagus.− Transports venous blood to the liver.
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Anatomy and PhysiologyAnatomy 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
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Anatomy and PhysiologyAnatomy 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.
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Anatomy and PhysiologyAnatomy 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.
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Anatomy and PhysiologyAnatomy 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
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Anatomy and PhysiologyAnatomy and Physiology
• The small intestine− Where 90% of
absorption occurs
− Divided into three sections:• Duodenum
• Jejunum
• Ileum
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Anatomy and PhysiologyAnatomy and Physiology
• Colon (large intestine)− Moves undigested
food (feces) to be eliminated from the body
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Anatomy and PhysiologyAnatomy 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.
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Scene Size-UpScene Size-Up
• Ensure safety.
• Look for MOI or NOI.
• Take standard precautions.
• Always have equipment for hygiene.
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Primary AssessmentPrimary Assessment
• Form a general impression.− Where was the patient found?
− What is the patient’s body posture?
− Is there an odor?
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Primary AssessmentPrimary 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
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Primary AssessmentPrimary Assessment
• Circulation− Assess skin color, temperature, and moisture.
− Determine pulse rate.
− Ensure blood pressure reading is accurate.
− Take note of amount of blood.
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Primary AssessmentPrimary Assessment
• Transport decision− Based on primary assessment
− If positive orthostatic vital signs, carefully consider how to move the patient.
− Choose the mode of ambulance.
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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
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History TakingHistory Taking
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Secondary AssessmentSecondary Assessment
• Detailed abdominal examination− Keep the muscles
from flexing.
− Check for skin irregularities.• Scars
• Striae© Medical-on-Line Alamy Images
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Secondary AssessmentSecondary Assessment
• Asymmetric abdomen could mean:− Tumors
− Hernia
− Enlarged organs
− Pregnancy
• Check shape of the abdomen.
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Secondary AssessmentSecondary Assessment
• Protuberance may be caused by:− Excessive weight
gain
− Ascites
− Pregnancy
− Organ enlargement
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Secondary AssessmentSecondary Assessment
• Auscultate for bowel sounds.
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Secondary AssessmentSecondary Assessment
• Percuss the abdomen.− The abdomen should sound tympanic.
− The upper left and upper right quadrants will sound duller.
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Secondary AssessmentSecondary Assessment
• Palpate the abdomen.− Begin farthest
away from the pain.
− Indent the abdomen wall about 2″ to 4″.
− Assess for discomfort, rigidity, and masses.
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Secondary AssessmentSecondary Assessment
• Abdominal pain may indicate:− Trauma
− Hemorrhage
− Infection
− Obstruction
− Other serious problems
• Types of pain include:− Visceral pain
− Parietal pain (rebound)
− Somatic pain
− Referred pain
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Secondary AssessmentSecondary 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.
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Secondary AssessmentSecondary 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
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Secondary AssessmentSecondary 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
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Secondary AssessmentSecondary Assessment
• Many GI diseases affect electrolyte levels. − Use a handheld blood analyzer to test.
• Ultrasonography and intra-abdominal pressure testing may also be available.
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ReassessmentReassessment
• Routine monitoring includes:− Pulse rate
− Electrocardiogram
− Blood pressure
− Respiratory rate
− Pulse oximetry
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ReassessmentReassessment
• Pain medication includes:− Meperidine hydrochloride
− Morphine
− Ketorolac
− Nalbuphine
− Fentanyl
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ReassessmentReassessment
• Nausea medications include:− Ondansetron
− Diphenhydramine
− Hydroxyzine
− Promethazine
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Emergency Medical CareEmergency Medical Care
• Repeat assessment if patient’s condition suddenly changes dramatically.
• Do not let patients eat or drink anything.
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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.
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BreathingBreathing
• Associated with decreased hemoglobin levels− Administer high-concentration oxygen.
− Prevent aspiration.
− Auscultate lung sounds.
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CirculationCirculation
• Concerns: dehydration and hemorrhage− Fluids depend on circulatory perfusion status.
• Hypotonic solution for stable conditions
• Isotonic solution for profound dehydration
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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.
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Specific Abdominal and Gastrointestinal Emergencies
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.
