NON-TRAUMATIC ABDOMINAL EMERGENCIES

INTRODUCTION

Optimal patient care requires that the EMT-I understand pathophysiology and principles of management of the patient with a non-traumatic abdominal emergency. The following topics

will be discussed during this lesson:

· Anatomy and physiology of the abdomen.

· Assessment of the abdomen.

· Abdominal pathophysiology.

· Prehospital care of patients with abdominal pain.

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

1. Identify the four quadrants of the abdominal cavity.

2. Name major organs located in each of the four quadrants.

3. State what should be included in the initial assessment and detailed history and physical exam assessment.

4. Describe the pertinent questions to be included in the history assessment of a patient with abdominal pain.

5. State the signs/symptoms and field treatment of different GI emergencies.

6 Recognize the signs/symptoms of different GU emergencies.

7. Identify signs/symptoms of reproductive emergencies including field treatment.

8. State the general principles of field treatment for the patient experiencing abdominal pain.

9. Discuss the EMT-I responsibilities when dealing with a patient experiencing abdominal

pain.

10. Discuss transport decisions for non-traumatic abdominal emergencies.

SKILLS

Orthostatic vital signs

KEY VOCABULARY

The following terms will be used during this lesson:

· Abdominal Aneurysm - tear in between layers of the aorta creating a balloon

effect which may rupture causing massive bleeding

· Anorexia - lack or loss of appetite

· Anemia - a decrease in blood hemoglobin

· Appendicitis - inflammation/infection of the appendix

· Diverticula - small pouches on the colon from degeneration of the muscle layer

· Esophageal Varices - enlarged (dilated) blood vessels in the esophagus which may

be easily ruptured causing severe bleeding; usually caused by liver disease

· Hematemesis - vomiting blood

· Hematuria - blood in the urine

· Hemorrhoid - enlarged blood vessels near the anus

· L.M.P. - abbreviation for last menstrual period

· Melena - black, tar like feces caused by gastrointestinal bleeding

· N.P.O. - an abbreviation that means nothing by mouth

· Peritoneum - a fibrous sac surrounding the abdominal cavity

· Peritonitis - an inflammation of the peritoneum

· Periumbilical - area surrounding the umbilicus.

· Ulcer - erosion of the stomach or intestinal lining which causes pain and/or

bleeding

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts discussed by the instructor.

ABDOMINAL ANATOMY

Boundaries of the Abdomen

· Diaphragm

· Anterior abdominal wall

· Pelvic skeletal structure

· Vertebral column

· Muscles of the abdomen and flank

Surface Anatomy

· Upper quadrants (2)

o Right and left

o Upper border - xiphoid

· Lower quadrants

o Right and left (2)

o Lower border - symphysis pubis

The point of intersection is the umbilicus.

Left Upper Quadrant

· Spleen

· Tail of the pancreas

· Stomach

· Left kidney

· Part of the colon

Right Upper Quadrant

· Liver

· Gall bladder

· Head of the pancreas

· Right kidney

· Part of the duodenum

· Part of the colon

Left Lower Quadrant

· Small intestines

· Descending colon

· Left ovary and fallopian tubes

Right Lower Quadrant

· Appendix

· Ascending colon

· Small intestine

· Right ovary and fallopian tube

Structure and Function of the Gastrointestinal System

· Function: The gastrointestinal system is responsible for converting raw food into an energy form that the body can use.

· Organs of digestion:

o Oral cavity

o Esophagus

o Intestines

· Accessory Organs of Digestion

o Salivary glands

o Teeth

o Liver

o Gallbladder

o Pancreas

o Appendix

INITIAL ASSESSMENT AND FOCUSED HISTORY AND DETAILED PHYSICAL

EXAMINATION FOR NON-TRAUMATIC ABDOMINAL EMERGENCIES

1). Assess environment: (may need to manipulate the environment)

· Safety of rescuers and environment

Environmental factors

Medications (may offer clues to past medical history)
Witnesses (may help to explain circumstances)