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Specific Abdominal and Gastrointestinal Emergencies
Specific Abdominal and Gastrointestinal Emergencies
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Specific Abdominal and Gastrointestinal Emergencies
Specific Abdominal and Gastrointestinal Emergencies
• Hypovolemia can be caused by:− Dehydration from
vomiting and/or diarrhea• Electrolyte levels
are affected during this process.
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Specific Abdominal and Gastrointestinal Emergencies
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
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Gastrointestinal BleedingGastrointestinal Bleeding
• GI bleeding is a symptom, not the disease.− Determine onset and medical history.
− Treatment includes:• Fluid resuscitation
• Establish an IV line.
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Gastrointestinal BleedingGastrointestinal Bleeding
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Upper Gastrointestinal Bleeding: Esophagogastric Varices
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.
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Upper Gastrointestinal Bleeding: Esophagogastric Varices
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
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Upper Gastrointestinal Bleeding: Esophagogastric Varices
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
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Upper Gastrointestinal Bleeding:Mallory-Weiss Syndrome
Upper Gastrointestinal Bleeding:Mallory-Weiss Syndrome
• Pathophysiology− Junction between the esophagus and the
stomach tears• Generally due to severe vomiting
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Upper Gastrointestinal Bleeding:Mallory-Weiss Syndrome
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
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Upper Gastrointestinal Bleeding:Mallory-Weiss Syndrome
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
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Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD)
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
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Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD)
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
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Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD)
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
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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.
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Upper Gastrointestinal Bleeding: Gastroesophageal Reflux DiseaseUpper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease
• Assessment− Signs and symptoms
• Heartburn
• Coughing or difficulty swallowing
• Bleeding, resulting in hematemesis and melena
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Upper Gastrointestinal Bleeding: Gastroesophageal Reflux DiseaseUpper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease
• Management− Treatment focuses on decreasing acidity.
• Antacids, proton pump inhibitors, H2 blockers
− Symptoms can be confused with myocardial infarction.
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Lower Gastrointestinal Bleeding: HemorrhoidsLower Gastrointestinal Bleeding: Hemorrhoids
• Pathophysiology− Swelling and inflammation of blood vessels
around the rectum
− Caused by increased rectal pressure or irritation
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Lower Gastrointestinal Bleeding: HemorrhoidsLower Gastrointestinal Bleeding: Hemorrhoids
• Assessment − Signs and symptoms:
• Hematochezia
• Rectal itching
• Small mass on rectum
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Lower Gastrointestinal Bleeding: HemorrhoidsLower 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.
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Lower Gastrointestinal Bleeding: Anal FissuresLower Gastrointestinal Bleeding: Anal Fissures
• Pathophysiology− Linear tears in the
mucosal lining near and in the anus
![Page 68: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/68.jpg)
Lower Gastrointestinal Bleeding: Anal FissuresLower Gastrointestinal Bleeding: Anal Fissures
• Assessment− Painful defecation
• Management− Place dressing over anus.
− Do NOT pack fissure or anus.
![Page 69: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/69.jpg)
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.
![Page 70: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/70.jpg)
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.
![Page 71: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/71.jpg)
Cholecystitis and Biliary Tract Disorders
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
![Page 72: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/72.jpg)
Cholecystitis and Biliary Tract Disorders
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
![Page 73: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/73.jpg)
Cholecystitis and Biliary Tract Disorders
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.
![Page 74: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/74.jpg)
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
![Page 75: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/75.jpg)
AppendicitisAppendicitis
• 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.
![Page 76: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/76.jpg)
AppendicitisAppendicitis
• Management− Assess for septicemia.
− Volume resuscitation • Use dopamine if crystalloids are not effective.
− Administer pain and antinausea medications.
![Page 77: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/77.jpg)
DiverticulitisDiverticulitis
• Pathophysiology− Diverticulum: weak area in the colon that begins
to have pockets (diverticula)
− Diverticulosis: condition of having diverticula
− Diverticulitis: Inflammation of diverticuli
![Page 78: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/78.jpg)
DiverticulitisDiverticulitis
• 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
![Page 79: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/79.jpg)
DiverticulitisDiverticulitis
• Assessment− Signs and symptoms include:
• Abdominal pain, usually localized on the left lower abdomen
• Classic infection signs
• Constipation or diarrhea
![Page 80: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/80.jpg)
DiverticulitisDiverticulitis
• Management− Ensure severe infection is not present.
− Patients may need fluids and/or dopamine.
− In-hospital treatment includes:• Antibiotics
• Liquid diet
• Surgery
![Page 81: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/81.jpg)
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
![Page 82: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/82.jpg)
PancreatitisPancreatitis
• Assessment− Signs and symptoms may include:
• Sharp pain in the epigastric area or right upper abdomen
• Pain radiating to the back
• Muscle spasms
![Page 83: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/83.jpg)
PancreatitisPancreatitis
• Assessment (cont’d)− Internal
hemorrhage may be indicated by:• Cullen sign
• Grey-Turner sign
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![Page 84: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/84.jpg)
PancreatitisPancreatitis
• Management− Directed by general management guidelines
− Assess for signs of severe hemorrhage.
− Meperidine is the choice for pain management.
![Page 85: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/85.jpg)
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
![Page 86: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/86.jpg)
Ulcerative ColitisUlcerative Colitis
• Assessment− Signs and symptoms may include:
• Gradual onset of bloody diarrhea
• Hematochezia
• Mild to severe abdominal pain
• Skin lesions
![Page 87: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/87.jpg)
Ulcerative ColitisUlcerative Colitis
• Management− Determine the degree of hemodynamic
instability.
− Administer fluids, if necessary.
− Follow the general management guideline.
![Page 88: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/88.jpg)
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
![Page 89: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/89.jpg)
Irritable Bowel Syndrome (IBS)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
![Page 90: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/90.jpg)
Irritable Bowel Syndrome (IBS)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.
![Page 91: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/91.jpg)
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
![Page 92: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/92.jpg)
Crohn DiseaseCrohn Disease
• Assessment− Signs and symptoms may include:
• Rectal bleeding
• Weight loss
• Skin disorders
![Page 93: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/93.jpg)
Crohn DiseaseCrohn Disease
• Management− Prehospital care should focus on general
management guidelines, including: • Volume resuscitation
• Control of nausea and pain
![Page 94: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/94.jpg)
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
![Page 95: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/95.jpg)
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.
![Page 96: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/96.jpg)
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
![Page 97: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/97.jpg)
Acute GastroenteritisAcute Gastroenteritis
• Assessment− Symptoms may show anywhere from several
hours to several days from contact
− Can last two or three days, or several weeks
![Page 98: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/98.jpg)
Acute GastroenteritisAcute 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.
![Page 99: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/99.jpg)
Acute GastroenteritisAcute Gastroenteritis
• Management− Determine the degree of fluid deficit.
− Obtain orthostatic vital signs.
− Analgesic and antiemetic medications
− Teach patients about safe food and water use.
![Page 100: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/100.jpg)
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
![Page 101: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/101.jpg)
Rectal AbscessRectal Abscess
• Assessment− Symptoms may include:
• Rectal pain that increases with defecation
• Rectal drainage
• Constipation
• Management− Focus on keeping the patient comfortable.
![Page 102: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/102.jpg)
Liver Disease: CirrhosisLiver Disease: Cirrhosis
• Pathophysiology− Early liver failure, which may be hallmarked by:
• Portal hypertension
• Deficiencies with coagulation
• Diminished detoxification
![Page 103: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/103.jpg)
Liver Disease: CirrhosisLiver Disease: Cirrhosis
• Assessment− First stage may include:
• Weakness and fatigue
• Nausea and vomiting
• Anorexia
• Pruritus
![Page 104: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/104.jpg)
Liver Disease: CirrhosisLiver 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
![Page 105: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/105.jpg)
Liver Disease: CirrhosisLiver Disease: Cirrhosis
• Assessment (cont’d)− Common blood tests:
• Aminotransferases
• Alkaline phosphatase
• Albumin
• Bilirubin
![Page 106: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/106.jpg)
Liver Disease: CirrhosisLiver Disease: Cirrhosis
• Management− Prehospital care should be supportive.
− Involves bleeding control and medication
− Use lower ends of medication dose range.
![Page 107: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/107.jpg)
Liver Disease: Hepatic Encephalopathy
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
![Page 108: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/108.jpg)
Liver Disease: Hepatic Encephalopathy
Liver Disease: Hepatic Encephalopathy
• Assessment− Can range from mild memory loss to coma
− May be precipitated by:• Infection
• Renal failure
• GI bleeding
• Constipation
![Page 109: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/109.jpg)
Liver Disease: Hepatic Encephalopathy
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.