3). Breathing: assess the rate and quality of respirations

5). Skin signs: assess color, temperature and moisture

Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction

If signs of poor perfusion, consider placing patient supine

7). Determine chief complaint:

4). Circulation: palpate for pulse noting rate/rhythm/quality

2). Airway: determine responsiveness and patency of airway

FOCUSED HISTORY AND DETAILED PHYSICAL EXAMINATION

6). Assess Neurological Status:

Assess level of consciousness using the GCS, and neuro deficits

3). Vital Signs

Blood pressure—not a reliable early indicator of shock; assess for more subtle signs (capillary refill, heart rate, altered LOC)

Orthostatic vital signs if indicated

Pulse—rate and quality

Respirations—rate, depth, tidal volume, and lung sounds (present, absent, or abnormal)

Pupils—(pupillary size and reaction to light)

1). Elicit history of chief complaint or problem (PQRST)

P         provoking factor

Q         quality of pain

R         radiation or region

S         severity

T          time of onset

4). Special Questions

Ask questions specific to chief complaint:

Nausea/vomiting

Diarrhea/constipation

Hematuria

Melena

Anorexia

Fever

Weakness/syncope

2). Elicit personal history (HAM)

H medical history/under a doctors care

A   allergies/age

M   medications-current over the counter and prescription

5). Pertinent Body Check:

Medical or minor trauma—perform body check pertinent to chief complaint

Head to toe examination:

Assessment must include the following:

· Inspection

· Palpation

· Vital signs

· Orthostatic vital signs

PATHOPHYSIOLOGY, SIGNS AND SYMPTOMS, AND FIELD MANAGEMENT OF COMMON GASTROINTESTINAL PROBLEMS

Appendicitis

Pathophysiology:

An inflammation of the vermiform appendix which may rupture and cause peritonitis.

Signs and symptoms:

· Pain in the right lower quadrant

· Acute onset of pain often beginning in the periumbilical area

· Nausea/vomiting/anorexia

· Fever

· Rebound tenderness from inflammation of the peritoneum

· Guarding and rigidity are signs that the appendix may have ruptured

Field Management:

BLS Procedures:

· Oxygen 15 liters by mask

· Position of comfort

· Shock position if necessary

· Transport

ALS Procedures:

· Venous access (large bore)

Upper G.I. Hemorrhage

Pathophysiology:

Bleeding from the esophagus, duodenum, or the stomach;

common causes are gastritis, peptic ulcers, esophagitis, tumors,

and esophageal varices

Signs and symptoms:

· Chief complaint may be general weakness

· Hematemesis

· Black or coffee ground emesis

· Epigastric or left upper quadrant pain

Field Management

BLS Procedures:

· High flow oxygen by mask (cannula if vomiting)

· Orthostatic vital signs

· Trendelenberg position for shock if indicated

· Left lateral position if vomiting

· Assist with ALS procedures

· Transport

ALS Procedure

· Monitor

· Venous access (large bore)

· Fluid challenge if clear lung sounds and hypotension

· Transport

Lower G.I. Hemorrhage

Pathophysiology:

Bleeding from the distal small intestine, colon, or rectum.

Common causes are tumors, diverticulosis, hemorrhoids, or rectal fissures.

Signs and symptoms:

· Rectal bleeding

· Frequent stools

· Pain is not always present

· Pain may be crampish or diffuse

Field Management

BLS Procedures:

· High flow oxygen

· Trendelenberg position if indicated

· Orthostatic vital signs

· Assist with ALS procedures

· Transport

ALS Procedures:

· Monitor

· Venous access (large bore)

Pancreatitis

Pathophysiology:

Inflammation of the pancreas frequently associated with chronic alcohol abuse

Signs and symptoms:

· Abrupt onset of abdominal pain

· Mid-abdominal pain radiating to the back and shoulders

· Nausea/vomiting

Field Management

BLS Procedures:

High flow oxygen

· Position of comfort

· Left lateral if vomiting

· Assist with ALS procedures

· Transport

ALS Procedures:

· Monitor

· Venous access

Cholecystitis

Pathophysiology:

Inflammation of the gallbladder, often the result of a stone lodged in the cystic duct.

Signs and symptoms:

· Colic type pain in the right upper quadrant

· Often follows food ingestion (fatty foods usually)

· Antacids usually do not relieve gall bladder pain

Field Management

BLS Procedures:

· High flow oxygen

· Position of comfort

· Assist with ALS procedures

· Transport

ALS Procedures

· Monitor/Venous access

Peptic Ulcers

Pathophysiology:

Erosions of the esophagus, stomach, or duodenum; often caused

by alcohol abuse, drugs (aspirin, motrin, naprosyn)

Signs and symptoms:

· Burning type pain in the epigastric area or left upper quadrant

· Often meals or antacids will improve the pain

Field Management

BLS Procedures:

· High flow oxygen

· Position of comfort

· Assist with ALS procedures

· Transport

ALS Procedures:

· Monitor/venous access (large bore)

Aortic Aneurysm

Pathophysiology:

Ballooning of the wall of the aorta from weakness,

usually a result of aging.

Signs and symptoms:

· Diffuse abdominal pain

· Severe back pain

· Pain may be described as tearing if the vessel is dissecting

· Pulsatile abdominal mass may be noted

· Unequal pulses in the extremities may be noted

Field Management

BLS Procedures:

· High flow oxygen

· Trendelenberg position if indicated

· Assist with ALS procedures

· Transport

ALS Procedures:

· Monitor

· Venous access (large bore x2)

Function of the Genitourinary system

Function:

The Genitourinary System is responsible for removing waste products, maintaining acid - base balance, controlling salt and water levels and reproduction

Organs of the Genitourinary System:

· Kidneys

· Ureters

· Urinary bladder

· Urethra

PATHOPHYSIOLOGY, SIGNS AND SYMPTOMS, AND FIELD MANAGEMENT OF GENITOURINARY EMERGENCIES

Kidney stones

Pathophysiology:

Stone formation in the collecting system of the kidney. Most common in men between 20 and 50 years of age. Often result from urinary tract infections, tumors, metabolic disorders, gout, immobilization.

Signs and symptoms:

· Colic type pain as the stone enters the ureter

· Pain may be in the flank, back, or along the ureter

· Nausea/vomiting

· Hematuria

· Restlessness

Field Management

BLS Procedures:

· High flow oxygen

· Position of comfort

· Assist with ALS procedures

· Transport

ALS Procedures:

· Rarely an ALS response

· Venous access if indicated

Function of the Reproductive System

Function:

The Reproductive System is responsible for the continuation of the species.

Organs of the Reproductive System

Female:

· Ovaries

· Fallopian tubes

· Uterus

· Vagina

· Vulva

Male:

· Testes

· Epididymus

· Prostate

· Vas Deferens

· Urethra

· Penis

PATHOPHYSIOLOGY, SIGNS AND SYMPTOMS, AND FIELD MANAGEMENT OF FEMALE REPRODUCTIVE SYSTEM EMERGENCIES

Ectopic Pregnancy

Pathophysiology:

A fetus is developing in a location outside of the uterus, usually in

the fallopian tubes. As the fetus develops it exerts increasing

pressure on the tube which may rupture the tube.

Signs and symptoms:

· Pallor

· Weakness

· Syncope

· Tachycardia

· Hypotension

· Pain and tenderness

· Referred pain to the shoulder

Field Management

BLS Procedures:

· High flow oxygen

· Orthostatic vital signs

· Trendelenberg position

· Assist with ALS procedures

· Transport

ALS Procedures:

· Monitor

· Venous access (large bore)

· Fluid challenge if hypotensive and lungs clear

· Rapid transport

Pelvic Inflammatory Disease

Pathophysiology:

An infection of the female reproductive organs that is usually sexually transmitted.

Signs and symptoms:

· Fever

· Chills

· Low abdominal pain

· Vaginal bleeding or discharge

· Pain while walking or during intercourse