![Page 110: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/110.jpg)
Obstructive ConditionsObstructive Conditions
• Intestines are unable to move material through the digestive tract.− Two main reasons:
• Paralysis of the intestines
• Intestinal lumen diameter compromise
![Page 111: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/111.jpg)
Small-Bowel ObstructionSmall-Bowel Obstruction
• Pathophysiology− Most often caused by post-operative adhesions
− Other causes include:• Cancer
• Crohn disease
• Hernias
• Foreign bodies
![Page 112: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/112.jpg)
Small-Bowel ObstructionSmall-Bowel Obstruction
• Assessment− Signs and symptoms may include:
• Crampy and intermittent abdominal pain
• Initial diarrhea, nausea, and vomiting
• Increased pressure
• Constipation
![Page 113: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/113.jpg)
Small-Bowel ObstructionSmall-Bowel Obstruction
• Management− Monitor blood pressure, and perform volume
resuscitation.
− Administer dopamine as needed.
− Consider using a nasogastric tube.
− Antiemetics are indicated.
![Page 114: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/114.jpg)
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
![Page 115: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/115.jpg)
Large-Bowel ObstructionLarge-Bowel Obstruction
• Assessment− Signs and symptoms may include:
• Nausea and vomiting
• Distended abdomen
• Absent bowel sounds
• Peritonitis signs if bowel has ruptured
![Page 116: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/116.jpg)
Large-Bowel ObstructionLarge-Bowel Obstruction
• Management− Same as for small bowel obstruction
![Page 117: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/117.jpg)
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.
![Page 118: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/118.jpg)
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
![Page 119: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/119.jpg)
HerniaHernia
• Assessment− Four types
• Reducible
• Incarcerated
• Strangulated
• Incisional
![Page 120: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/120.jpg)
HerniaHernia
• Management− Focus on supportive measures.
− Pain management
− Assess for sepsis
![Page 121: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/121.jpg)
Rectal Foreign Body Obstruction
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.
![Page 122: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/122.jpg)
Rectal Foreign Body Obstruction
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.
![Page 123: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/123.jpg)
Mesenteric IschemiaMesenteric Ischemia
• Pathophysiology− Interruption of the blood supply to the
mesentery
− Can be caused by:• Arterial embolism
• Thrombosis
• Profound vasospasm
![Page 124: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/124.jpg)
Mesenteric IschemiaMesenteric Ischemia
• Assessment− Gradual or sudden onset
− Symptoms include:• Severe pain with ill-defined location
• Nausea, vomiting, and diarrhea
• Possible blood in stool
![Page 125: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/125.jpg)
Mesenteric IschemiaMesenteric Ischemia
• Management− Patients require rapid transportation.
− Monitor closely.
− Check vitals for signs of sepsis.
− Fluid resuscitation in cases of shock
− Give analgesics as needed.
![Page 126: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/126.jpg)
Gastrointestinal Conditions in Pediatric Patients
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.
![Page 127: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/127.jpg)
Gastrointestinal Conditions in Pediatric Patients
Gastrointestinal Conditions in Pediatric Patients
• Congenital GI anomalies− Gastrochisis:
portions of the GI system lie outside the abdominal wall
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Gastrointestinal Conditions in Pediatric Patients
Gastrointestinal Conditions in Pediatric Patients
• Congenital GI anomalies (cont’d)− Intestinal
malrotation: intestines rotated incorrectly during development
![Page 129: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/129.jpg)
Gastrointestinal Conditions in Pediatric Patients
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.
![Page 130: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/130.jpg)
Gastrointestinal Conditions in Pediatric Patients
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.
![Page 131: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/131.jpg)
Gastrointestinal Conditions in Pediatric Patients
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.
![Page 132: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/132.jpg)
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.
![Page 133: Chapter 20 Abdominal and Gastrointestinal Emergencies.](https://reader033.fdocuments.us/reader033/viewer/2022061616/56649cb45503460f94978aec/html5/thumbnails/133.jpg)
Prevention StrategiesPrevention Strategies
• Many behaviors can prevent or limit severity of GI diseases.
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Prevention StrategiesPrevention Strategies
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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.
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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.
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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.
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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.
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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.
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SummarySummary
• The four major conditions responsible for abdominal and GI emergencies are:− Hypovolemia
− Acute or chronic inflammation
− Infection
− Obstruction
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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.
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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.